Chapter 40. Intra-Aortic Balloon Pump Insertion

Introduction

An intra-aortic balloon pump (IABP) is an electrocardiogram (ECG) synchronized endovascular balloon that inflates in the proximal descending aorta (Figure 40-1) during cardiac diastole, acting both to augment coronary perfusion and cardiac output, and deflates during systole, permitting cardiac ejection.

Definitions and Terms

• ▪  Counterpulsation: Rhythmic mechanical pumping synchronized with the heartbeat.
• ▪  Systole: The phase of the heartbeat during which cardiac muscle contracts actively ejecting blood through the open aortic valve.
• ▪  Diastole: The phase of the heartbeat during which the left ventricle fills with blood from the left atrium through the open mitral valve, and during which the majority of coronary perfusion occurs.

Techniques

• ▪  Indications:
  • —Unstable angina
  • —Cardiogenic shock
  • —Cardiac insufficiency following cardiac surgery
  • —Mechanical cardiac support in the setting of certain cardiac lesions such as acute mitral insufficiency or intracardiac shunt
• ▪  Contraindications:
  • —Aortic dissection
  • —Aortic insufficiency
  • —Severe atherosclerotic disease of the aorta
  • —Aortic aneurysm
  • —Aortic graft
• ▪  Prior to procedure, obtain patient consent, prep and drape, and perform universal protocol as described in Section I.
• ▪  The IABP is almost invariably placed through one of the femoral arteries.
• ▪  Preparation:
  • —Skin: The Center for Disease Control and Prevention (CDC) recommends preparation of the cannulation site with a 2% aqueous chlorhexidine-gluconate solution, which has been associated with lower blood stream infection rates than povidone-iodine or alcohol-based preparations. The skin and tissue around the vessel should be infiltrated with 1% lidocaine solution, except in patients with a known allergy to lidocaine, in whom alternative local anesthetics can be used.
  • —Hygiene: The operator should observe proper hand-hygiene and use maximal barrier precautions including gown, mask and gloves, and a large sterile drape or multiple drapes covering a large area.
• ▪  Methods (see Chapter 34 on vessel cannulation):
  • —Direct cannulation.
  • —Transfixion.
  • —Seldinger technique is used as an adjunct for catheter exchange with either of the above cannulation techniques.
  • —Ultrasound guided vessel location can be used for femoral cannulation.
• ▪  Following access to the vessel, the IABP is inserted to a premeasured depth so as to lie in the proximal descending aorta (Figures 40-2, 40-3, 40-4, and 40-5).
• ▪  Balloon inflation is timed to occur during diastole, and gated to the ECG or arterial pulse wave (Figure 40-6).
• ▪  The pumping ratio is typically 1:1, although it may be reduced to 1:2 and/or 1:3 prior to removal.
• ▪  A confirmatory chest x-ray is used to identify the location of the tip of the balloon.
• ▪  Complications are varied, and include:
  • —Leg ischemia or compartment syndrome
  • —Aortic dissection
  • —Embolization of debris to the brain and/or visceral organs