1) Intra-aortic balloon counterpulsation (IABP) provides systolic unloading and diastolic augmentation to improve cardiac output. 2) IABP is indicated for cardiogenic shock, high-risk PCI/CABG, and mechanical complications. 3) Potential complications include limb ischemia, infection, bleeding, and aortic injury. 4) Optimal IABP waveform analysis and timing are important to maximize hemodynamic support.

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

2. Intra aortic balloon counter pulsation( IABP):
Concepts:
- Systolic unloading
- Diastolic augmentation

4. Indications for IABP
1. Cardiogenic shock:
2. In association with CABG :
Preoperative insertion
- Patients with severe LV dysfunction
- Patients with intractable ischemic arrhythmias
Postoperative insertion
- Postcardiotomy cardiogenic shock
- Associated with acute MI
- Mechanical complications of MI - MR , VSD
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

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

7. 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)
Cardiac cycle

13. Interpreting IABP waveforms

14. IABP –instrumentation and
techniques

15. The IAB Counter pulsation system
 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.

17. 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

18. 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%

20. 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.

21. Intra Aortic Balloon

22. IABP sizing chart

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

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

25. Intraaortic balloon

26. 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)
STEP BY STEP- IABP insertion

27. Before taking the Catheter out of Tray

28. 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

29. ●
• 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
Inserting the Balloon catheter
- Many vascular complications occur during insertion itself
- Resistance during insertion either indicates PVOD, or dissection
- Kinking of IABP » improper inflation/deflation

30. - 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
Positioning

31. 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

33. 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)

34. 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)

35. 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
Initial settings

40. Increased coronary
perfusion
The “normal” augmented waveform

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

42. 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

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

45. 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.

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.
 Check if diastolic augmented wave is › systolic wave

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
 Confirm if end diastolic wave
following the augmented wave
is less than an non augmented
wave.
 Is Deflation slope ok

49. 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

50. Early Deflation
 Premature deflation of the IAB during the diastolic phase.

51. 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

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

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

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

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

57. 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

58. 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

59. “Balloon too
large”
syndrome

60. 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°.

61.  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
Patient Management During IABP support

63. 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

64. 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.

65. Thank you

66. • 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

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

68. 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 %

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

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

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

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

73. 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

74. 9. Identify the tracing abnormality

75. 10. Identify the tracing abnormality

76. • 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

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

78. 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 %

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

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

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

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

83. 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

84. 9.

85. 10.