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The Internet Journal of Thoracic and Cardiovascular Surgery TM
ISSN: 1524-0274
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Intra Aortic Balloon Pump (IABP) Counterpulsation
P. J Overwalder, M.D.
Department of Surgery I
Division of Cardiac Surgery
University Hospital Graz
P. J Overwalder: Intra Aortic Balloon Pump (IABP) Counterpulsation . The Internet
Journal of Thoracic and Cardiovascular Surgery. 1999. Volume 2 Number 2.
Table of Contents
Physiologic Effects of IABP Therapy
Control of the IABP
Insertion Techniques
Experience at a Single Center
In 1958 Harken described for the first time a method to treat left ventricular failure by
using counterpulsation or diastolic augmentation. He suggested removing a certain blood
volume from the femoral artery during systole and replacing this volume rapidly during
diastole. By increasing coronary perfusion pressure this concept would therefore augment
cardiac output and unload the functioning heart simultaneously 1 , 2 . This method of
treatment was limited because of problems with access (need for arteriotomies of both
femoral arteries), turbulence and development of massive hemolysis by the pumping
apparatus. Even experimental data showed that no augmentation of coronary blood flow
was obtained 3 .
Then in the early 1960s Moulopoulus et al. 4 , 5 from the Cleveland Clinic developed an
experimental prototype of the intra-aortic balloon (IAB) whose inflation and deflation
were timed to the cardiac cycle. In 1968 the initial use in clinical practice of the IABP
and it`s further improvement was realized resp. continued by A. Kantrowiz`s group 6 , 7 .
In its first years, the IABP required surgical insertion and surgical removal with a
balloons size of 15 French. In 1979 after subsequent development in IABP technology a
dramatic headway with the introduction of a percutaneous IAB with a size of 8,5 to 9,5
French was achieved 8 , 9 . This advance made it for even nonsurgical personnel possible,
to perform an IAB insertion at the patient’s bedside. In 1985 the first prefolded IAB was
Today continued improvements in IABP technology permit safer use and earlier
intervention to provide hemodynamic support. All these progresses have made the IABP
a mainstay in the management of ischemic and dysfunctional myocardium.
Physiologic Effects of IABP Therapy
After correct placement of the IAB in the descending aorta with it`s tip at the distal aortic
arch (below the origin of the left subclavian artery) the balloon is connected to a drive
console. The console itself consists of a pressurized gas reservoir, a monitor for ECG and
pressure wave recording, adjustments for inflation/deflation timing, triggering selection
switches and battery back-up power sources. The gases used for inflation are either
helium or carbon dioxide . The advantage of helium is its lower density and therefore a
better rapid diffusion coefficient. Whereas carbon dioxide has an increased solubility in
blood and thereby reduces the potential consequences of gas embolization following a
balloon rupture.
Inflation and deflation are synchronized to the patients’ cardiac cycle. Inflation at the
onset of diastole results in proximal and distal displacement of blood volume in the aorta.
Deflation occurs just prior to the onset of systole (Fig. 1) .
Figure 1: Intra aortic balloon (IAB) during systole and diastole
The primary goals of IABP treatment are to increase myocardial oxygen supply and
decrease myocardial oxygen demand. Secondary, improvement of cardiac output (CO),
ejection fraction (EF), an increase of coronary perfusion pressure, systemic perfusion and
a decrease of heart rate, pulmonary capillary wedge pressure and systemic vascular
resistance occur 10 , 11 , 12 (Tab.1)
There are several determinants of oxygen supply and demand (Tab.2).
Table 1: Hemodynamic effects of IABP Therapy
Table 2: Determinants of Myocardial Oxygen Supply and Demand
In particular systolic wall tension uses approximately 30% of myocardial oxygen
demand. Wall tension itself is affected by intraventricular pressure, afterload, enddiastolic volume and myocardial wall thickness. Regarding to the studies of Sarnoff et al.
the area under the left ventricular pressure curve, TTI (= tension-time index ), is an
important determinant of myocardial oxygen consumption 13 . On the other hand, the
integrated pressure difference between the aorta and left ventricle during diastole (DPTI
= diastolic pressure time index) represents the myocardial oxygen supply (i.e.
hemodynamic correlate of coronary blood flow) 14 , 15 .
Figure 2: Schematic representation of coronary blood flow, aortic and left
ventricular pressure wave form with / without IABP. (Effects on DPTI and TTI .
Balloon inflation during diastole augments diastolic pressure and increases
coronary perfusion pressure as well as improving the relationship between
myocardial oxygen supply and demand (DPTI:TTI ratio)
a) Inflation of the balloon during diastole (= augmentation of the aortic diastolic
pressure) increases coronary blood flow ( DPTI ).
b) Deflation of the balloon occurs just prior to the onset of systole and reduces
impedance to left ventricular ejection (TTI ). This results in less myocardial work,
decreased myocardial oxygen consumption and increased cardiac output 16 .
Control of the IABP
To achieve optimal effect of counterpulsation, inflation and deflation need to be correctly
timed to the patient’s cardiac cycle. This is accomplished by either using the patient’s
ECG signal, the patient’s arterial waveform or an intrinsic pump rate. The most common
method of triggering the IAB is from the R wave of the patient’s ECG signal. Mainly
balloon inflation is set automatically to start in the middle of the T wave and to deflate
prior to the ending QRS complex. Tachyarrhythmias, cardiac pacemaker function and
poor ECG signals may cause difficulties in obtaining synchronization when the ECG
mode is used. In such cases the arterial waveform for triggering may be used.
It is important that the inflation of the IAB occurs at the beginning of diastole, noted on
the dicrotic notch on the arterial waveform. Deflation of the balloon should occur
immediately prior to the arterial upstroke. Balloon synchronization starts usually at a beat
ratio of 1:2. This ratio facilitates comparison between the patient’s own ventricular beats
and augmented beats to determine ideal IABP timing. Errors in timing of the IABP may
result in different waveform characteristics and a various number of physiologic effects
(Fig. 3).
Figure 3: Arterial pressure wave form alterations associated with inflation and
deflation of the IAB
If the patient’s cardiac performance improves, weaning from the IABP may begin by
gradually decreasing the balloon augmentation ratio (from 1:1 to 1:2 to 1:4 to 1:8) under
control of hemodynamic stability . After appropriate observation at 1:8 counterpulsation
the balloon pump is removed.
Indications and Contraindications (Table 3)
Early purposed indications for intraaortic balloon pumping have included cardiogenic
shock or left ventricular failure, unstable angina, failure to separate a patient from
cardiopulmonary bypass and prophylactic applications, including stabilization of
preoperative cardiac patients as well as stabilization of preoperative noncardiac surgical
patients 10, 17 , 18 , 19 , 20 , 21 . Today more extending indications are: Cardiac patients
requiring procedural support during coronary angiography and PTCA, or as a bridge to
heart transplantation. Further on in pediatric cardiac patients and as well as in patients
with stunned myocardium, myocardial contusion, septic shock and drug induced
cardiovascular failure the IABP can be life-saving 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31
IABP therapy should only be considered only for use in patients who have the potential
for left ventricular recovery, or to support patients who are awaiting cardiac
transplantation. Absolute contraindications of IABP are relatively few (Tab.3). There are
successful reports of its usage in patients with aortic insufficiency 32 , 33 and in patients
with acute trauma to the descending aorta 34 .
Table 3: IABP Counterpulsation Indications and Contraindications
Insertion Techniques
In the early years of IABP - therapy, insertion of the balloon was performed by surgical
cut down to the femoral vessels. After a longitudinal incision in the groin, the femoral
arteries were identified and controlled. A vascular graft was then sewn to the common
femoral artery in an end-to-side fashion. The balloon was introduced into the artery via
the graft and properly positioned in the thoracic aorta and the graft tightly secured to the
distal portion of the balloon catheter. Finally the skin incision was closed. Removal of the
balloon required a second operation.
Since 1979, a percutaneous placement of the IAB via the femoral artery using a modified
Seldinger technique allows an easy and rapid insertion in the majority of situations. After
puncture of the femoral artery a J-shaped guide wire is inserted to the level of the aortic
arch and then the needle is removed. The arterial puncture side is enlarged with the
successive placement of an 8 to 10,5Fr dilator/sheath combination. Only the dilator needs
to be removed.
Continuing, the balloon is threaded over the guide wire into the descending aorta just
below the left subclavian artery. The sheath is gently pulled back to connect with the
leak-proof cuff on the balloon hub, ideally so that the entire sheath is out of the arterial
lumen to minimize risk of ischemic complications to the distal extremity. Recently
sheathless insertion kits are available. Removal of a percutaneously placed IAB may
either be via surgical removal or closed technique. There are alternative routes for
balloon insertion. In patients with extremely severe peripheral vascular disease or in
pediatric patients the ascending aorta or the aortic arch may be entered for balloon
insertion 35 , 36 . Other routes of access include subclavian, axillary or iliac arteries 37 , 38 , 39 .
Although the incidence of complications has decreased significantly as experience with
the device has increased, IABP therapy in today’s patients` population does still hold a
risk for complications (Tab.4). Because today’s patient population is elderly (68 - 80
years), very often female and may suffer from severe peripheral vascular disease and
hypertension or diabetes. The most common vascular complication is limb ischemia. It
may occur in 14-45% of patients receiving IABP therapy 40 , 41 . Therefore the patient must
be consistently observed for any symptoms of ischemia during IABP counterpulsation. If
signs of ischemia appear the balloon should be removed. In general, vascular injuries
should be dealt with directly by surgical interventions and repair. Balloon related
problems and infection require removal and / or replacement of the IAB .
Table 4: Complications of IABP counterpulsation
Experience at a Single Center
Treatment of low cardiac output syndrome using IABP counterpulsation has been used at
our institution since 1983. Till December 1993 a total number of 440 patients (pts)
(9,95%) out of 4420 patients, who underwent cardiac surgery procedures with the use of
cardiopulmonary bypass, were supported with an IABP.(Age distribution : Tab. 6) There
were 294 male and 146 female patients. Overall survival rate after implantation of the
IABP was 75% (n=330 pts) .
Table 5: Diagnosis prior to IABP implantation
Table 6: Age Distribution of IABP patients
In the early years (1983-1989) as method of choice, implantation of the balloon was
performed via a surgical cut down of the femoral artery. Complications were observed in
20 pts (8.4%) : In 9 pts (3.7%) positioning of the balloon was impossible due to severe
vascular disease, 5 pts (2.1%) developed a thrombosis of the femoral artery and 1 patient
(0.4%) died because of untreatable thrombosis of the mesenteric artery. Hospital
mortality in this group was 36% (survival rate of 64%). Mean pumping time was 3 days
(1 - 15).
Since 1990 we prefer the percutaneous insertion of the device. After a learning curve
more than 90% of 202 patients received an IABP using this technique. Complication rate
was less than 8% (mainly leg ischemia with amputation of the leg in 1 patient, 3
infections of the puncture point and 4 cases of impossible positioning of the balloon ).
Survival rate was 68.5% (hospital mortality of 31.5%) . 278 pts (63%) received the
balloon pump at the operating theater - mainly because of failure to wean from
cardiopulmonary bypass -151 pts (34,3%) at an intensive care unit and 11 pts (2,5%) as a
bridge to transplant. Table 6 shows a detailed list of all various diagnoses prior to IABP
therapy .
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