Treatments

Intra-Aortic Balloon Pump (IABP)

The Intra-Aortic Balloon Pump, commonly called IABP, is a catheter-based procedure for patients with severe heart disease (e.g. heart attack, heart failure, etc.) or for patients waiting for a heart transplant. Because it is easy to insert, the IABP is the most widely used form of mechanical circulatory support.

Hospital Stay: Hospital Stay: 2 days
Duration: Duration: 4 hrs
Cost Estimate: Cost Estimate: 1125 USD - 4395 USD These are indicative prices in Indian Hospitals

The procedure requires placement of an intra-aortic balloon catheter into an artery, usually in the groin (the femoral artery) and then advanced into the largest artery in your body, the aorta. Next, the intra-aortic balloon catheter is connected to a machine, called an IABP. The IABP is used to control the inflation/deflation and timing, so that the intra-aortic balloon will inflate when the heart muscle relaxes and deflate just before the heart pumps again. This process is called “counterpulsation.”
The IABP, which is at the bedside, inflates the intra-aortic balloon within the aorta when the heart is relaxed. This allows the heart to receive more oxygen-rich blood without working so hard. Then, just before the heart gets ready to pump this oxygenated blood, the pump deflates the intra-aortic balloon. This creates a drop in the pressure within the aorta, assisting the heart by reducing the amount of work on the heart, so the heart can pump the blood more easily throughout the body.
Once the heart stabilizes and can function properly on its own, the intra-aortic balloon catheter is removed, and pressure is applied to the insertion site to stop bleeding.
Although the IABP was first used for surgical patients, the pump can now be used along with interventional cardiology procedures and medical therapy (medications). The IABP is typically used for the following situations:

  • During emergency situations, including heart attack and heart failure.
  • During severe angina episodes.
  • Before, during, or after open-heart surgery (in certain patients only).
  • Before, during, or after balloon angioplasty (in certain patients only).
  • During the waiting period for a donor heart for heart transplantation.

Support during high-risk percutaneous transluminal coronary (balloon) angioplasty, rotoblator procedures, and coronary stent placement.

The device consists of a catheter introduced via the femoral artery, which extends retrogradely to the proximal descending thoracic aorta. A balloon is located at the end of the catheter, spanning 26-28cm in length, which is rapidly inflated at the beginning of diastole and rapidly deflated at the end of diastole. The balloon is inflated with carbon dioxide.
As the balloon forcibly inflates it displaces blood both forwards and backwards, known as diastolic augmentation. As such it provides not only additional forward momentum to the blood in the distal descending aorta but more importantly increases perfusion to the vessels arising from the arch of the aorta, most importantly the coronary arteries which are perfused primarily during diastole 1-2.
This has a dual effect: firstly it decreases left ventricular afterload, decreasing myocardial(heart muscle) oxygen requirements, and secondly increases myocardial perfusion (during diastole)

The Pump

The IABP is a polyethylene balloon mounted on a catheter, which is generally inserted into the aorta through the femoral artery in the leg. The pump is available in a wide range of sizes (2.5 cc to 50 cc) that will fit patients of any age and size. The balloon is guided into the descending aorta, approximately 2 cm from the left subclavian artery. At the start of diastole, the balloon inflates, augmenting coronary perfusion. At the beginning of systole, the balloon deflates; blood is ejected from the left ventricle, increasing the cardiac output by as much as 40 percent and decreasing the left ventricular stroke work and myocardial oxygen requirements. In this manner, the balloon supports the heart indirectly.
The balloon is inflated with helium, an inert gas that is easily absorbed into the bloodstream in case of rupture. Inflation of the balloon can be triggered according to the patient’s electrocardiogram, their blood pressure, a pacemaker (if they have one), or by a pre-set internal rate.

The Console

The IABP is driven by the balloon pump console. The operating controls are located on a touch pad below the display monitor and can be programmed to produce rates as high as 140 beats per minute. The on-board battery provides power for up to 2 hours.

Technique:

Device insertion
In modern usage, intra-aortic balloon counterpulsation is performed with a polyethylene balloon mounted on a flexible catheter positioned 1-2 cm below the origin of the left subclavian. The shaft of the balloon catheter contains 2 lumens: one allows for gas exchange from console to balloon; the second is used for catheter delivery over a guide wire and for monitoring of central aortic pressure after installation.
Balloon inflation is performed using helium, which, owing to its low density, can be rapidly exchanged through the tubing and catheter to allow for rapid balloon inflation and deflation during the cardiac cycle.
Insertion is generally performed via either one of the femoral arteries using a standard percutaneous Seldinger technique over a 0.030-inch guidewire provided with the balloon catheter.
The device catheter can be introduced via a sheath. A sheathless approach can also be used in patients with peripheral vascular disease. The sheathless method has been shown to reduce limb ischemia, but the risk of infection and minor bleeding is increased with this method.
McBride et al described the insertion of an intra-aortic balloon pump (IABP) catheter via the axillary artery to allow for more patient mobility. This is performed via a cutdown, often using a 6-12 mm GoreTex or Dacron sleeve sewn onto the axillary artery to facilitate introduction of the device.
An IABP device can also be inserted via the brachial artery or subclavian artery or, during open-heart surgery, directly into the ascending or thoracic aorta.

Initial set-up and troubleshooting

Following installation, the balloon catheter is connected to the console and the system is purged with helium. The central lumen of the catheter is connected to pressure tubing and a pressure transducer to allow for monitoring of central aortic pressure.
Heparin should be given as a bolus and continuous infusion to maintain a partial thromboplastin time (PTT) of 60-80 seconds or an activated clotting time (ACT) of 1.5-2.0 times normal.
An appropriately timed IABP will effectively lower impedance to left ventricular (LV) ejection and augment diastolic pressure. However, improper timing can lead to inefficient LV support or counteract the intended purpose of therapy.

The IABP has two parts:

  1. a large bore catheter with a long sausage-shaped balloon at the distal tip, and
  2. a console containing a pump that inflates the balloon.

The balloon is designed to sit in the proximal descending aorta. It comes in various lengths according to body height, with balloon volumes of about 30-50 ml. The balloon is usually filled with helium gas, and when inflated should fill up 80-90% of the aortic diameter. The IABP works by inflating and deflating at different phases of the cardiac cycle. Balloon inflation augments diastolic blood pressure and balloon deflation decreases afterload during systole.
Balloon inflation in early diastole (usually triggered by the R wave on the ECG) increases diastolic blood pressure. This in turn increases systemic perfusion and coronary perfusion (at least in the hypotensive patient). Balloon inflation thus displaces blood both proximally and distally. The increase in coronary perfusion increases myocardial oxygen supply.
Balloon deflation occurs at the end of diastole resulting in a decreased end diastolic blood pressure. This reduces the aortic pressure at the start of systolic ejection, thus decreasing the afterload that the heart has to pump against. This decreases myocardial oxygen demand and improves systemic perfusion during systole.

The IABP can be used whenever there is cardiac pump failure if:

  • It may resolve spontaneously, or
  • A corrective procedure is planned.

In other words, there has to be some hope of the patient being able to survive without an IABP in the future.

Some situations where an IABP is used include:

  • Cardiogenic shock after coronary artery bypass grafting (CABG) or acute myocardial infarction
  • Unstable angina
  • Acute mitral incompetence
  • Planned cardiac transplant
  • Ventricular arrhythmias refractory to conventional treatment
  • Cardiotoxicity from poisoning, e.g. verapamil overdose

IABPs are usually inserted using the Seldinger technique via the femoral artery so that the tip of the catheter is advanced proximally into the aorta. Fluoroscopy is not essential for insertion, so an IABP can be placed emergently.

IABP’s must be appropriately positioned:

  • The balloon tip is positioned just distal to the origin of the left subclavian artery, and the entire balloon should lie above the renal arteries.

Contra-indications include:

  • Aortic insufficiency
  • Aortic dissection
  • Patent ductus arteriosus
  • Severe peripheral vascular disease
  • Thoracic aortic graft <12 months old
  • The patient’s cardiac index is too low for there to be a clinical benefit from IABP assistance

IABP efficiency is determined by:

  • Timing of balloon inflation and deflation
  • Assist ratio
  • Heart rate (efficiency is greatly decreased at heart rates >130/min)
  • Gas loss from balloon (balloon volume)
  • Minimum cardiac index of 1.2 – 1.4 L/min/m2 is required for IABP assistance to be clinically beneficial

Optimization can be achieved by ensuring that:

  • Inflation of the balloon occurs at the dicrotic notch (forming the sharp ‘V’)
  • The slope of rise of augmented diastolic waveform is straight and parallel to the systolic upstroke
  • The augmented DBP at balloon deflation exceeds or is equal to end-systolic BP
  • The end-diastolic BP at balloon deflation is lower than the preceding unassisted end-DBP by 15-20 mmHg
  • The assisted SBP (following a cycle of balloon inflation) is lower than the previous unassisted SBP by 5 mmHg

Complications can occur during insertion, while the IABP is in use, during removal, or after removal.
During insertion

  • Failure to advance catheter beyond iliofemoral system because of atherosclerotic disease (common)
  • Aortic dissection and arterial perforation – may cause retroperitoneal hemorrhage.

During use

  • Ischemia
    • Ischemia of the lower limbs (up to 25% of all IABP patients)
      • May occur while the IABP is in place, or hours after removal due to thromboembolic showers
      • Ischemia usually results from thrombosis at the insertion site
      • Can affect contra-lateral leg due to cholesterol emboli and thromboembolic showers from the balloon
      • Close neurovascular monitoring essential – sensorimotor loss generally mandates removal
      • Pulseless limb may need to be tolerated if IABP is life-saving
    • Visceral ischemia
    • Spinal ischemia
  • Balloon rupture causing helium embolus
    • This may be heralded by high balloon inflation pressures.
    • The key indicator of balloon rupture is the presence of blood in the connecting tubing.
    • Management involves immediate cessation of counterpulsation, placement of the patient head down and IAB removal.
    • Consider giving broad spectrum antibiotics as the gas chamber of the balloon is not sterile.
  • Hemolysis and consumptive thrombocytopenia
  • Peripheral neuropathy
  • Catheter-related infection
  • Small perforation in balloon membrane
    • This may allow a small amount of blood to leak into balloon lumen.
    • The blood is dessicated by the dry helium and forms a hard pellet which may stop the balloon from being removed without surgical aortotomy.

During or after removal:

  • Haematoma
  • Pseudoaneurysm
  • AV fistula
  • Entrapment of the IABP

The intra-aortic balloon pump insertion is usually done in the Heart & Vascular Hospital Cardiovascular Lab. Occasionally, it is performed in the Operating Room (OR) or the Intensive Care Unit (ICU).

The placement of the IABP takes about 30 minutes. The catheter and IABP are then left in place until they are no longer needed – usually a few days.

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