Intra-aortic balloon pump

Use of an intra-aortic balloon pump (IABP)

The intra-aortic balloon pump (IABP) is an emergency medical aid to support insufficient heart activity (e.g. after a heart attack ) with the aim of avoiding cardiogenic shock . It is required to perform the intra-aortic balloon counter-pulsation . Their use is indicated when other measures such as medication and ventilation are not sufficient.

history

The concept of intra-aortic balloon counter-pulsation was developed in 1962 by cardiologist SD Moulopoulos. The first use of intra-aortic balloon counter-pulsation was carried out in the late 1960s by Adrian Kantrowitz in patients in cardiogenic shock. As the process progressed, there was increasing automation of the devices required for this (intra-aortic balloon pump = IABP) , as well as considerable progress in the field of intra-aortic balloon catheters (IAB catheters) . The process became more and more popular through numerous publications. Nowadays, IABP therapy is a relatively simple, quickly usable and, compared to other assist systems, relatively few complications support procedure.

Basics

principle

Scheme of the aortic arch with branches. The IABP is placed directly below the exit of the left subclavian artery . * Emptied in the systole, it allows the systolic blood flow distally largely unhindered. * When filled in diastole , it inhibits the diastolic blood flow distally.

The IABP is required to perform intra-aortic balloon counter-pulsation. It is placed (e.g. via the femoral artery using the Seldinger technique ) in the descending aorta directly below the exit of the left subclavian artery and above the exit of the renal arteries. This corresponding catheter is connected to the IABP. A subsequent position check (X-ray markers at the proximal and distal balloon ends enable this by means of an X-ray of the chest ) is mandatory. Ultrasound can also be used to check the correct position. Using a TEE probe in the esophagus, the descending aorta with the exit of the left subclavian artery can be visualized. The tip of the IABP should be 1–2 cm below the exit of the left subclavian artery.

Immediately after the aortic valve closes, the balloon inflates with about 30–40 cm ^{3 of} helium , thereby preventing diastolic blood flow towards the lower half of the body. In contrast, this increases the diastolic flow in the upper half of the body. Immediately before the start of the systole , the balloon actively deflates ("sucking empty") and thus releases the blood flow towards the lower half of the body. The device is individually adapted, whereby filling and emptying are not always carried out with every cardiac action.

In order not to miss the optimal times for inflating and aspirating the balloon, a trigger is helpful. When filling, a pressure measurement directly via the IABP (characteristic change in arterial pressure when the aortic valve closes) or a point in time based on the pressure profile in a radial wrist artery or a leg artery are used for this purpose. With active emptying, the time of the lowest diastolic pressure is best recognized by measuring directly via the IABP.

effect

The main effect of the intra-aortic balloon counterpulsation is the myocardial to increase oxygen supply and decrease myocardial oxygen consumption:

• Inflating the IABP in diastole increases blood flow in the upper half of the body and thus improves the blood supply to the brain and heart (diastolic pressure in the aorta ↑ and coronary perfusion pressure ↑) ,
• The active emptying of the IABP reduces the end-diastolic aortic pressure and thus reduces the workload on the left cardiac ventricle (duration of isovolumetric contraction of the left ventricle ↓, end-systolic pressure in the left ventricle ↓ and left ventricular afterload ↓) .

In summary, this results in an increase in the myocardial oxygen supply (coronary perfusion) and a decrease in the myocardial oxygen demand by reducing afterload, and the cardiac output increases by up to 40%.

Due to the increase in cardiac output, the reduction in the heart's oxygen demand and the improvement in coronary and cerebral perfusion, the affected patient can be stabilized (kept alive) at least temporarily in appropriate cases.

application

Basically, IABP is indicated for patients with threatened or manifest cardiogenic shock when other measures such as medication or artificial respiration are not sufficient. The prerequisites for this, however, are still measurable blood pressure, a regular heart rhythm and heart failure that is not too advanced ( heart index at least 1.5 l / minute / m ² ) :

Indications

1. Refractory unstable angina pectoris
2. Impending heart attack
3. Acute myocardial infarction
4. Refractory ventricular failure
5. Complications of an acute heart attack
6. Cardiogenic shock
7. Support for diagnostic, percutaneous revascularization and interventional procedures
8. Ischemia-related , refractory ventricular arrhythmias
9. Septic shock
10. Intraoperative generation of a pulsatile flow
11. Weaning from the heart-lung machine
12. Cardiac support for non-cardiac surgery
13. Prophylactic support in preparation for cardiac surgery
14. Post-surgical myocardial dysfunction / low output syndrome
15. Myocardial contusion
16. Mechanical bridging to other ventricular assist devices
17. Cardiac support after correction of anatomical defects

Contraindications

The following are absolute contraindications :

1. Aortic regurgitation
2. Aortic aneurysm (thoracic or abdominal)
3. Advanced aorto-iliac arteriosclerosis

The following are considered relative contraindications:

1. Clotting disorders
2. Existing bleeding

Complications

Classic complications include arterial occlusive disease that makes the targeted introduction of the balloon impossible, as well as a piercing (perforation) of the pelvic artery or aorta. If the balloon catheter is placed too far distally or slips, the renal arteries can become obstruction and lead to kidney failure .

Web links

• Kerstin Flemming, Kerstin Schäfer: Caring for patients with IABP therapy. A guide to the smock pocket. Heart Center Dresden, University Clinic, (PDF; 9.0 MB).

Individual evidence

1. ↑ ^{a b c d e} H.-W. Baenkler among others: internal medicine. Thieme Verlag, 2001, ISBN 3-13-128751-9 , pp. 254ff. (online) .
2. ^ JE McGee: Intra-aortic balloon pump: a perspective. In: Journal of the National Medical Association. Volume 73, Number 9, September 1981, pp. 885-887. PMID 7277524 , PMC 2552747 (free full text).
3. ↑ SD Moulopoulos, S. Topaz, WJ Kolff: Diastolic balloon pumping (with carbon dioxide) in the aorta - a mechanical assistance of the failing circulation. In: American Heart Journal . Volume 63, 1962, pp. 669-675.
4. ↑ H. Burchardi among others: The intensive medicine. Springer, 2007, ISBN 978-3-540-72295-3 , pp. 421ff. (online) .
5. ↑ ^{a b c d e f g} U. Stierle et al.: Clinic Guide Cardiology. Urban & Fischer, 2008, ISBN 978-3-437-22281-8 , pp. 104ff. (online) .
6. ↑ Matthew A. Klopman, Edward P. Chen, Roman M. Sniecinski: Positioning an Intraaortic Balloon Pump Using Intraoperative Transesophageal Echocardiogram Guidance . In: Anesthesia & Analgesia . tape 113 , no. 1 , July 1, 2011, ISSN  0003-2999 , p. 40–43 , doi : 10.1213 / ane.0b013e3182140b9a ( ovid.com [accessed March 30, 2018]).

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