Intra-aortic balloon counterpulsation (IABP) provides temporary circulatory support through systolic unloading and diastolic augmentation. It increases coronary perfusion and decreases myocardial oxygen demand, and is used in patients with cardiogenic shock. Indications include cardiogenic shock, high-risk PCI, and post-cardiotomy shock. Contraindications are severe aortic insufficiency or aneurysm. The IABP catheter is inserted via the femoral artery and connected to a console for inflation and deflation. Waveform analysis ensures proper timing and augmentation.

1. Dr Sajeer KT
Senior Resident
Dept.of Cardiology, MCH Calicut
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Intra aortic balloon counter pulsation( IABP):
Most common and widely available methods of mechanical
circulatory support
Temporary support for the left ventricle by mechanically
displacing blood within the aorta
Concepts:
- Systolic unloading
- Diastolic augmentation
Traditionally used in surgical and non surgical patients
with cardiogenic shock

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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

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

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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

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Interpreting IABP waveforms

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IABP –instrumentation and
techniques

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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

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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

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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%

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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.

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Intra Aortic Balloon

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IABP sizing chart

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

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

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Intraaortic balloon

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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

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Before taking the Catheter out of Tray

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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

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• 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

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- 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

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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

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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)

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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)

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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

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Increased coronary
perfusion
The “normal” augmented waveform

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

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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

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

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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.

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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

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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

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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

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

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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

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

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

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

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

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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

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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

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“Balloon too
large”
syndrome

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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°.

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 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

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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

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IABP Removal
-Discontinue heparin 1 hour 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.

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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
67

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
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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 %
69

70. 4. late inflation of the balloon can result in?
A) premature augmentation
B) increased augmentation
C) decreased augmentation
D) increased coronary perfusion
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71. 5. A rounded balloon pressure wave form
indicate?
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the aorta
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72. 6. width of balloon pressure wave form
corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) helium level
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73. 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
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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
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75. 9. Identify the tracing abnormality
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76. 10. Identify the tracing abnormality
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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
77

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

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

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

83. 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

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
84

85. 9.
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86. 10.
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