1. IABP- Instrumentation, Indications and Complications
Dr Sajeer KT
Senior Resident
Dept.of Cardiology, MCH Calicut

2. Intra aortic balloon counter pulsation( IABP):
Temporary support for the left ventricle by mechanically
displacing blood within the aorta
Most common and widely available methods of mechanical
circulatory support
Concepts:
- Systolic unloading
- Diastolic augmentation
Traditionally used in surgical and non surgical patients with cardiogenic shock

4. Indications for IABP 1. Cardiogenic shock:
- Associated with acute MI
- Mechanical complications of MI - MR , VSD
2. In association with CABG :
Preoperative insertion
- Patients with severe LV dysfunction
- Patients with intractable ischemic arrhythmias Postoperative insertion
- Postcardiotomy cardiogenic shock
3. In association with nonsurgical revascularization:
Hemodynamically unstable infarct patients
High risk coronary interventions
- severe LV dysfunction, LMCA, complex coronary artery disease 4.
Stabilization of cardiac transplant recipient before insertion of VAD
Post infarction angina
Ventricular arrhythmias relathed to ischemia

6. Contraindications to IABP
Severe aortic insufficiency
Aortic aneurysm
Aortic dissection
Limb ischemia
Thrombo embolism

8. Cardiac cycle LV contraction: - Isovol. Contraction (b)
- maximal ejection (c)
LV relaxation:
- start of relaxation and reduced
ejection (d)
- isovol.relaxation (e)
LV filling:
- LV filling , rapid phase (f)
- slow LV filling (g)
- atrial systole( a)

14. Interpreting IABP waveforms

15. IABP –instrumentation and techniques

16. The IAB Counter pulsation system - two principal parts
A flexible catheter -2 lumen
first - for distal aspiration/flushing or pressure monitoring
second - for the periodic delivery and removal of helium gas to a
closed balloon.
A mobile console
system for helium transfer
computer for control of the inflation and deflation cycle

18. HEMODYNAMIC EFFECTS — Inflation and deflation of the balloon
Blood is displaced to the proximal aorta by inflation during
diastole.
Aortic volume ( afterload) is reduced during systole through a
vacuum effect created by rapid balloon deflation

19. Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock
- Decrease in SBP by 20 %
Increase in aortic Diastolic Press. by 30 % ( raise coronary blood flow)
Increase in MAP
Reduction of the HR by 20%
Decrease in the mean PCWP by 20 %
- Elevation in the COP by 20%

21. IABP catheter:
10-20 cm long polyurethane bladder
25cc to 50cc capacity
Optimal 85% of aorta occluded (not 100%)
The shaft of the balloon catheter contains 2 lumens:
- one allows for gas exchange from console to
balloon
- second lumen
- for catheter delivery over a guide wire
- for monitoring of central aortic pressure
after installation.

22. Intra Aortic Balloon

23. IABP sizing chart

24. Benefits of larger volume IABs
􀁑 More blood volume displacement
􀁑 More diastolic augmentation
􀁑 More systolic unloading

25. IABP Kit Contents Introducer needle • Guide wire • Vessel dilators
• Sheath
• IABP (34 or 40cc)
• Gas tubing
• 60-mL syringe
• Three-way stopcock

26. Intraaortic balloon

27. STEP BY STEP- IABP insertion
Connect ECG
Set up pressure lines
Femoral access – followed by insertion of the supplied
sheath(7.5 F)
0.030 inch supplied J-shaped guide wire to the level of the
aortic arch (LAO view)

28. Before taking the Catheter out of Tray

29. Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray.)
Pull out the T- handle only as shown

30. Inserting the Balloon catheter
• Remove stylet/aspirate/Flush
• Insert the balloon only over the guide wire
• Hold the catheter close to skin insertion point
• Advance in small steps of 1 to 2 cm at a time and
stop if any resistance.
• The IABP should advance freely
Many vascular complications occur during insertion itself
Resistance during insertion either indicates PVOD, or dissection
- Kinking of IABP » improper inflation/deflation

31. Positioning
The end of the balloon should be just distal (1-2 cm) to the takeoff of the
left subclavian artery
- Position should be confirmed by fluoroscopy or chest x-ray

32. Connecting to console:
- Connect helium gas tube to the console via a long extender
Open helium tank.
The central lumen of the catheter is flushed and connected to pressure
tubing with 3 way and then to a pressure transducer to allow for
monitoring of central aortic pressure.
- Zero the transducer
Initial set-up:
- Once connected properly the console would show ECG and pressure
waveforms.
- Check Basal mean pressure
- Make sure the setting is at “auto”
- Usually IABP started at 1:1 or 1:2 augmentation
- Usually Augmentation is kept at maxim

34. Trigger modes Trigger :
- Event the pump uses to identify the onset of cardiac cycle (systole)
- Pump must have consistent trigger in order to provide patient assist
- If selected trigger not detected, counter pulsation will interrupted
1.ECG
- uses the slope of QR segment to detect triggering point
2. AP(Arterial pressure wave)
- Systolic upstroke of the arterial pressure wave form is the trigger
3. IN(Internal trigger)

35. ECG signal – most common
• Inflation
- middle of T wave
• Deflation
– peak of R wave
• Pacer (v/a)
• Arterial waveform
• An intrinsic pump rate
(VF, CPB)

36. Initial settings Auto Operation Mode
 Automatic lead and trigger selection
 Automatic and continuous inflation
and deflation timing management
- User has ability to fine-tune
deflation timing
 Automatic management of irregular
rhythms
Semi-Auto Operation Mode
 Operator selects most appropriate
lead and trigger source

41. The “normal” augmented waveform
Increased coronary
perfusion

42. Not all Sub optimal augmentation is due to Timing errors/kinks

43. Factors affecting diastolic augmentation
Patient
- Heart rate
- Mean arterial pressure
- Stroke volume
- Systemic vascular resistance
Intra aortic balloon catheter
- IAB in sheath
- IAB not unfolded
- IAB position
- Kink in the IAB catheter
- IAB leak
- Low helium concentration
Intra aortic balloon pump
- Timing
- Position of IAB augmentation control

44. How to check waveform is acceptable ?
First change from 1:1 to 1:2 augmentation

46. How to check waveform is acceptable ?
First change from 1:1 to 1:2 augmentation
Check the dicrotic notch
See if augmentation starts at that point
This should produce a sharp “V” at inflation.

47. How to check waveform is acceptable ?
First change from 1:1 to 1:2 augmentation
Check the dicrotic notch
See if augmentation starts at that point
This should produce a sharp “V” at inflation.
Check if diastolic augmented wave is › systolic wave

48. How to check waveform is acceptable ?
First change from 1:1 to 1:2 augmentation
Check the dicrotic notch
See if augmentation starts at that point
This should produce a sharp “V” at inflation.
Check if diastolic augmented wave is › systolic wave
Confirm if end diastolic wave
following the augmented wave
is less than an non augmented
wave.
Is Deflation slope ok

50. Late Inflation
Inflation of the IAB markedly after closure of the aortic valve.
Waveform Characteristics:
• Inflation of IAB after the dicrotic notch.
• Absence of sharp V.
Sub optimal diastolic augmentation

51. Early Deflation
Premature deflation of the IAB during the diastolic phase.

52. Late Deflation Late deflation of the IAB during the diastolic phase.
Waveform Characteristics:
• Assisted aortic end diastolic pressure may be equal to the unassisted aortic end diastolic pressure.
• Rate of rise of assisted systole is prolonged.
• Diastolic augmentation may appear widened

53. Normal Balloon Pressure Waveform
Once Arterial waveform is ok, check balloon waveform
Normal Balloon Pressure Waveform

55. Variation in balloon pressure wave forms
Decreased duration
of plateau due to
shortened diastolic
phase
Increased duration of
plateau due to longer
diastolic phase

56. Variation in balloon pressure wave forms
Varying R-R intervals
result in irregular
plateau durations

57. Variation in balloon pressure wave forms
Increased height
or amplitude of
the waveform
Decreased height
or amplitude of the
waveform

58. Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing the
balloon pressure waveform to fall below
zero baseline..
due to a loose connection
a leak in the IAB catheter
- H2O condensation in the external tubing
a patient who is tachycardiac and febrile which causes increased gas
diffusion through the IAB membrane

59. Catheter Kink Rounded balloon pressure waveform
- Loss of plateau resulting from a kink or
obstruction of shuttle gas
- Kink in the catheter tubing
Improper IAB catheter position
Sheath not being pulled back to allow
inflation of the IAB
- IAB is too large for the aorta
IAB is not fully unwrapped
H2O condensation in the external tubing

60. “Balloon too large” syndrome

61. Patient Management During IABP support
Anticoagulation-- maintain apTT at 50 to 70 seconds
CXR daily – to R/O IAB migration
Check lower limb pulses - 2 hourly.
- If not palpable » ? - vascular obstruction
- thrombus, embolus, or dissection
(urgent surgical consultation)
Prophylactic antibiotics --??
Hip flexion is restricted, and the head of the bed should not be
elevated beyond 30°.

62. Patient Management During IABP support
Never leave in standby by mode for more than 20 minutes > thrombus formation
Daily
– Haemoglobin (risk of bleeding or haemolysis)
– Platelet count (risk of thrombocytopenia)
– Renal function (risk of acute kidney injury secondary to distal
migration of IABP catheter)
Wean off the IABP as early as possible as longer duration is associated
with higher incidence of limb complications

64. Weaning of IABP Timing of weaning:
- Patient should be stable for 12 – 24 hours
- Decrease inotropic support
- Decrease pump ratio
– From 1:1 to 1:2 or 1:3
- Decrease augmentation
- Monitor patient closely
– If patient becomes unstable, weaning should be
immediately discontinued

65. IABP Removal Discontinue heparin six hours prior to removal
Disconnect the IAB catheter from the IAB pump
- Patient blood pressure will collapse the balloon membrane for withdrawal
- Withdraw the IAB catheter through the introducer sheath until resistance
is met.
NEVER attempt to withdraw the balloon membrane through the
introducer sheath.
Remove the IAB catheter and the introducer sheath as a unit
- Check for adequacy of limb perfusion after hemostasis is achieved.

66. Thank you

67. 1. Major physiological effects of counter pulsation include?
A) increased coronary artery perfusion, increased preload, decreased after load, decreased myocardial oxygen consumption
B) increased coronary artery perfusion, increased preload, increased after load, decreased myocardial oxygen consumption
C) increased coronary artery perfusion, decreased preload, decreased after load, increased myocardial oxygen consumption
D) increased coronary artery perfusion, decreased preload, decreased after load, decreased myocardial oxygen consumption

68. 2. the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection

69. 3. Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except?
A) Decrease in SBP by 20 %
B) Increase in aortic DP by 30 %
C) Decrease in MAP by 10%
D) Reduction of the HR by 20%
E)Decrease in the mean PCWP by 20 %

70. 4. late inflation of the balloon can result in?
premature augmentation
increased augmentation
C) decreased augmentation
D) increased coronary perfusion

71. 5. A rounded balloon pressure wave form indicate
5. A rounded balloon pressure wave form indicate? A) helium leak B) power failure C) hypovolemia D) balloon occluding the aorta

72. 6. width of balloon pressure wave form corresponds to A) length of systole B) length of diastole C) arterial pressure D) helium level

73. 7. true statement
Dicrotic notch- land mark used to set deflation
Deflation is timed to occur during period of iso volumetric contraction
Most common trigger used is arterial pressure wave method
Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

74. 8. true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50% paced rhythm
C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form

75. 9. Identify the tracing abnormality

76. 10. Identify the tracing abnormality

77. 1. Major physiological effects of counter pulsation include?
A) increased coronary artery perfusion, increased preload, decreased after load, decreased myocardial oxygen consumption
B) increased coronary artery perfusion, increased preload, increased after load, decreased myocardial oxygen consumption
C) increased coronary artery perfusion, decreased preload, decreased after load, increased myocardial oxygen consumption
D) increased coronary artery perfusion, decreased preload, decreased after load, decreased myocardial oxygen consumption

78. 2. the dicrotic notch on the arterial wave form reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric contraction
D)rapid ejection

79. 3. Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except?
A) Decrease in SBP by 20 %
B) Increase in aortic DP by 30 %
C) Decrease in MAP by 10%
D) Reduction of the HR by 20%
E)Decrease in the mean PCWP by 20 %

80. 4. late inflation of the balloon can result in?
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion

81. 5. A rounded balloon pressure wave form indicate?
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta

82. 6. width of balloon pressure wave form corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level

83. 7. true statement
Dicrotic notch- land mark used to set deflation
Deflation is timed to occur during period of iso volumetric contraction
Most common trigger used is arterial pressure wave method
Internal trigger mode is acceptable to use in a patient with normal sinus rhythm

84. 8. true statement
A) pacing spikes are automatically rejected in ECG triggered modes
B) pacing trigger modes can be used in a patient of 50% paced rhyth
C) Varying R-R interval result in regular plateau durations in Balloon press. Wave form

85. 9.

86. 10.