1) Intra-aortic balloon pumps (IABPs) are cylindrical balloons inserted into the aorta to reduce workload on the heart. They inflate during diastole to boost coronary and peripheral perfusion and deflate during systole to reduce afterload.
2) Prophylactic placement of IABPs before high-risk percutaneous coronary interventions (PCIs) may improve outcomes compared to rescue placement after complications arise. However, randomized controlled trials have had mixed results on the benefits of IABPs.
3) Routine anticoagulation is not necessary for IABPs, as the risk of bleeding outweighs the small risk of clot formation or balloon rupture. Careful monitoring of
Module for Grade 9 for Asynchronous/Distance learning
Intra-Aortic_Balloon_Pumps-2014-1jltbfe.ppt
1. Intra-Aortic Balloon Pumps: A Review for
Cardiologists
Quinn Capers, IV, MD, FACC, FSCAI
Division of Cardiovascular Medicine
The Ohio State University Medical
Center
2. IABP: Definition
40 cc volume, cylindrical balloon
Advanced from femoral artery into aorta
Usually percutaneously (Seldinger technique), with a
sheath (6.5-10.5)
3. IABP: Definition
Attached via gas and arterial pressure tubing to
portable control module
Inflated with inert gas immediately at aortic valve
closure
Actively deflated immediately prior to systole
4. 4
IABP inflates with aortic valve closure:
Provides pressurized pulse of blood against
closed aortic valve, increasing coronary perfusion
IABP deflates immediately prior to aortic valve opening:
Reduces LV afterload
5. IABP: Physiology
Inflation at aortic valve closure:
Increases aortic diastolic blood pressure
Increases diastolic coronary perfusion
Net neutral effect on cerebral perfusion
Increases C.O./“runoff” to subdiaphragmatic organs
Deflation prior to systole:
Reduces impedance to LV ejection (afterload)
Reduces myocardial oxygen consumption
6. IABP: Physiology
2 main beneficial effects:
1) Augmented coronary perfusion
2) Reduced LV afterload/Increased CO
7. IABP: Physiology
2 main beneficial effects:
1) Augmented coronary perfusion
Only in normal coronary arteries
No augmentation beyond severe stenoses pre PCI
Augmentation beyond severe stenoses post PCI
2) Reduced LV afterload/Increased CO
8. IABP: Physiology
2 main beneficial effects:
1) Augmented coronary perfusion
2) Reduced LV afterload/Increased CO
Most important of 2 main effects when severe coronary
stenoses present
9. 9
Cardiogenic shock
Unstable AMI pt
Prior to hi risk PCI
Prior to hi risk CABG
Refractory CHF
Refractory VT/VF
Severe MR
Refractory angina
“Rescue” after failed
PCI going to CABG
Bridge to heart txp
IABP: Indications
10. 10
Absolute
Known severe aortic
pathology (dissxn,
ulcer, mobile plaques)
Significant AI
Patient refusal
Relative
Severe PVD
AAA
Mild AI
IABP: Contraindications
11. IABP: Current Practice
Ferguson. JACC 2001.
Registry, 6/96-8/00: 16, 909 pts in 203 ctrs
Indications:
20.6% high risk cath/PCI
18.8% cardiogenic shock
16.1% weaning from CPB
13% preop CABG, high risk or unstable pt
12.3% refractory USA
15. IABP Insertion: Methods
Note that sheath is not mandatory
Advantage: IABP passage may be less traumatic
Disadvantage: Bigger hole, ? more limb ischemia
16. IABP Insertion: Methods
Advance IABP over wire under fluoro
Distal (cephalad) marker placed at carina
(Caudad to L SC artery)
Aspirate blood from lumen of IABP
Hook up “bubble free” to fluid filled pressure tubing
17. IABP Insertion: Methods
Connect gas line and fill IABP
Begin pumping 1:2 under fluoro
Ensure full expansion, no kinking, IABP not in iliac
artery
Examine pressure wave forms
27. IABP: Essential Questions
Anecdotally, we think it is a beneficial in cardiogenic
shock and high risk coronary revascularization.
1. Do we have randomized data that it is beneficial in high risk PCI?
2. If IABP is beneficial in high risk PCI, does the timing of IABP
placement matter? (i.e., prior to PCI, during PCI after complications
arise, after PCI?)
3. Is anticoagulation necessary when IABPs are in place?
28. IABP: To Anticoagulate or Not?
J Zheijiang Univ Sci 2003 Sep-Oct; 4 (5): 607-611
153 pts with IABP x 48 hrs randomized to IV heparin
or placebo
No difference in limb ischemia, clot on balloon surface
upon removal
Increased major and minor bleeding in heparin group
29. Acute Card Care. 2008
The role of heparin anticoagulation during intra-aortic balloon
counterpulsation in the coronary care unit.
Cooper HA1, Thompson E, Panza JA.
Universal Heparin (n=102) vs Strategic Heparin (n=150) in IABP pts
100% of UH pts and 47% of SH pts received Heparin
Major bleeding 10.8% vs 3.2% (p<0.05) in Universal vs Strategic
group
Bleeding was non-access site related
30. J Card Surg. 2012 Heparin-free management of intra-aortic balloon
pump after cardiac surgery.
Kogan A1, Preisman S, Sternik L, Orlov B, Spiegelstein D, Hod H,
Malachy A, Levin S, Raanani E.
203 pts requiring IABP post-CABG
None treated with Heparin
IABP duration: < 24 hr in 81 pts, > 24 hrs in 122 pts
No major bleeding complications in any pts
31. IABP: To Anticoagulate or Not?
No recommendations by manufacturers
Generally not thought to be necessary if pumping
1:1
Reasonable if during a long wean while pumping 1:2
or 1:3
32. IABP in High-Risk PCI
Is it Useful?
IABP placed for PCI
Brodie AJC 1999
Cardiac arrest decreased by 52%
O’Murchu JACC 1995
Decrease MI in rotational atherectomy
Ohman Circ 1994
Decreased reocclusion of IRA in MI pts
Decreased MACE
33. IABP in High-Risk PCI
IABP placed after PCI
Van’t Hof Eur Heart J 1999
No benefit
PAMI II JACC 1997
No benefit
34. IABP in High-Risk PCI
What if it’s placed before the high risk PCI?
35. IABP in High-Risk PCI
Mishra AJC 2006
300 high risk pts, 69 had IABP inserted
prophylactically
Remaining pts had sheath inserted, leads on chest,
IABP in the room, “on standby”
46 pts needed “rescue” IABP
36. IABP in High-Risk PCI
Prophylactic (69) “Rescue” (46)
In hosp death: 0% 22%
MI: 20% 62%
30 day death: 4% 27%
Mishra AJC 2006
37. IABP in High-Risk PCI
Briguori AHJ 2003
133 pts with LVEF < or = 30%
Prophylactic “Rescue”
Shock: 0% 15%
MACE: 0% 17%
(MI, CABG, Death)
*Prophylactic pts had more high risk characteristics
38. IABP in High-Risk PCI
Prophylactic strategy proven superior to
“standby” strategy in several studies:
SHOCK trial (Death rate 57% vs 72%)1
GUSTO (MACE rate 47% vs 60%)2
NRMI (MACE rate 49% vs 67%)3
1Hochman Circ 1995
2Topol JACC 1995
3Circ 2003
39. IABP in High-Risk PCI?
Briguori AHJ 2006
219 pts with unprotected LM lesions
Prophylactic (69) “Rescue” (150)
Shock: 0% 8%
MACE: 1.5% 9.5%
*Prophylactic pts had more high risk characteristics
40. IABP in High-Risk PCI
A strategy of prophylactic placement of IABP before
high risk PCI appears to be superior to a “rescue”
strategy
If you think you need it, you probably do!
42. N Engl J Med. 2012 Oct 4;367(14):1287-96. doi: 10.1056/NEJMoa1208410.
Epub 2012 Aug 26.
Intraaortic balloon support for myocardial infarction with cardiogenic
shock.
Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M,
Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm M, Ebelt H, Schneider S,
Schuler G, Werdan K; IABP-SHOCK II Trial Investigators.
600 pts with STEMI complicating cardiogenic
shock
Randomized to IABP vs no IABP
Primary endpoint: Mortality
43. 43
“there was no significant difference in mortality between the 37 patients (13.4%) in
whom the balloon pump was inserted before revascularization and the
240 patients (86.6%) in whom the balloon pump was inserted after revascularization”
N Engl J Med. 2012 Oct 4;367(14):1287-96. doi: 10.1056/NEJMoa1208410. Epub 2012
Aug 26.
Intraaortic balloon support for myocardial infarction with cardiogenic shock.
Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G,
Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm
M, Ebelt H, Schneider S, Schuler G, Werdan K; IABP-SHOCK II Trial Investigators.
“In this large, randomized trial involving patients with cardiogenic shock complicating
acute myocardial infarction, for whom early revascularization was planned,
intraaortic balloon pump support did not reduce 30-day mortality.”
44. 44
“In the group assigned to elective IABP treatment, the balloon catheter is inserted at the
start of the procedure, before coronary intervention.”—
BCIS trial investigators
BCIS-1 long term follow up vs IABP-Shock II
(What’s the difference?)
“there was no significant difference in mortality between the 37 patients (13.4%) in
whom the balloon pump was inserted before revascularization and the 240 patients
(86.6%) in whom the balloon pump was inserted after revascularization”---
IABP Shock II investigators
45. IABP: Important Questions:
1) Do we have randomized data?
2) Does it matter if they are placed prior to or after PCI?
3) Is anticoagulation necessary?
Yes, but mostly anecdotal and registry
?
No, if </= 48hrs
47. PROTECT II MACCE**
47
Per Protocol Population, N=426
Log rank test, p=0.04
Death, Stroke, MI,
Repeat revasc. IABP
IMPELLA
48. 48
IABP: Post-Test
• Iliac artery atherosclerosis is an absolute
contraindication for placing an IABP. True or False?
• There is no evidence that systemic anticoagulation is
indicated in patients with an indwelling IABP. True or
False?
• The most common complication of IABPs is related to
balloon rupture/leak. True or False?
49. 49
IABP: Post-Test
• In patients with multiple, critical coronary stenoses and
refractory angina, IABPs are useful to decrease angina.
In such situations the main mechanism of benefit is:
• LV afterload reduction
• Increased coronary perfusion
• Increased peripheral arterial blood pressure
• Increased peripheral arterial “runoff”
50. 50
IABP: Post-Test
• You are about to perform a complex PCI in a patient with
severe LMCA disease and severe LV dysfunction? You
think you may need a balloon pump. How will you
proceed?
• Placing the IABP prior to PCI
• Placing the IABP after PCI
• Having the IABP “ready to go” (in the room, sheath
in groin, IABP EKG leads on pt) in case the patient
“crashes”
51. 51
IABP: Post-Test
• Based on currently available evidence, which of the
following pts would you predict to have the highest risk
for a complication of IABP placement?:
• A morbidly obese (350#) man with diabetes
• A 65 year old man with femoral bruits
• A 90 year old woman that weighs 90 # and suffers
from severe claudication
• A 70 year old man with a small (3.5 cm) AAA
52. 52
IABP: Post-Test
Analyze this aortic pressure waveform in a pt with an IABP in place.
What is the problem? How do you fix it?
53. Conclusions
IABPs are extremely useful in stabilizing pts with complicated
cardiac disease
Risk factors for complications with IABPs are: female sex, PVD,
small BSA, age
Troubleshooting with waveform analysis is critical, and is just as
important as knowing how to insert an IABP
54. Conclusions
Prophylactic insertion of an IABP for hemodynamic support in high
risk PCI pts may be superior to a “rescue” strategy
Controversy has arisen as to the utility of IABPs, but registry data,
randomized data, and anecdotal data can be quoted to support their
benefit.
More studies needed, especially re: impact of timing of placement