Intra-Aortic Balloon Pumps: A Review for Cardiologists Quinn Capers, IV, MD, FACC, FSCAI Division of Cardiovascular Medicine The Ohio State University.

Intra-Aortic Balloon Pumps: A Review for Cardiologists

Quinn Capers, IV, MD, FACC, FSCAIDivision of Cardiovascular MedicineThe Ohio State University Medical

Center

IABP: Definition

40 cc volume, cylindrical balloon

Advanced from femoral artery into aorta

Usually percutaneously (Seldinger technique), with a sheath (6.5-10.5)

IABP: Definition

Attached via gas and arterial pressure tubing to portable control module

Inflated with inert gas immediately at aortic valve closure

Actively deflated immediately prior to systole

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IABP inflates with aortic valve closure:Provides pressurized pulse of blood against closed aortic valve, increasing coronary perfusion

IABP deflates immediately prior to aortic valve opening:Reduces LV afterload

IABP: Physiology

Inflation at aortic valve closure: Increases aortic diastolic blood pressure Increases diastolic coronary perfusion Net neutral effect on cerebral perfusion Increases C.O./“runoff” to subdiaphragmatic organs

Deflation prior to systole: Reduces impedance to LV ejection (afterload) Reduces myocardial oxygen consumption

IABP: Physiology

2 main beneficial effects:

1) Augmented coronary perfusion

2) Reduced LV afterload/Increased CO

IABP: Physiology

2 main beneficial effects:

1) Augmented coronary perfusion Only in normal coronary arteries No augmentation beyond severe stenoses pre PCI Augmentation beyond severe stenoses post PCI

2) Reduced LV afterload/Increased CO

IABP: Physiology

2 main beneficial effects:

1) Augmented coronary perfusion

2) Reduced LV afterload/Increased CO Most important of 2 main effects when severe coronary

stenoses present

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Cardiogenic shock Unstable AMI pt Prior to hi risk PCI Prior to hi risk CABG Refractory CHF Refractory VT/VF Severe MR Refractory angina

“Rescue” after failed PCI going to CABG

Bridge to heart txp

IABP: Indications

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Absolute

Known severe aortic pathology (dissxn, ulcer, mobile plaques)

Significant AI Patient refusal

Relative

Severe PVD AAA Mild AI

IABP: Contraindications

IABP: Current Practice

Ferguson. JACC 2001. Registry, 6/96-8/00: 16, 909 pts in 203 ctrs Indications:

20.6% high risk cath/PCI 18.8% cardiogenic shock 16.1% weaning from CPB 13% preop CABG, high risk or

unstable pt 12.3% refractory USA

IABP: Complications

Ferguson. JACC 2001. Benchmark Registry. 16, 909 pts, 203 ctrs Complications:

2.9% Limb ischemia 2.4% Access site bleeding 1% Balloon leak 0.05% Death attributable to IABP

IABP: ComplicationsRisk Factors Odds Ratios for Major complications with IABP

therapy:

PVD: 2.0 Female Gender: 1.7 Small BSA: 1.5 Advanced age: 1.3

(Little Old Ladies!!!)

IABP Insertion: Methods

Choose groin with strongest pulse

Consider iliac angiogram

Document pedal pulses before IABP inserted

IABP Insertion: Methods

Note that sheath is not mandatory

Advantage: IABP passage may be less traumatic

Disadvantage: Bigger hole, ? more limb ischemia

IABP Insertion: Methods

Advance IABP over wire under fluoro

Distal (cephalad) marker placed at carina(Caudad to L SC artery)

Aspirate blood from lumen of IABP

Hook up “bubble free” to fluid filled pressure tubing

IABP Insertion: Methods

Connect gas line and fill IABP

Begin pumping 1:2 under fluoro

Ensure full expansion, no kinking, IABP not in iliac artery

Examine pressure wave forms

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IABP: Essential Questions

Anecdotally, we think it is a beneficial in cardiogenic shock and high risk coronary revascularization.

1. Do we have randomized data that it is beneficial in high risk PCI?

2. If IABP is beneficial in high risk PCI, does the timing of IABP placement matter? (i.e., prior to PCI, during PCI after complications arise, after PCI?)

3. Is anticoagulation necessary when IABPs are in place?

IABP: To Anticoagulate or Not?

J Zheijiang Univ Sci 2003 Sep-Oct; 4 (5): 607-611 153 pts with IABP x 48 hrs randomized to IV heparin

or placebo No difference in limb ischemia, clot on balloon surface

upon removal Increased major and minor bleeding in heparin group

Acute Card Care. 2008The role of heparin anticoagulation during intra-aortic balloon counterpulsation in the coronary care unit.

Cooper HA1, Thompson E, Panza JA.

Universal Heparin (n=102) vs Strategic Heparin (n=150) in IABP pts

100% of UH pts and 47% of SH pts received Heparin

Major bleeding 10.8% vs 3.2% (p<0.05) in Universal vs Strategic group

Bleeding was non-access site related

J Card Surg. 2012 Heparin-free management of intra-aortic balloon pump after cardiac surgery.Kogan A1, Preisman S, Sternik L, Orlov B, Spiegelstein D, Hod H, Malachy A, Levin S, Raanani E.

203 pts requiring IABP post-CABG

None treated with Heparin

IABP duration: < 24 hr in 81 pts, > 24 hrs in 122 pts

No major bleeding complications in any pts

IABP: To Anticoagulate or Not?

No recommendations by manufacturers

Generally not thought to be necessary if pumping 1:1

Reasonable if during a long wean while pumping 1:2 or 1:3

IABP in High-Risk PCIIs it Useful? IABP placed for PCI

Brodie AJC 1999 Cardiac arrest decreased by 52%

O’Murchu JACC 1995 Decrease MI in rotational atherectomy

Ohman Circ 1994 Decreased reocclusion of IRA in MI pts Decreased MACE

IABP in High-Risk PCI

IABP placed after PCI

Van’t Hof Eur Heart J 1999 No benefit

PAMI II JACC 1997 No benefit

IABP in High-Risk PCI

What if it’s placed before the high risk PCI?

IABP in High-Risk PCI

Mishra AJC 2006 300 high risk pts, 69 had IABP inserted

prophylactically

Remaining pts had sheath inserted, leads on chest, IABP in the room, “on standby”

46 pts needed “rescue” IABP

IABP in High-Risk PCI

Prophylactic (69) “Rescue” (46)

In hosp death: 0% 22%

MI: 20% 62%

30 day death: 4% 27%

Mishra AJC 2006

IABP in High-Risk PCI

Briguori AHJ 2003 133 pts with LVEF < or = 30%

Prophylactic “Rescue” Shock: 0% 15% MACE: 0% 17%

(MI, CABG, Death)

*Prophylactic pts had more high risk characteristics

IABP in High-Risk PCI

Prophylactic strategy proven superior to “standby” strategy in several studies:

SHOCK trial (Death rate 57% vs 72%)1

GUSTO (MACE rate 47% vs 60%)2

NRMI (MACE rate 49% vs 67%)3

1Hochman Circ 1995

2Topol JACC 1995

3Circ 2003

IABP in High-Risk PCI?

Briguori AHJ 2006 219 pts with unprotected LM lesions

Prophylactic (69) “Rescue” (150) Shock: 0% 8% MACE: 1.5% 9.5%

*Prophylactic pts had more high risk characteristics

IABP in High-Risk PCI

A strategy of prophylactic placement of IABP before high risk PCI appears to be superior to a “rescue” strategy

If you think you need it, you probably do!

41Date of download: 7/18/2013

Copyright © 2012 American Medical Association. All rights reserved.

From: Elective Intra-aortic Balloon Counterpulsation During High-Risk Percutaneous Coronary Intervention:  A Randomized Controlled Trial

JAMA. 2010;304(8):867-874. doi:10.1001/jama.2010.1190

Mortality at 6 months was numerically lower in the elective intra-aortic balloon pump (IABP) group than in the no planned IABP group, although this was not statistically significant (4.6% vs 7.4%, P = .32 by the χ2 test).

Figure Legend:

N Engl J Med. 2012 Oct 4;367(14):1287-96. doi: 10.1056/NEJMoa1208410. Epub 2012 Aug 26.Intraaortic balloon support for myocardial infarction with cardiogenic shock.Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm M, Ebelt H, Schneider S, Schuler G, Werdan K; IABP-SHOCK II Trial Investigators.

600 pts with STEMI complicating cardiogenic shock

Randomized to IABP vs no IABP

Primary endpoint: Mortality

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“there was no significant difference in mortality between the 37 patients (13.4%) in whom the balloon pump was inserted before revascularization and the240 patients (86.6%) in whom the balloon pump was inserted after revascularization”

N Engl J Med. 2012 Oct 4;367(14):1287-96. doi: 10.1056/NEJMoa1208410. Epub 2012 Aug 26.Intraaortic balloon support for myocardial infarction with cardiogenic shock.Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Fuhrmann J, Böhm M, Ebelt H, Schneider S, Schuler G, Werdan K; IABP-SHOCK II Trial Investigators.

“In this large, randomized trial involving patients with cardiogenic shock complicating acute myocardial infarction, for whom early revascularization was planned, intraaortic balloon pump support did not reduce 30-day mortality.”

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“In the group assigned to elective IABP treatment, the balloon catheter is inserted at the start of the procedure, before coronary intervention.”—BCIS trial investigators

BCIS-1 long term follow up vs IABP-Shock II(What’s the difference?)

“there was no significant difference in mortality between the 37 patients (13.4%) in whom the balloon pump was inserted before revascularization and the 240 patients (86.6%) in whom the balloon pump was inserted after revascularization”---IABP Shock II investigators

IABP: Important Questions:

1) Do we have randomized data?

2) Does it matter if they are placed prior to or after PCI?

3) Is anticoagulation necessary?

Yes, but mostly anecdotal and registry

?

No, if </= 48hrs

Impella

Percutaneous LVAD

14 Fr sheath

Increases cardiac output (2.5 L/min) & unloads LV

Pressure Lumen

Motor

Blood outlet

Blood Inlet

PROTECT II MACCE**PROTECT II MACCE**

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Per Protocol Population, N=426Per Protocol Population, N=426

Log rank test, p=0.04Log rank test, p=0.04

Death, Stroke, MI,Death, Stroke, MI,Repeat revasc.Repeat revasc. IABPIABP

IMPELLAIMPELLA

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IABP: Post-Test

• Iliac artery atherosclerosis is an absolute contraindication for placing an IABP. True or False?

• There is no evidence that systemic anticoagulation is indicated in patients with an indwelling IABP. True or False?

• The most common complication of IABPs is related to balloon rupture/leak. True or False?

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IABP: Post-Test

• In patients with multiple, critical coronary stenoses and refractory angina, IABPs are useful to decrease angina. In such situations the main mechanism of benefit is:

• LV afterload reduction• Increased coronary perfusion• Increased peripheral arterial blood pressure• Increased peripheral arterial “runoff”

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IABP: Post-Test

• You are about to perform a complex PCI in a patient with severe LMCA disease and severe LV dysfunction? You think you may need a balloon pump. How will you proceed?

• Placing the IABP prior to PCI • Placing the IABP after PCI• Having the IABP “ready to go” (in the room, sheath

in groin, IABP EKG leads on pt) in case the patient “crashes”

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IABP: Post-Test

• Based on currently available evidence, which of the following pts would you predict to have the highest risk for a complication of IABP placement?:

• A morbidly obese (350#) man with diabetes• A 65 year old man with femoral bruits• A 90 year old woman that weighs 90 # and suffers

from severe claudication• A 70 year old man with a small (3.5 cm) AAA

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IABP: Post-Test

Analyze this aortic pressure waveform in a pt with an IABP in place. What is the problem? How do you fix it?

Conclusions

IABPs are extremely useful in stabilizing pts with complicated cardiac disease

Risk factors for complications with IABPs are: female sex, PVD, small BSA, age

Troubleshooting with waveform analysis is critical, and is just as important as knowing how to insert an IABP

Conclusions

Prophylactic insertion of an IABP for hemodynamic support in high risk PCI pts may be superior to a “rescue” strategy

Controversy has arisen as to the utility of IABPs, but registry data, randomized data, and anecdotal data can be quoted to support their benefit.

More studies needed, especially re: impact of timing of placement