Insertion and Removal of the Intra-Aortic Balloon Pump
Intra-aortic balloon pump (IABP) counterpulsation has emerged as one of the most effective and most frequently employed methods of mechanical circulatory support. Specifically, it relies on the twin concept of diastolic augmentation and afterload reduction to facilitate the functioning of an ischemic and failing myocardium. The concept was originally proposed by Moulopoulos et al in 1962 and documented improvement in hemodynamic parameters in an experimental animal model. The first clinical report of human use by Adrian Kantrowitz appeared in 1967. In the last 4 decades, there have several technological evolutions, which every student and cardiac surgeon must be aware.
Dr Kantrowitz (October 4, 1918 – November 14, 2008) was an American cardiac surgeon whose team performed the world's first pediatric heart transplant at Maimonides Medical Center in Brooklyn on December 6, 1967. The actual surgery was performed in the middle of the night by his resident. It was only the second time that a human heart had been transplanted into another human being, taking place just three days after Christiaan Barnard's seminal attempt in South Africa made headlines around the world and ushered in a new era in clinical organ transplantation. Kantrowitz also invented the intra-aortic balloon pump (IABP), a left ventricular assist device (L-VAD), and an early version of the implantable pacemaker. The principal objective of balloon counterpulsation is to enhance the balance between myocardial oxygen consumption and supply. Several factors affect the achievement of a favorable balance: the volume of the balloon; its position in the aorta; the underlying heart rate and rhythm; the compliance of the aorta; lastly, the systemic vascular resistance. For instance, an increase in arterial compliance (a property which is affected by arterial wall elasticity) is associated with a greater degree of hemodynamic improvement in patients with the use of an IABP counter pulsation therapy.
The following steps are involved during insertion of an IABP:
1. An initial physical examination focusing on peripheral vasculature should be conducted including palpation and demarcation of the femoral, popliteal, Dorsalis pedis, and posterior tibial pulses and auscultation for femoral and abdominal bruits.
2. The side with the better arterial pulsations should be selected for insertion.
3. The inguinal region should be inspected for landmarks and the femoral artery should be identified.
4. The inguinal region should be prepared and draped in a sterile fashion.
5. Following administration of a local anesthetic agent, a skin incision is made 2 to 3 cm below the inguinal ligament.
6. Using a modified Seldinger technique, the femoral artery is cannulated with a needle and a J-tipped guide wire is then advanced through the needle after brisk flow of arterial blood is confirmed.
7. The guide wire should be advanced to the level of the descending aorta under fluoroscopic guidance.
8. A dilator is inserted and removed until an arterial sheath can be safely placed.
9. The intra-aortic balloon is passed over the guide wire to a position just distal to the origin of the left subclavian artery.
10. The guide wire is subsequently removed and the catheter lumen is aspirated to remove any residual air or thrombus.
11. The intra-aortic balloon is connected to the drive system console and counterpulsation can subsequently begin.
12. The hemodynamic tracing should be inspected for proper timing.
13. A chest radiograph should be obtained to document correct positioning.
14. The intra-aortic balloon catheter and femoral sheath should be secured with sutures.
Removal of an IABP:
1. Anticoagulation should be stopped; confirm that the activated clotting time (ACT) is less than 180 seconds or the activated partial thromboplastin time (aPTT) is less than 40 seconds.
2. Conscious patients should receive a low dose narcotic and/ or analgesic agent.
3. The securing sutures are cut.
4. The drive system console is turned off.
5. The intra-aortic balloon is completely deflated by aspiration with a 20-mL syringe attached to the balloon inflation port.
6. The sheath and intra-aortic balloon catheter are pulled as one unit.
7. Blood is allowed to flow from the arterial access site for a few seconds to remove any thrombi.
8. Manual pressure is applied above the puncture site for 30 minutes or longer if hemostasis is not obtained; a mechanical compression device can also be used to help apply pressure to promote hemostasis.
9. Distal arterial pulsations are palpated.
10. The patient should remain recumbent for a minimum of 6 hours to prevent any subsequent hemorrhage or vascular complications at the arterial access site
Dr Kantrowitz (October 4, 1918 – November 14, 2008) was an American cardiac surgeon whose team performed the world's first pediatric heart transplant at Maimonides Medical Center in Brooklyn on December 6, 1967. The actual surgery was performed in the middle of the night by his resident. It was only the second time that a human heart had been transplanted into another human being, taking place just three days after Christiaan Barnard's seminal attempt in South Africa made headlines around the world and ushered in a new era in clinical organ transplantation. Kantrowitz also invented the intra-aortic balloon pump (IABP), a left ventricular assist device (L-VAD), and an early version of the implantable pacemaker. The principal objective of balloon counterpulsation is to enhance the balance between myocardial oxygen consumption and supply. Several factors affect the achievement of a favorable balance: the volume of the balloon; its position in the aorta; the underlying heart rate and rhythm; the compliance of the aorta; lastly, the systemic vascular resistance. For instance, an increase in arterial compliance (a property which is affected by arterial wall elasticity) is associated with a greater degree of hemodynamic improvement in patients with the use of an IABP counter pulsation therapy.
The following steps are involved during insertion of an IABP:
1. An initial physical examination focusing on peripheral vasculature should be conducted including palpation and demarcation of the femoral, popliteal, Dorsalis pedis, and posterior tibial pulses and auscultation for femoral and abdominal bruits.
2. The side with the better arterial pulsations should be selected for insertion.
3. The inguinal region should be inspected for landmarks and the femoral artery should be identified.
4. The inguinal region should be prepared and draped in a sterile fashion.
5. Following administration of a local anesthetic agent, a skin incision is made 2 to 3 cm below the inguinal ligament.
6. Using a modified Seldinger technique, the femoral artery is cannulated with a needle and a J-tipped guide wire is then advanced through the needle after brisk flow of arterial blood is confirmed.
7. The guide wire should be advanced to the level of the descending aorta under fluoroscopic guidance.
8. A dilator is inserted and removed until an arterial sheath can be safely placed.
9. The intra-aortic balloon is passed over the guide wire to a position just distal to the origin of the left subclavian artery.
10. The guide wire is subsequently removed and the catheter lumen is aspirated to remove any residual air or thrombus.
11. The intra-aortic balloon is connected to the drive system console and counterpulsation can subsequently begin.
12. The hemodynamic tracing should be inspected for proper timing.
13. A chest radiograph should be obtained to document correct positioning.
14. The intra-aortic balloon catheter and femoral sheath should be secured with sutures.
Removal of an IABP:
1. Anticoagulation should be stopped; confirm that the activated clotting time (ACT) is less than 180 seconds or the activated partial thromboplastin time (aPTT) is less than 40 seconds.
2. Conscious patients should receive a low dose narcotic and/ or analgesic agent.
3. The securing sutures are cut.
4. The drive system console is turned off.
5. The intra-aortic balloon is completely deflated by aspiration with a 20-mL syringe attached to the balloon inflation port.
6. The sheath and intra-aortic balloon catheter are pulled as one unit.
7. Blood is allowed to flow from the arterial access site for a few seconds to remove any thrombi.
8. Manual pressure is applied above the puncture site for 30 minutes or longer if hemostasis is not obtained; a mechanical compression device can also be used to help apply pressure to promote hemostasis.
9. Distal arterial pulsations are palpated.
10. The patient should remain recumbent for a minimum of 6 hours to prevent any subsequent hemorrhage or vascular complications at the arterial access site
Next: Physiologic Principles of IABP Functioning