IABP

Intra Aortic
Ballon Pumping
 History
1958 Harken described for the first time a
method to treat left ventricular failure

1960s Moulopoulus et al. from the

Cleveland Clinic

1979, a percutaneous placement of the IAB

Coronary Artery Perfusion
Deflate Inflate
S D S D
Deflate Inflate
Arterial Waveform Variation
during IABP
Physiologic Effects of IABP
Physiologic Effects of IABP
Therapy

IAB catheter is placed in the

descending aorta with it`s tip at the
distal aortic arch (below the origin of
the left subclavian artery)
Physiologic Effects of IABP
 Diastolic / inflation

Increase coronary/cerebral perfusion

Potential increase in coronary collateral circulation
Increase coronary/cerebral perfusion
Systolic / deflation

Decrease afterload
Decreased myocardial work & mVO2
Increased stroke volume & Cardiac output
 Indication
bridge to definitive therapy for unstable
patients
cardiogenic shock
unstable angina refractory to medical th/
weaning from CPB
perioperative circulatory support for general
patients
 I A B P Therapy i n S e p s i s

During sepsis, the increased metabolic demands

placed on the heart by hypotension, tachycardia
and often anemia can result in cardiac failure.

For patients not responding to maximal

intravenous therapy, IABP increases coronary
blood flow, reduces left ventricular workload, and
improves tissue perfusion

Intra-aor tic Balloon Pumping Theory and Clinical Applications in the

21st Centur y, a Monograph for the Clinician
J o e l K K a h n , MD, FACC, FSC A I
 I A B P Therapy
in Infants and Children
IABP therapy has been applied to infants and
children with left ventricular dysfunction or complex
cardiac anomalies.

IABP therapy can serve as an alternative to

extracorporeal membranous oxygenation.

Indications include post-cardiac surgery, as a

bridge to cardiac transplant, and as an adjunct to
medicalIntra-aor
therapy to a reversibly failing heart.
tic Balloon Pumping Theory and Clinical Applications in the
21st Centur y, a Monograph for the Clinician
J o e l K K a h n , MD, FACC, FSC A I
 Contra Indication
AI
Aneurysm
Terminal disease
Brain death
Severe coagulopathy
PDA
Relatif Contra Indication
-severe Ao /fem atherosclerosis
-symptomatic PVD
-bilateral FP bypass
-sepsis
Arterial Waveform Variation
during IABP
Early deflate Late deflate

Early inflate Late inflate

 Removal

CO/CI sufficient w/minimal support

Leg ischemia
Baloon malfunction
Infection
 Complication
Insertion
Ao dissect
Arterial perforation
Dislodge Pumping
Limb ischemia
Emboli
Thrombosis
Infection
Ao rupture
Bleeding
Hemodynamic Compr Removal
Obstruction Dislodge
Compartement syndr Bleeding
Infection
Entrapment
 Efficacy and Cost-Effectiveness of Preoperative IABP in Patients with Ejection Fraction of
0.25 or Less
Charles A. Dietl, MD, Marie D. Berkheimer, RN, Edward L. Woods, MD, Christian L. Gilbert,
MD, William F. Pharr, MD, Charles H. Benoit, MD Department of Cardiovascular and Thoracic
Surgery, Geisinger Medical Center, Danville, Pennsylvania

Background. The purposes of this study are to determine whether patients with severe left
ventricular dysfunction benefit from prophylactic insertion of an intraaortic balloon pump and to
evaluate its cost-effectiveness.
Methods. Between January 1991 and December 1995, 163 consecutive patients with a left
ventricular ejection fraction of 0.25 or less underwent isolated coronary artery bypass grafting. An
intraaortic balloon pump was inserted before operation in 37 patients (group A). The remaining
126 patients underwent operation without preoperative insertion of the device (group B).
Preoperatively, 91.9% (34/37) of group A patients and 54.8% (69/126) of group B patients were in
New York Heart Association functional class III or IV (p < 0.001).
Results. The 30-day mortality rate was 2.7% (1/37) and 11.9% (15/126) for groups A and B,
respectively (p < 0.005). All deaths occurred in patients in functional class III or IV. In group B, 28
patients (22.2%) required an intraaortic balloon pump after cardiotomy for low cardiac output,
42.9% (12/28) of whom died. Median postoperative hospital stay was 9.9 days and 12.0 days,
and mean hospital charges were $50,627 and $54,818 for survivors in groups A and B,
respectively (p = not significant).
Conclusions. Our experience suggests that patients with severe left ventricular dysfunction
undergoing coronary artery bypass grafting may benefit from preoperative intraaortic balloon
pump insertion, especially patients in functional class III or IV. This approach improved survival
significantly, reduced hospital stay, and was more cost-effective.
 Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients
JT Christenson, F Simonet, P Badel and M Schmuziger
Cardiovascular Surgery, Columbia Hopital de la Tour, Meyrin-Geneva, Switzerland.

OBJECTIVE: The intra-aortic balloon pump (IABP) is an established additional support to pharmacological
treatment of the failing heart after myocardial infarction, unstable angina and cardiac surgery. The effect of
preoperative IABP in high risk patients was evaluated. METHODS: Between June 1994 and March 1996 all high
risk patients for CABG (two or more of these criteria: Left ventricular ejection fraction (LVEF) < or = 40%, left main
stem stenosis > or = 70%, REDO-CABG, unstable angina) were randomized into either of 3 groups: (1) IABP 1
day prior to surgery, (2) IABP 1-2 h prior to CPB and (3) no preoperative IABP, controls. Exclusion criteria:
cardiogenic shock preoperatively. Fifty-two patients have entered the study-group 1 (13 patients), group 2 (19
patients) and group 3 (20 patients). Preoperative patient characteristics and operative data revealed no group
differences. There were 56% REDO's, unstable angina 59%, LVEF < or = 40%, 87% (34.0 +/- 11.6%) and left
main stem stenosis in 35%. RESULTS: The CPB-time was shorter in groups 1 and 2 88.7 +/- 20.3 min than in
group 3 105.5 +/- 26.8 min, P < 0.001, while ischemia time did not differ. Hospital mortality was higher in group 3,
25% vs. 6% (groups 1 and 2). Postoperative low cardiac output was seen in 12 patients (60%) in group 3 vs. 6
patients (19%) in groups 1 and 2, P < 0.05. Cardiac index increased significantly prior to CPB in groups 1 and 2.
After CPB cardiac index was significantly higher in groups 1 and 2 compared to Group 3 and continued to
increase. The IABP was removed after 3.1 +/- 1.0 days in group 3 vs. 1.3 +/- 0.6 days in groups 1 and 2, P <
0.001. In group 3, 11 patients required IABP postoperatively compared to only 4 patients in groups 1 and 2. ICU
stay was shorter in groups 1 and 2--2.3 +/- 0.9 days vs. 3.5 +/- 1.1 days for group 3, P = 0.004. All patients
received dopamin postoperatively, however in a lower dose in groups 1 and 2, 4.5 vs. 13.5 microg/kg/min.
Dobutamine was added in 23% of the patients (group 1), 32% (group 2) and 95% (group 3). Adrenalin/amrinonum
was required in 40% of the patients in group 3, 5% in group 2 and none in group 1. Group 1 patients had a better
improvement of cardiac performance than group 2, while other parameters did not differ. Three months follow up
of hospital survivors showed no group differences. CONCLUSIONS: The use of preoperative IABP in high risk
patients lowers hospital mortality and shortens the stay in ICU, due to improved cardiac performance, compared
to a controls. The procedure was cost-beneficial. One day preoperative IABP treatment improves cardiac
performance more than 1-2 h preoperative IABP treatment, but does not significantly affect the outcome in terms
of hospital mortality or postoperative morbidity.
Preoperative Intraaortic Balloon Pump Enhances Cardiac Performance and Improves the
Outcome of Redo CABG
Jan T. Christenson, MD, PhD, Pierre Badel, MD, Franois Simonet, MD, Martin Schmuziger, MD
Department of Cardiovascular Surgery, Columbia Hpital de la Tour, Meyrin-Geneva, Switzerland

Background. Reoperative coronary artery bypass grafting (redo CABG) is associated with an increased operative
risk compared with primary CABG. Because the hospital mortality in redo CABG is known to be influenced by
poor left ventricular function (left ventricular ejection fraction 0.40), unstable angina, and left main stem stenosis
greater than or equal to 70%, a preoperative intraaortic balloon pump (IABP) support could be beneficial to
improve the outcome in high-risk redo CABG.
Methods. Between June 1994 and October 1996, 48 high-risk patients underwent redo CABG and were
randomized into the following groups: group 1 (24 patients) who received preoperative IABP treatment on
average 2 hours before cardiopulmonary bypass, and group 2 (24 patients) who received no preoperative IABP
and served as controls. Mean age was 65 years and 90% (43 patients) were men. Forty-one patients had
preoperative left ventricular ejection fraction less than or equal to 0.40 (85%), 38% (18 patients) had left main
stem stenosis greater than or equal to 70%, and 54% (26 patients) had unstable angina preoperatively.
Preoperative patient characteristics did not differ between the groups.
Results. The time on cardiopulmonary bypass was shorter in group 1, 86 versus 110 minutes (p = 0.006). There
were no hospital deaths in group 1, but four deaths occurred in the control group (p = 0.049). Cardiac index rose
significantly preoperatively after introduction of the IABP in group 1. Cardiac index was significantly higher
postoperatively in group 1 compared with group 2 and remained significantly higher during the first 24 hours after
cardiopulmonary bypass. Significantly fewer patients in the IABP group had postoperative low cardiac output (4
versus 13 patients). Nine patients in group 2 required IABP support postoperatively for 4.1 1.7 days. Only 2
patients in group 1 needed IABP postoperatively, and their IABPs were successfully removed on the first
postoperative day. The preoperative IABP-supported patients had a shorter intensive care unit stay, 2.4 0.8
days compared with group 2, 4.5 2.2 days (p = 0.007), as well as a shorter hospital stay. The preoperative IABP
treatment was found to be cost-effective.
Conclusions. Preoperative treatment with IABP in high-risk redo CABG patients is an effective modality to
prepare these patients to have their myocardial revascularization in an as nonischemic situation as possible,
which resulted in a significantly lower hospital mortality, fewer instances of postoperative low cardiac output, and
shorter stays in both the intensive care unit and the hospital.
The Future: Permanent
IABP
The Future:
Portable IABP