Intra-Aortic Balloon Pump Counterpulsation Iskander Al-Githmi, MD, FRCSC Assistant Professor of Surgery King Abdulaziz University

Historical Perspective 1958- Harken: Described the diastolic augmentation and counterpulsation to treat LV failure 1962-Moulopoulus: From Cleveland clinic, developed an experimental (IAB) whose inflation and deflation were timed to cardiac cycle 1968-Kantrowitz: Introduce the (IAB) to the clinical practice in patient with post-infarction cardiogenic shock

Intra-Aortic Pump Catherter

Physiologic effect of IABP Reduction of left ventricular afterload Increase aortic root pressure and coronary perfusion Decrease myocardial oxygen demand

Coronary Artery Flow Autoregulation Flow=Pressure/ resistnce

Indications: Cardiogenic shock or pump failure Unstable angina Failure to wean patient off CPB Prophylaxis: High grade left main coronary stenosis Post infarction acute mitral regurgitation and septal defect

Contraindications: Severe aortic regurgitation Aortic dissection Severe peripheral vascular disease Non-salvageable patient- Irreversible brain injury

Arterial Waveform

IABP Arterial Waveform

IAB catheter insertion technique Seldinger technique Cut-down

Timing

Balloon pressure waveform 1.zero baseline 2.Fill pressure baseline 3.IAB inflation 4.Pressure artifact/positive overshoot 5.Plateau pressure (IAB inflated) 6.IAB deflation 7.Vaccum artifact/negative overshoot 8.Return to baseline (IAB deflated)

Timing Basics To patient arterial waveform (always) To patient EKG signal

Timing problems Early inflation

Timing Problems Early deflation

Timing Problem Late deflation

Triggering Trigger on the R wave- preferred method Good quality EKG signal and lead i.e unidirectional QRS complex, R wave is taller than P and T waves also it has adequate amplitude

Triggering Good Lead

Triggering QRS complex cause wandering timing

Complications Limb ischemia (10-25%) Balloon rupture Thrombosis within the balloon Infection Bleeding False aneurysm Femoral neuropathy Lymphocele

Questions

Question1 Asses the timing in the following strip Correct Timing Early inflation and late deflation Early inflation and early deflation Correct inflation and early deflation Late inflation and early deflation

Question 2 What is wrong with the arterial pressure line AP line is dampened Transducer need to zerod The IBP is too high and the tip of art.line is being occluded as it hit the arch Nothing There is air in the pressure tubing

Question 3 Asses the timing in the following strip Early inflation and early deflation Late inflation and late deflation Correct inflation and late deflation Late inflation and early deflation Correct timing

The pump is the peak trigger mode ,what part of the EKG complex is being recognized as the trigger event? The R wave The pacer spike The arterial pressure waveform The T wave No trigger is seen

Question 5 The indications for IABP therapy include: Cardiogenic shock following acute myocarditis Acute mitral regurgitation with pulmonary edema from papillary muscle rupture Acute VSD following myocardial infarction Acute aortic regurgitation from edocarditis