Guidelines for intraaortic balloon counterpulsation

1. G
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FO
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A
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B
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LSATIO
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B
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. A
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2. GUIDELINES FOR MANAGEMENT
OF DECOMPENSATED LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
If drug therapy fails:
• IABP
• ECMO
• VAD
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;19:278-292.

3. INTRAAORTIC BALLOON
COUNTERPULSATION
Indications:
• Cardiogenic shock
• Postcardiotomy LV systolic failure unresponsive to inotropes
• Persistent myocardial ischemia (preop or postop)
• Complications of acute MI
• Preoperative IABP (high-risk patients)
• Support for high-risk catheterization or failed PCI
• Cardiac support during non-cardiac surgery
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

4. INTRAAORTIC BALLOON
COUNTERPULSATION
Physiologic effects:
• Diastolic aortic pressure ↑
• Coronary blood flow ↑
• Myocardial oxygen delivery ↑
• LV wall tension & afterload ↓
• Myocardial oxygen consumption ↓
• Stroke volume ↑
• Cardiac output ↑
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

5. INTRAAORTIC BALLOON
COUNTERPULSATION
Contraindications:
• Severe aortic insufficiency
• Aortic aneurysm
• Aortic dissection
• Descending thoracic aortic atheroma
• Aorto-iliac-femoral occlusive disease
• Lower extremity ischemia
• Dynamic LVOTO
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

6. INTRAAORTIC BALLOON
COUNTERPULSATION
Timing of counterpulsation:
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

7. INTRAAORTIC BALLOON
COUNTERPULSATION
IABP timing frequency:
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

8. INTRAAORTIC BALLOON
COUNTERPULSATION
IABP timing modes:
• Automatic
• Semiautomatic (operator must adjust inflation & deflation)
• Manual (operator must adjust inflation & deflation)
(& can set fixed rate)
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

9. INTRAAORTIC BALLOON
COUNTERPULSATION
Timing of inflation:
• First identify the dicrotic notch (when the aortic valve closes)
• If inflation is too early the balloon inflates before the aortic valve closes and
pumps blood backwards into the LV, and ↑ LVEDV & LVEDP
• If inflation is too late there will be sup-optimal coronary perfusion
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

10. INTRAAORTIC BALLOON
COUNTERPULSATION
Early inflation:
Interpreting intra-aortic balloon pump waveforms. Nursing 2009;39 Cardiac Insider:9-10.

11. INTRAAORTIC BALLOON
COUNTERPULSATION
Late inflation:
Interpreting intra-aortic balloon pump waveforms. Nursing 2009;39 Cardiac Insider:9-10.

12. INTRAAORTIC BALLOON
COUNTERPULSATION
Timing of deflation:
• First identify the dicrotic notch (when the aortic valve closes)
• If deflation is too late the balloon remains inflated too long, causing ↑
afterload because the heart is trying to pump against an inflated balloon
• If deflation is too early there will be inadequate afterload reduction and
sup-optimal coronary perfusion
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

13. INTRAAORTIC BALLOON
COUNTERPULSATION
Late deflation:
Interpreting intra-aortic balloon pump waveforms. Nursing 2009;39 Cardiac Insider:9-10.

14. INTRAAORTIC BALLOON
COUNTERPULSATION
Early deflation:
Interpreting intra-aortic balloon pump waveforms. Nursing 2009;39 Cardiac Insider:9-10.

15. INTRAAORTIC BALLOON
COUNTERPULSATION
Troubleshooting:
• Poor augmentation
timing error
incorrect position of balloon
↓ SVR
↑ compliance of arterial tree
• Loss of triggering
• Balloon leak / balloon rupture
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

16. INTRAAORTIC BALLOON
COUNTERPULSATION
Complications:
• Lower extremity ischemia
• Insertion site bleeding / hematoma
• Retroperitoneal hematoma
• Aortic dissection or perforation
• Malperfusion syndrome
• Thrombocytopenia
• Infection / sepsis
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

17. INTRAAORTIC BALLOON
COUNTERPULSATION
IABP weaning & removal:
• Decrease inotropic support
• Decrease IABP ratio
• Discontinue heparin (+ platelet transfusion?)
• Deflate balloon
• Remove balloon while alternating pressure above and below insertion site to
expel clots
• Apply constant pressure to insertion site at least 30 min
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

18. GUIDELINES FOR MANAGEMENT
OF LEFT HEART FAILURE
IN CARDIAC SURGERY PATIENTS
Weaning acute support:
• Reduce inotropic support to low level
• Wean IABP support
• Remove IABP
• Wean ventilatory support
• Continue low dose inodilator therapy during ventilator weaning
• Loop diuretic & ACE inhibitor
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.

19. IABP QUIZ
Early inflation:
Courtesy of Datascope, Fairfield, NJ.

20. IABP QUIZ
Early deflation:
Courtesy of Datascope, Fairfield, NJ.

21. IABP QUIZ
Late inflation:
Courtesy of Datascope, Fairfield, NJ.

22. IABP QUIZ
Late deflation:
Courtesy of Datascope, Fairfield, NJ.

23. IABP QUIZ
Which timing errors are more deleterious?
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;22:342-364.