INTRA AORTIC BALLON COUNTERPULSATION PHYSIOLOGY INDICATIONS REVIEW IABP

INTRA AORTIC BALLON COUNTERPULSATION PHYSIOLOGY, INDICATIONS & REVIEW

IABP MOULOPOLOS & ASSOCIATES GAVE BIRTH THE CONCEPT OF IABP IN 1962. KANTROWITZ & ASSOCIATES USED IABP FIRST TIME CLINICALLY IN 1968. THE IABP AS OF NOW IS THE MOST COMMON MECHANICAL CIRCULATORY ASSIST DEVICE WITH TREMENDOUS SUCCESS TALES BEHIND.

IABP : PHYSIOLOGY SARNOFF & COLLEGUES CORRELATED , VETRICULAR WORK & MYOCARDIAL ENERGETICS. THEY DETERMINED, PRESSURE WORK (TTI) INFLUENCED MYOCARDIAL O 2 DEMANDS MORE THAN PRE-LOAD, HEART RATE & LV STROKE WORK. DIASTOLIC PRESSURE TIME INDEX (DPTI), GIVES HEMODYNAMIC CORRELATION OF CORONARY PERFUSION.

IABP : PHYSIOLOGY IABP DECRASES TTI & INCREASES DPTI i. e. • LEFT VENTRICULAR WORK REDUCTION • AUGMENTATION OF CORONARY PERFUSION THUS IMPROVING CARDIAC FUNCTION. DURING COUNTERPULSATION, RAPID COLLAPSE OF BALLON REDUCES IMPEDANCE TO AORTIC FLOW IN PROXIMAL AORTA THUS OPENING THE AORTIC VALVE IN 10 – 20 % LESS SYSTOLIC PRESSURE DECREASING LV WORK LOAD & O 2 CONSUMTION.

IABP : PHYSIOLOGIC EFFECTS AORTIC SYSTOLIC PRESSURE DECREASES AORTIC DIASTOLIC PRESSURE INCREASES LV SYSTOLIC PRESSURE DECREASES LV EDP DECREASES CARDIAC OUTPUT INCREASES AFTERLOAD DECREASES PRE-LOAD DECREASES

IABP : PHYSIOLOGIC EFFECTS LV WALL TENSION DECREASES LV VOLUME DECREASES LV STROKE WORK DECREASES CORONARY BLOOD FLOW INCREASES RENAL BLOOD FLOW INCREASES.

IABP : INDICATIONS 1. INTRACTABLE CARDIAC FAILURE AFTER OHS (35 -40) 2. REFRACTORY ANGINA DESPITE MAXIMAL MEDICAL TREATMENT (15 -25%) 3. PERI-OPERATIVE TREATMENT OF COMPLICATIONS OF 4. MI (10%) INCLUDES……… 5. 0 ACUTE VSD. 6. 0 ACUTE MR 7. 8. 0 ARRYTHMIAS 0 VENTRICULAR ANEURYSMS

IABP : INDICATIONS 4. FAILED PTCA & SUPPORT DURING COMPLEX INTV. PROCE. 5. AS A BRIDGE TO CARDIAC TRANSPLANTATION.

IABP : INDICATIONS OF IABP DURING CARDIAC SURGERY : INABILITY TO DISCONTINUE BYPASS : MULTIPLE INTERVENTIONS INADEQUATE HEMODYNAMICS: SYSTOLIC BLOOD PRESSURE LESS THAN 80 mm. hg. CARDIAC INDEX LESS THAN 2. 0 L/min/sq. m LA PREESSURE MORE THAN 20 mm. Hg. VASCULAR RESISTANCE MORE THAN 2500 dynes/sec/cm-5 LARGE DOSES OF MULTIPLE INOTROPIC DRUGS CONTINUED REFRACTORY VENTRICULAR ARRYTHMIAS

IABP : CONTRA-INDICATIONS A. SEVERE AORTIC REGURGITATION B. ABDOMINAL OR AORTIC ANEURYSM C. SEVERE CALCIFIC AORTO-ILLIAC DISEASE. D. SEVERE PERIPHERAL VASCULAR DISEASE.

IABP: COMPLICATIONS q BALLON MEMBRANE PERFORATION q LIMB ISCHEMIA q BLEEDING AT INSERTION SITE q INFECTION q THROMBOCYTOPENIA q AORTIC DISSECTION q THROMBOSIS

IABP : INSERTION TECHNIQUE Ø PERCUTANEOUS INSERTION. MODIFIED SELDINGER TECHNIQUE. Ø SURGICAL INSERTION TRANS FEMORAL TRANS-AXILLARY TRANS-THORACIC

IABP : BALLON CATHETER REMOVAL Ø Ø Ø Ø IONOTROPIC SUPPORT MODERATE HEPARIN SHOULD STOPPED 6 HRS PRIOR TO IT PLATELET & PT SHOULD BE CORRECTED TOTAL EVACUATION OF BALLON CONSTANT POINT PRESSURE –FOR 30 MTS DISTAL PULSES SHOULD BE MONITORED DURING SURGICAL REMOVAL-EMBOLECTOMY CATHETER SHOULD BE PASSED BOTH PROXIMALLY AND DISTALLY THROMBOSED CTHETER SHOULD BE REMOVED I OT

IABP : TIMING OF COUNTERPULSATION Ø BALLON INFLATION: 40 m sec BEFORE ARTERIAL DICROTIC NOTCH, THE ASCENDING T WAVE IN ECG Ø BALLON DEFLATION: DURING EARLY ISOVOLUMIC CONTRACTION, AFTER THE P WAVE- TOTAL DEFLATION MUST OCCUR BEFORE R WAVE.

IABP IN CHILDREN : q q q q Ø USE OF IABP IN CHILDREN IS LIMITED TECHNICAL DIFFICULTY GREATER COMPLIANCE OF PAEDITRIC AORTA LARGE BRONCHIAL VESSELS IN CYANOTIC HIGHER HEART RATE ISOLATED RV FAILURE PUL. ARTERIAL HYPERTENSION ALL THESE MAKE AUGMENTATION DIFFICULT TO ACHIEVE

IABP IN CHILDREN : REPORTED SURVIVAL WITH IABP IN CHILDREN 25%- 66%, WHERE AS IN ECHMO IT IS 61%-71%. q Nand K. kejriwal et al from Liver pool hosp , London reported Fourteen children requiring IABP over a time of 3 yrs. Failure to wean from CPB Sudden deteriotion in ICU Progressive deteriotion Prophylactic for poor LV 5 pts 3 pts 4 pts 2 pts.

IABP IN CHILDREN

IABP IN CHILDREN : Insertion site : a. Ascending aorta 5 pts purse-stringed cardioplegia site b. Common femoral cut down 6 directly & in 3 using gore-tex sheath. Results: 10 pts were weaned from balloon successfully. 2 died later on , one due to SVC thrombosis and another due to mesenteric ischemia 8 patients were long time survivor.

IABP IN CHILDREN : Authors concluded , IABP theraphy can give properly selected young children in refractory low cardiac out put state after heart surgery a greater chance of survival

Elective pre-operative IABP : A no of case series has shown, pre-operative IAB was associated with better outcomes than intraop or post-op. Pre-operative IABP was associated with 74%-90% Survival benefit. Concept of prophylactic IABP was given by Hallman et al.

Pre-operative IABP : q Gutfinger et al showed, efficacy of pre-operative IABP in high risk CABG cases. q They defined some liberal criteria for pre-op balloon insertion e. g. . o o urgent CABG- failed PTCA/repeat CABG critical left main stenosis (70% or more) significant LV dysfunction USA refractory to medical theraphy.

Pre-operative IABP : Ø Out of 206 pts 97 pts fulfilled the iabp insertion criteria and remaining 109 patients no pre-op IABP was inserted. Ø In spite of having higher predictive operative risk in IABP group , there was no statistically significant difference in operative mortality and post-op complications. Ø Authors recommended, aggressive pre-op balloon use a. decrease delayed insertion b. decrease complications.

IABP: ELECTIVE PRE-OP

Pre-operative IABP : Christenson et al showed, pre-operative balloon use in high risk re do-CABG pts is an effective modality to revascularise in an non-ischemic situation as possible thus… • significant lower hospital mortality • fewer instances of post op low cardiac output. • shorter stay in ICU and hospital In 48 re-do CABG cases, they put balloon in 24 and rest are used as control.

Cardiac index comparison: IABPVS NO-IABP

RESULTS:

PRE-OP IABP :

Pre-operative IABP : THOUGH NO UNANIMOUS DECISION HAS BEEN TAKEN REGARDING IINSERTION TIME OF IABP, ITS PROVEN BEYOND DOUBT THAT IN HIGH RISK PATIENTS AND SELECTED GROUPS, PRE-OP IABP IS MORE BENEFICIAL, LESS HARMFUL AND COST EFFECTIVE.

Pre-operative IABP in OPCABG: Joseph M craver et al from Atlanta, Georgia. reported a series of 16 patients undergoing high risk beating heart cabg with pre-operative elective IABP insertion. Patients with : q q q severe proximal CAD severe LV dysfunction recent AMI cardiomegaly— cardiomyopathy documented CVA

Pre-operative IABP in OPCABG: IABP PROVIDED HEMODYNAMIC STABILITY & VIRTUAL ELIMINATION OF INOTROPIC SUPPORT DURING DISLOCATIONS OF HEART NEEDED FOR DISTAL ANASTOMOSIS. NO COMPLICATION OCCURRED.

ASCENDING VS DESCENDING