This is a concise presentation on IABP. I tried to cover almost all possible information on IABP.

1. INTRA AORTIC
BALLOON PUMP
Dr. Soham J Shah KEM,
Hospital Mumbai

2. Points for discussion :
1. History
2. Principles of IABP function
3. Physiology and Pathophysiology of IABP
4. Indications and Contraindications
5. Anatomy of device
6. Techniques of insertion, complications
and removal
7. References
8. Video presentation.

3.  ADRIAN
KANTROVITZ
 Started experiments
on DIASTOLIC
AUGMENTATION at
Western Reserve
University as a
research fellow
(1952) in the
Department of
Cardiovascular
Physiology under
Dr.Carl Wiggers.

4.  In 1958, Harken :
 “Removal of some of
the blood volume via
the femoral artery
during systole and
replacing it rapidly in
diastole, so called
diastolic augmentation
as a treatment for left
ventricular failure.

5. S.MOULOPOULOS
& team (1962)
At Cleveland clinic , conducted
preliminary studies with latex
tubing tied around the end of
polyethylene catheter with
multiple side holes.
The tubing,catheter and balloon
formed a closed system that was
filled with CO2.
Stroke was triggered with the aid
of ECG.

6.  Moulopoulos and colleagues developed a
prototype in which IABP inflation and deflation
were timed to the cardiac cycle.

7. In 1967 Adrian Kantrowitz after gaining enough experience in
animal experiments, He identified that the use of helium as the
shuttle gas gave sufficient transit speed to assure appropriate
timing.
“ On June 29, 1967, 45-year-old woman who was comatose,
anuric, cold, and cyanotic , her blood pressure was
unobtainable. The patient was clearly near death.“
They inserted the balloon pump and she was pumped for about
7 hours, her condition stabilized, and the pump was removed.
The patient recovered and was subsequently discharged from
the hospital.

8. Contibutors
BUKLEY et al- Balloon inflation in diastole
augments coronary perfusion and deflation just
before systole markedly reduces resistance to the
left ventricular ejection and thereby reduces cardiac
work and myocardial o2 consumption.
In 1973 two different groups headed by
Buckley.M.J & Housman LB, reported the
successful utilization of IABP in patients who
were unable to be weaned from
cardiopulmonary bypass.

9. MUNDTH & coworkers:Reported a patient who sustained
cardiogenic shock following myocardial infarction and was
stabilised with IABP and subsequently underwent coronary
revascularisation with the support of the balloon pump and
had an uneventful recovery. This was the first report where
the application of the IABP extended successfully to
support heart failure post coronary artery surgery.

10. Percutaneous insertion (1980)
 Bregman D, Casarella WJ.
First Percutaneous insertion of intra-aortic balloon pump:
Initial clinical experience. Ann Thorac Surg
 Subramanian VA et al.
Preliminary clinical experience with percutaneous intra-aortic
balloon pumping.
The first prefolded IAB was developed in 1986.

11. 2
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

12. Physiologicaleffects of IABPtherapy
• The primary goal of IABP treatment is to improve the
ventricular performance of the failing heart by
facilitating an increase in myocardial oxygen supply
and a decrease in myocardial oxygen demand.

13. • IABP inflates at the onset of diastole, thereby
increasing diastolic pressure and deflates just before
systole, thus reducing LV afterload. Increases coronary
perfusion

14.  Primary effect of IABP
1) Increase myocardial oxygen supply
2) Decrease myocardial oxygen demand
 Secondary effect of IABP
1) Increase in cardiac output
2) Increasing in MAP that will lead to
improvement of perfusion to all organ
3) Increases LV ejection

15.  Effects on other systems
 Renal = increases renal perfusion and urine
output
 Neurological= increasing cerebral perfusion
and enhancing neurological state
 Vascular- increases peripheral perfusion

16. Basicprinciples of counterpulsation
• Counterpulsation (augmentation) is a term that
describes balloon inflation in diastole and deflation
in early systole.
• Balloon inflation causes ‘volume displacement’ of blood
within the aorta, both proximally and distally. This
leads to a potential increase in coronary blood flow
and potential improvements in systemic perfusion by
augmentation of the intrinsic ‘Windkessel effect

19. 3
Indications for IABP
1. Cardiogenic shock:
- Associated with acute MI
VSR, Ischaemic MR
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

20. 4

21. CONTRAINDICATIONS
Absolute-
▫ Significant aortic regurgitation
▫ Aortic dissection
▫ Aortic stents
Relative -
▫ Severe atherosclerosis
Abdominal aortic aneurysm
▫ Uncontrolled septicemia
▫ Uncontrolled bleeding diathesis
▫ Severe bilateral peripheral vascular disease

23. Working principles of IABP
• Balloon pump device
• Insertion of IABP
• Position of balloon
• Effects of IABP
• Management of IABP
• Troubleshooting
• Weaning & Removal

24. 11
The Device

27. THE DEVICE
 Monitor system

29. 17
Introducer needle
• Guide wire
• Vessel dilators
• Sheath
• IABP (34 or 40cc)
• Gas tubing
• 60-mL syringe
• Three-way stopcock
IABP Kit Contents

34. 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.

35. Intra Aortic Balloon Catheter

36. Tip

37. 15
Balloon sizing
Sizing based on patients
height
Four common balloon
sizes
Balloon length and
diameter increases with
each larger size
40 cm³ balloon is most
commonly used
Paediatric balloons also
available : sizes 2.5, 5.0,
12.0 and 20 cm³
Balloon size Height
50 cm³ > 6 feet
40 cm³ 5 feet 4 inch
to 6 feet
34 cm³ 5 feet to 5
feet 4 inch
25 cm³ < 5 feet

39. Insertion
 1) Percutaneous insertion
via trans Femoral, Axillary, Brachial and Radial
approach
 2) Femoral artery cutdown insertion
 3) Intraoperatively insertion through Ascending
aorta (Transthoracic insertion)

40. Insertion
Majority by femoral artery
by Seldinger technique
Alternatively
•Ascending aorta
•Axillary artery
•Brachial artery
•Radial artery

43. 18
Connect ECG
Set up pressure lines
Femoral access – followed by insertion of the supplied
sheath
IABP insertion

44. 19
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

47. 22
Connecting to console:
- 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 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

48. 24

49. POSITION OF IABP
The tip should be
situated distal to left
subclavian artery
take off.
On chest radiography
optimal position will be
level of the carina or
b/w the 2nd and 3rd
intercostal spaces.
Too far— subclavian &
vertebral occlusion
Too low— mesenteric
& renal ischemia

51. 1) ECG signal – most
common
• Inflation
- middle of T wave
• Deflation
– peak of R wave

52. 1) ECG
2) Pressure wave
3) Internal
4) Pacer V/AV
5) Pacer A

53. Modes of operation

57. The normal IABP blood pressure
waveform

59. TIMING

62. The “normal” augmented waveform
Increased coronary
perfusion

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

64. How to check waveform is acceptable ?
Check the dicrotic notch
See if augmentation starts at that point
This should produce a sharp “V” at inflation.
and diastolic augmented wave > Systolic
wave.

65. Timing Errors

73. “Balloon too
large”
syndrome

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

78. IMP management during IABP

79. Never leave in standby by mode for more than 20 minutes >
thrombus formation
Patient Management During IABP
support

80. Complications
• Limb ischemia
• Bleeding at insertion site
• Infection
• Aortic dissection – tearing aorta during ballon
insertion
• Thromboembolism

81. • Reducing urine output
• Balloon catheter rupture and gas loss
• Hemolysis
• Thrombocytopenia

83. 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
-ABG,Urine output, blood
pressure should be good
– If patient becomes unstable, weaning should be
immediately discontinued

84. Weaning

85. Controversies
 There has been different schools of thought
regarding weaning methods
 Volume vrs Ratio .. Which is better ?
 Ratio – reduction in augmention from 1:1 to
1:2 for 4 hours then 1:3 for one hour then
removal
 Volume – 10% of volume reduction every hour
for 5 hours then removal.

86.  Few papers have published regarding weaning
which is better includes
1. Onarati et al (2013) Italy sample size -30
2. Tokita et.all (2014) USA, sample size- 30
3. Hsin et al. (2013) Taiwan sample size -85
4. Bigmani et al. (2012) Italy
5. Lewis et al. (2006) Australia – says Volume
weaning is better
6. Manohar et al (2012) USA sample size 429

87.  The inference from all above mentioned
papers is There has been no clear evidence
regarding which method is superior in weaning
from IABP still inconclusive.

89.  Impella Vrs IABP
 1) Impella vrs IABP in acute MI . Brunilda
Alushi et.all Germany
 2) Impella vrs IABP in acute MI. Abdelmoniem
Moustafa et.all USA
 Impella is asssociated with higher incidence of
bleeding, limb compliocations, hemolysis.

90. Video Presentation

91. References
 Cardiopulmonary bypass priciples and techniques- Amman Jordan
 Manual of perioperative care in cardiac surgery- Robert M.Bojar
 Oxford handbook of cardiac surgery
 Sabiston Spencer book of cardiac surgery
 IABP: history-evolution pathophysiology indications:what we need
to know H. Parissis, V. Graham*et al.
 A prospective randomized study comparing surgical and
percutaneous removal of intraaortic balloon pump Michael J. Rohrer
et al.
 Percutaneous Intraaortic Balloon pumping: Initial Clinical
Experience.. David Bregman, M.D., and William J. Casarella, M.D.
 Intra-aortic balloon pump postcardiac surgery: A literature review
Mansour Jannati et al.
 Intra-aortic balloon pump in CABG – Factors affecting outcome Okonta KE,
*Kanagarajan N, Anbarasu M.

92. Thank you.