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Table of Contents
History
Physiologic Effects of IABP Therapy
Control of the IABP
Insertion Techniques
Complications
Experience at a Single Center
References
History
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 , . This method of
1 2
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. , from the Cleveland Clinic developed an
4 5
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 , . This advance made it for even nonsurgical personnel possible,
8 9
to perform an IAB insertion at the patient’s bedside. In 1985 the first prefolded IAB was
developed.
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.
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) .
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
TRIGGERING
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, , , , , . Today more extending indications are: Cardiac patients
17 18 19 20 21
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 , and in patients
32 33
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 , . Other routes of access include subclavian, axillary or iliac arteries , , .
35 36 37 38 39
Complications
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 .
References
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Belgium
3. Dormandy JA, Goetz RH, Kripke DC (1969) Hemodynamics and coronary blood flow
with counterpulsation. Surgery 65: 311
6. Kahn JK, Rutherford BD, McConahay DR (1990) Supported High Risk coronary
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12. Akyurekli Y, Taichmann JC, Keon WJ (1980) Effectivness of intra aortic balloon
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13. Pennington DG, Swartz MT (1990 ) Mechanical circulatory support prior to cardiac
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14. Grotz RL, Yeston NS (1989) Intraaortic balloon counterpulsation in high risk cardiac
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