intra-aortic balloon pumping in cardiac … cme.pdf · other assist devices. ventricular assist...
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INTRA-AORTIC BALLOON PUMPING IN CARDIAC SURGERY
DR.K.ASHOK
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IABP is a mechanical assist device that is used to improve the ventricular performance of the failing heart.
Facilitates
Increase in myocardial O2 supply.
Decrease in myocardial O2 demand.
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• IAB is a cylindrical polyethylene balloon positioned in the aorta, 2cms distal to the left subclavian artery and counterpulsates.
INTRA-AORTIC BALLOON
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COUNTERPULSATION
• IABP works by volume displacement and pressure changes caused by rapidly shuttling Helium gas in and out of the balloon.
• A computer-controlled mechanism inflates and deflates the balloon at precisely timed intervals.
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• 1952: Realization that coronary perfusion mainly occurs during diastole
• 1958: Harken suggested removal of blood via the femoral artery during systole and replacing it rapidly in diastole as a treatment for LV failure.
HISTORICAL MILESTONES
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HISTORICAL MILESTONES
1962 Kantrowitz and Moulopoulos - prototype
1967 1st successful Rx of cardiogenic shock
1969 The first commercially available IABP
1976 David Bregman - first use in heart surgery
1979 First double lumen surgical IAB catheter
1980 First Percutaneous IAB catheter
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PROTOTYPE
PUMP
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PRESENT PUMPS
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• Percutaneous• Femoral• Brachial• Axillary
• Surgical insertion• Femoral cut down• Trans-thoracic
INSERTION TECHNIQUES
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BALLOON PLACEMENT
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• The IAB Should be selected according to the following chart
IAB SIZING CHART
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PRIMARY EFFECTS OF IABP
MVO2
Supply Demand
IAB Inflation
IAB Deflation
=
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•Increase myocardial O2 delivery•Increased coronary collateral circulation•Increased systemic perfusion pressure
Systole:IAB Deflation
• Decreases afterload and preload• Decrease myocardial O2 consumption• Increase cardiac output
Diastole:IAB Inflation
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SURGICAL INDICATIONS
• Pre-operative severe LV dysfunction
• Post surgical LCOS
• Refractory ventricular arrythmias
• Inability to wean from CPB
• Acute ventricular septal rupture / Acute MR
• Bridging device for Cardiac Transplant
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• Cardiogenic Shock• Pre-Shock Syndrome• Extensive MI• Refractor y arrhythmias• Cardiac Contusion
MEDICAL INDICATIONS
• Support for• Coronary Angio• PCI• Thrombolysis• High risk interventions
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LV Dysfunction
VasoconstrictionNa & H2O retention
Sympathetic toneRAS
Coronary occlusion
Ischemia
Contractile mass
Arterial pressure
Coronary flow
Ischemia
Inotropes
Revascularization
IABPTherapy
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CONTRAINDICATIONS
• Aortic Insufficiency
• Dissecting Aortic Aneursym
• Severe atherosclerosis
• End-stage terminal disease
• Abdominal Aortic Aneurysms, not resected
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TIMING
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HOW IS PROPER TIMING ACHIEVED?
• Always performed using the arterial pressure waveform as the guide
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A = One complete cardiac cycleB = Unassisted aortic end diastolic pressureC = Unassisted systolic pressureD = Diastolic AugmentationE = Reduced aortic end diastolic pressureF = Reduced systolic pressure
Increased Coronary Artery Perfusion
mmHg
C D
A
B
E
F
Reduced MyocardialO2 Demand
120
100
80
B
TIMING ASSESSMENT
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DN DN
CORRECT INFLATION
Just prior to dicrotic notchAORTIC VALVE CLOSURE
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CORRECT DEFLATION
PSP
PAEDP
AORTIC VALVE OPEN
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TRIGGERING
• The computer in the IAB console needs a stimulus to cycle the pneumatic system which inflates and deflates the balloon.
• TRIGGERS• R wave of the ECG • Arterial pressure waveform • Pacing spikes
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ECG PATTERN
• This is the preset trigger mode.
• The computer analyzes the height, width and slope of a positively or negatively deflected QRS complex.
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FOR GOOD, CONSISTENT TRIGGERING IT IS IMPORTANTTO PROVIDE THE PUMP WITH A GOOD ECG SIGNAL
Good Choices –
Unidirectional QRS with minimal artifact
Poor Choices –
Biphasic QRS, tall T or P waves, wandering baseline, artifact present
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Arterial Pressure
The computer uses the systolic upstroke of the arterial pressure waveform as the trigger signal.
This mode is an option when an ECG is unavailable or distorted.
HR
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INTERNAL
The balloon inflates and deflates at a preset rate regardless of the patient’s cardiac activity.
This mode is only to be used when there is no cardiac output and no ECG.
Preset rate is 80 bpm; can be varied between 40 to 120.
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Increased cardiac output, 0.5 – 1 L/min
Increased urine output
Decreased preload
Decreased pulmonary congestion
Improved mentation
Decreased heart rate
Decreased lactic acidosis
Increased pulse pressure
Inflation Deflation
SIGNS OF IMPROVED CLINICAL CONDITION
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PATIENT CARE
• Heparinisation
• Serial activated clotting time
• Distal limb pulses - digital / doppler
• Distal limb colour , temperature and function.
• Serial platelet counts
• Higher antibiotics
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COMPLICATIONS
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OBSERVATION OF EARLY SIGNS OF COMPLICATIONS
Limb ischaemia / InfectionBalloon malpositioningBleeding / thrombus
ENSURING PROPER FUNCTIONING OF IABP
Correct timingConsistent triggeringTroubleshooting alarms
NURSING CARE
EVALUATION OF PATIENT’S RESPONSE
Hemodynamic statusSystemic perfusionRelief of symptoms
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Our Experience at SRM
• Total number of cardiac cases: 351
• Total number of CABGs: 76• On pump: 67• Beating heart: 09
• IABP usage: 05
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PREOPERATIVE LV FUNCTION (n=76)
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SURGICAL DATA
• Average number of bypass grafts: 3• Cardiopulmonary bypass time (mins)
• Range: 110 - 249• Mean: 175
• Aortic cross clamp time (mins)• Range: 80 - 100• Mean: 85.6
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INDICATIONS FOR IABP (n=5)
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INOTROPIC SUPPORT
• Dopamine 5• Dobutamine 3• Adrenaline 3• Noradrenaline 1
CARDIAC PACING
• Ventricular pacing 1
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DURATION OF MECHANICAL SUPPORT
• Intra aortic balloon pump: 18 – 49 hrs• Mechanical ventilation: 14 – 60 hrs• Cardiac pacing: 4 hrs
OUTCOME • Morbidity: None• Mortality: One
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• From its initial clinical use, over 40 years ago, to its current extensive use, IABP has developed into sophisticated, computer-assisted technology for mechanically aiding circulation.
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• Only assist device which has not undergone any major technical change since invention.
Simplicity of the technology
Least invasive among the LVADs
Proven efficacy
• Early aggressive strategy improves surgical outcomes
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OTHER ASSIST DEVICES
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VENTRICULAR ASSIST DEVICE (VAD)
• A mechanical pump that is surgically attached to one of the heart’s ventricles to augment or replace native ventricular function.
• Are powered by external power sources that connect to the implanted pump via a percutaneous lead (driveline) that exits the body on the right abdomen
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VENTRICULAR ASSIST DEVICES
• LVAD - the device is surgically attached to the LV of the heart and to the aorta for LV support
• RVAD - the device is attached to the right atrium and to the pulmonary artery
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THORATEC pVAD
• Short term use (up to 2 years)
– bridge to recovery
– bridge to transplant
– hospital discharge possible
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HEARTMATE XVE LVAS
• Internally implanted, electric pump
– left heart support only
– Medium‐ to long‐term therapy (months to years)
– bridge to transplant
– destination therapy
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TOTAL ARTIFICIAL HEART
• A synthetic replacement for the heart remains one of the long-sought holy grails of modern medicine.
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THANK YOU