intra-aortic balloon pump counterpulsation iskander al-githmi, md, frcsc assistant professor of...
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Intra-Aortic Balloon Pump Counterpulsation
Iskander Al-Githmi, MD, FRCSC
Assistant Professor of Surgery
King Abdulaziz University
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Historical Perspective
• 1958- Harken: Described the diastolic augmentation and counterpulsation to treat LV failure
• 1962-Moulopoulus: From Cleveland clinic, developed an experimental (IAB) whose inflation and deflation were timed to cardiac cycle
• 1968-Kantrowitz: Introduce the (IAB) to the clinical practice in patient with post-infarction cardiogenic shock
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Intra-Aortic Pump Catherter
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Physiologic effect of IABP
• Reduction of left ventricular afterload
• Increase aortic root pressure and coronary perfusion
• Decrease myocardial oxygen demand
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Coronary Artery Flow Autoregulation
• Flow=Pressure/ resistnce
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Indications:
• Cardiogenic shock or pump failure
• Unstable angina
• Failure to wean patient off CPB Prophylaxis:
• High grade left main coronary stenosis
• Post infarction acute mitral regurgitation and septal defect
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Contraindications:
• Severe aortic regurgitation
• Aortic dissection
• Severe peripheral vascular disease
• Non-salvageable patient- Irreversible brain injury
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Arterial Waveform
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IABP Arterial Waveform
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IAB catheter insertion technique
• Seldinger technique
• Cut-down
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Timing
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Balloon pressure waveform
1.zero baseline2.Fill pressure baseline3.IAB inflation4.Pressure artifact/positive overshoot5.Plateau pressure (IAB inflated)6.IAB deflation7.Vaccum artifact/negative overshoot8.Return to baseline (IAB deflated)
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Timing Basics
• To patient arterial waveform (always)
• To patient EKG signal
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Timing problems
• Early inflation
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Timing Problems
• Early deflation
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Timing Problem
• Late deflation
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Triggering
• Trigger on the R wave- preferred method
• Good quality EKG signal and lead i.e unidirectional QRS complex, R wave is taller than P and T waves also it has adequate amplitude
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Triggering
Good Lead
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Triggering
• QRS complex cause wandering timing
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Complications
• Limb ischemia (10-25%)• Balloon rupture• Thrombosis within the balloon • Infection • Bleeding• False aneurysm • Femoral neuropathy• Lymphocele
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Questions
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Question1
Asses the timing in the following strip
a. Correct Timingb. Early inflation and late deflationc. Early inflation and early deflationd. Correct inflation and early deflatione. Late inflation and early deflation
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Question 2
What is wrong with the arterial pressure line
a. AP line is dampenedb. Transducer need to zerodc. The IBP is too high and the tip of art.line is being occluded as it hit the archd. Nothing e. There is air in the pressure tubing
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Question 3
Asses the timing in the following strip
a. Early inflation and early deflationb. Late inflation and late deflationc. Correct inflation and late deflationd. Late inflation and early deflatione. Correct timing
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The pump is the peak trigger mode ,what part of the EKG complex is being recognized as the trigger event?
a. The R wave
b. The pacer spike
c. The arterial pressure waveform
d. The T wave
e. No trigger is seen
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Question 5
The indications for IABP therapy include:a. Cardiogenic shock following acute myocarditis
b. Acute mitral regurgitation with pulmonary edema from papillary muscle rupture
c. Acute VSD following myocardial infarction
d. Acute aortic regurgitation from edocarditis