Ballon de contre-pulsion intra-aortique

Mme Margrit CohenDr P. F Keller

2.10.07

© Datascope Corp.

© Datascope Corp.

4040

Arterial Pressure CurveArterial Pressure Curve

IsovolumetricIsovolumetricContractionContraction

IsovolumetricIsovolumetricRelaxationRelaxation

00

120120

100100

6060

Electrocardiogram

Ventricular Pressure

Arterial PressureArterial Pressure

Approx. TimeApprox. Time 00 0.10.1 0.20.2 0.30.3 0.40.4 0.50.5 0.60.6 0.70.7 0.80.8

8080

1010AV ValveAV Valve

OpensOpens

AV ValveAV ValveClosesCloses

SemiSemi--LunarLunarValve ClosesValve Closes

SemiSemi--LunarLunarValve OpensValve Opens

Pres

sure

(mm

Hg)

Pres

sure

(mm

Hg)

VentricularVentricularSystoleSystole

AtrialAtrialSystoleSystole

DiastoleDiastole

TT

RR

PP

QQ SS

VentricularVentricularFillingFilling

VentricularVentricularEjectionEjectionPhasePhaseAtrialAtrial

SystoleSystole

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DicroticDicrotic NotchNotch

Mean PressureMean Pressure

SystolicSystolic

PulsePulsePressurePressure

DiastolicDiastolic

120120

100100

8080

SystoleSystole DiastoleDiastole

mm Hgmm Hg

Aortic Pressure Waveform

300300

200200

100100

00SystoleSystole DiastoleDiastole

Left Left Coronary ArteryCoronary Artery

Right Coronary Artery

Coronary Coronary Blood Blood Flow Flow (ml/min)(ml/min)

Slide courtesy of A.C. Guyton, MD from Slide courtesy of A.C. Guyton, MD from Textbook of Medical Physiology, Textbook of Medical Physiology, Sixth Edition, 1981, W.B. Saunders Company Sixth Edition, 1981, W.B. Saunders Company

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DETERMINANTS OF MYOCARDIAL OXYGEN SUPPLY AND DEMAND

MVO2

SupplySupply DemandsDemands

Coronary artery anatomyCoronary artery anatomyDiastolic pressure Diastolic pressure Diastolic timeDiastolic timeOO22 ExtractionExtraction

HBGHBGPaOPaO22

Heart rateHeart rateAfterloadAfterloadPreloadPreloadContractilityContractility

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Left Ventricular FailureLeft Ventricular FailureLeft Ventricular Failure

MVO2

↑↑ DemandDemand

↓↓ SupplySupply

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IAB InflationIAB InflationIAB Inflation

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IAB DeflationIAB DeflationIAB Deflation

Arterial PressureArterial Pressure

Balloon PumpBalloon PumpConsoleConsole

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© Datascope Corp.

Primary Effect of IAB TherapyPrimary Effect of IAB TherapyPrimary Effect of IAB Therapy

MVO2

↑↑ Supply Supply -- IAB inflationIAB inflation

↓↓ Demand Demand -- IAB deflationIAB deflation

SupplySupply DemandDemand

Diastolic AugmentationDiastolic Augmentation↑↑ Coronary PerfusionCoronary Perfusion

Assisted Aortic End-Diastolic Pressure↓ MVO2 Demand

AssistedAssistedSystoleSystole

UnUnassistedassistedSystoleSystole

BalloonBalloonInflationInflation

UnUnassisted Aortic assisted Aortic EndEnd--Diastolic Diastolic

PressurePressure

140140

120120

100100

8080

6060

mm mm HgHg

Arterial Waveform Variations During IABP Therapy

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© Datascope Corp.

Physiologic Effects of IABPPhysiologic Effects of IABPPhysiologic Effects of IABP

AAAooorrrtttiiicccPPPrrreeessssssuuurrreee

CCCaaarrrdddiiiaaaccc BBBllloooooodddFFFlllooowww

LLLVVV PPPrrreeessssssuuurrreee LLLeeeffftttVVVeeennntttrrriiicccllleee

↓↓↓ SSSyyyssstttooollliiiccc ↓↓↓ AAAfffttteeerrrllloooaaaddd ↑↑↑ CCCooorrrooonnnaaarrryyybbblllooooooddd ffflllooowww

↓↓↓ SSSyyyssstttooollliiiccc ↓↓↓ VVVooollluuummmeee

↑↑↑ DDDiiiaaassstttooollliiiccc ↓↓↓ PPPrrreeellloooaaaddd ↑↑↑ CCCaaarrrdddiiiaaacccooouuutttpppuuuttt

↓↓↓ EEEnnnddd ---dddiiiaaassstttooollliiiccc

↓↓↓ SSStttrrroookkkeeewwwooorrrkkk

↑↑↑ RRReeennnaaalllbbblllooooooddd ffflllooowww

↓↓↓ WWWaaallllllttteeennnsssiiiooonnn

AAAooorrrtttiiicccPPPrrreeessssssuuurrreee

CCCaaarrrdddiiiaaaccc BBBllloooooodddFFFlllooowww

LLLVVV PPPrrreeessssssuuurrreee LLLeeeffftttVVVeeennntttrrriiicccllleee

↓↓↓ SSSyyyssstttooollliiiccc ↓↓↓ AAAfffttteeerrrllloooaaaddd ↑↑↑ CCCooorrrooonnnaaarrryyybbblllooooooddd ffflllooowww

↓↓↓ SSSyyyssstttooollliiiccc ↓↓↓ VVVooollluuummmeee

↑↑↑ DDDiiiaaassstttooollliiiccc ↓↓↓ PPPrrreeellloooaaaddd ↑↑↑ CCCaaarrrdddiiiaaacccooouuutttpppuuuttt

↓↓↓ EEEnnnddd ---dddiiiaaassstttooollliiiccc

↓↓↓ SSStttrrroookkkeeewwwooorrrkkk

↑↑↑ RRReeennnaaalllbbblllooooooddd ffflllooowww

↓↓↓ WWWaaallllllttteeennnsssiiiooonnn

Maccioli, GA, et al; Journal of Cardiothoracic Anesthesia1988 June; 2(3):365-373

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IndicationsIndicationsIndications

1. Refractory ventricular failure

2. Cardiogenic shock

3. Unstable refractory angina

1.1. Refractory ventricular failureRefractory ventricular failure

2.2. CardiogenicCardiogenic shockshock

3.3. Unstable refractory anginaUnstable refractory angina

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IndicationsIndicationsIndications

4. Impending infarction

5. Mechanical complications due to acute myocardial infarction

6. Ischemia related intractable ventricular arrhythmias

4.4. Impending infarctionImpending infarction

5.5. Mechanical complications due to Mechanical complications due to acute myocardial infarctionacute myocardial infarction

6.6. Ischemia related intractable Ischemia related intractable ventricular arrhythmiasventricular arrhythmias

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IndicationsIndicationsIndications

7. Cardiac support for high-risk general surgical and coronary angiography/ angioplasty patients

8. Septic shock

9. Weaning from cardiopulmonary bypass

7.7. Cardiac support for highCardiac support for high--risk general risk general surgical and coronary angiography/ surgical and coronary angiography/ angioplasty patientsangioplasty patients

8.8. Septic shockSeptic shock

9.9. Weaning from cardiopulmonary Weaning from cardiopulmonary bypassbypass

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IndicationsIndicationsIndications

10. Intraoperative pulsatile flow generation

11. Support for failed angioplasty and valvuloplasty

10.10. IntraoperativeIntraoperative pulsatilepulsatile flow flow generationgeneration

11.11. Support for failed angioplasty and Support for failed angioplasty and valvuloplastyvalvuloplasty

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ContraindicationsContraindicationsContraindications

1. Severe aortic insufficiency 2. Abdominal or aortic aneurysm 3. Severe calcific aorta-iliac disease or

peripheral vascular disease 4. Sheathless insertion with severe obesity,

scarring of the groin

1.1. Severe aortic insufficiencySevere aortic insufficiency 2.2. Abdominal or aortic aneurysmAbdominal or aortic aneurysm 3.3. Severe Severe calcificcalcific aortaaorta--iliac disease or iliac disease or

peripheral vascular diseaseperipheral vascular disease 4.4. SheathlessSheathless insertion with severe obesity, insertion with severe obesity,

scarring of the groinscarring of the groin

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Potential Side Effects and ComplicationsPotential Side Effects and Potential Side Effects and ComplicationsComplications

• Limb ischemia• Bleeding at the insertion site• Thrombocytopenia• Immobility of the balloon catheter• Balloon leak• Infection• Aortic dissection• Compartment syndrome

•• Limb ischemiaLimb ischemia•• Bleeding at the insertion siteBleeding at the insertion site•• ThrombocytopeniaThrombocytopenia•• Immobility of the balloon catheterImmobility of the balloon catheter•• Balloon leakBalloon leak•• InfectionInfection•• Aortic dissectionAortic dissection•• Compartment syndromeCompartment syndrome

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Factors Affecting Diastolic AugmentationFactors Affecting Diastolic Factors Affecting Diastolic AugmentationAugmentation

1. Patient Hemodynamics• Heart Rate• Stroke Volume• Mean Arterial Pressure• Systemic Vascular Resistance

1.1. Patient Patient HemodynamicsHemodynamics•• Heart RateHeart Rate•• Stroke VolumeStroke Volume•• Mean Arterial PressureMean Arterial Pressure•• Systemic Vascular ResistanceSystemic Vascular Resistance

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Factors Affecting Diastolic AugmentationFactors Affecting Diastolic Factors Affecting Diastolic AugmentationAugmentation

2. Intra-aortic Balloon Catheter• IAB in sheath• IAB not unfolded• IAB position• Kink in IAB catheter• IAB leak• Low Helium concentration

2.2. IntraIntra--aortic Balloon Catheteraortic Balloon Catheter•• IAB in sheathIAB in sheath•• IAB not unfoldedIAB not unfolded•• IAB positionIAB position•• Kink in IAB catheterKink in IAB catheter•• IAB leakIAB leak•• Low Helium concentrationLow Helium concentration

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Factors Affecting Diastolic AugmentationFactors Affecting Diastolic Factors Affecting Diastolic AugmentationAugmentation

3. IABP• Timing• Position of the IAB augmentation

control

3.3. IABPIABP•• TimingTiming•• Position of the IAB augmentation Position of the IAB augmentation

controlcontrol

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Acute MI and Cardiogenic ShockAcute MI and Acute MI and CardiogenicCardiogenic ShockShock

23%28%

68%

010203040506070

%

Group I Group II Group III

Survival Rates for AMI and Cardiogenic Shock

23%28%

68%

010203040506070

%

Group I Group II Group III

Survival Rates for AMI and Cardiogenic Shock

StomelStomel, R, et al; , R, et al; Chest Chest 1994; 105(4):9971994; 105(4):997--10021002

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2

5

0

1

2

3

4

5

In-H

ospt

ial M

orta

lity

(No.

of D

eath

s)

Group I & II (IABP) Group III (no IABP)

(p < 0.05)(p < 0.05)

Christenson, JT, et al; Eur J Cardiothorac Surg 1997; 11:1097-1103Christenson, JT, et al; Christenson, JT, et al; EurEur J J CardiothoracCardiothorac SurgSurg 1997; 11:10971997; 11:1097--11031103

Evaluation of Preoperative IABP Support in High-Risk Coronary PatientsEvaluation of Preoperative IABP Evaluation of Preoperative IABP Support in HighSupport in High--Risk Coronary PatientsRisk Coronary Patients

© Datascope Corp.

2389

731

1398

225 41.6 4.90

500

1000

1500

2000

2500

mg

Dopamine Dobutamine Norepinephrine

Postoperative Drug Consumption

No IABIAB

2389

731

1398

225 41.6 4.90

500

1000

1500

2000

2500

mg

Dopamine Dobutamine Norepinephrine

Postoperative Drug Consumption

No IABIAB

Preoperative IABP - Impact on Postoperative Inotropic Drug UsePreoperative IABP Preoperative IABP -- Impact on Impact on Postoperative Postoperative InotropicInotropic Drug UseDrug Use

Christenson, JT, et al; Christenson, JT, et al; TodayToday’’s Therapeutic Trendss Therapeutic Trends 1999;17(3):2171999;17(3):217--225225

P<0.0001

P<0.0001

P<0.0001

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Vascular ComplicationsVascular ComplicationsVascular Complications

8%

3% 2%0%2%4%6%8%

10%

%

Major Minor Late

Vascular Complications

8%

3% 2%0%2%4%6%8%

10%

%

Major Minor Late

Vascular Complications

ArafaArafa, OE, et al; , OE, et al; Ann Ann ThoracThorac SurgSurg 1999; 67:6451999; 67:645--651651

Timing Errors Timing Errors -- Early InflationEarly Inflation

AssistedAssistedSystoleSystole

Diastolic Diastolic AugmentationAugmentation

Assisted Aortic EndAssisted Aortic End--Diastolic PressureDiastolic Pressure

Unassisted Unassisted SystoleSystole

Inflation of the IAB prior to aortic valve Inflation of the IAB prior to aortic valve closureclosure

Waveform Characteristics:Waveform Characteristics:•• Inflation of IAB prior to Inflation of IAB prior to dicroticdicrotic notchnotch•• Diastolic augmentation encroaches onto Diastolic augmentation encroaches onto

systole (may be unable to distinguish)systole (may be unable to distinguish)

Physiologic Effects:Physiologic Effects:•• Potential premature closure of aortic Potential premature closure of aortic

valvevalve•• Potential increase in LVEDV and LVEDP Potential increase in LVEDV and LVEDP

or PCWPor PCWP•• Increased left ventricular wall stress or Increased left ventricular wall stress or

afterloadafterload•• Aortic regurgitationAortic regurgitation•• Increased MVOIncreased MVO22 demand demand

Timing Errors Timing Errors -- Late InflationLate Inflation

Assisted Assisted SystoleSystole

Diastolic Diastolic AugmentationAugmentation

DicroticDicroticNotchNotch

Assisted Aortic EndAssisted Aortic End--Diastolic PressureDiastolic Pressure

UnassistedUnassistedSystoleSystole

Inflation of the IAB markedly after Inflation of the IAB markedly after closure of the aortic valveclosure of the aortic valve

Waveform Characteristics:Waveform Characteristics:•• Inflation of the IAB after the Inflation of the IAB after the dicroticdicrotic

notchnotch•• Absence of sharp VAbsence of sharp V•• SubSub--optimal diastolic augmentationoptimal diastolic augmentation

Physiologic Effects:Physiologic Effects:•• SubSub--optimal coronary artery optimal coronary artery

perfusionperfusion

Timing Errors Timing Errors -- Early DeflationEarly Deflation

Assisted Assisted SystoleSystole

DiastolicDiastolicAugmentationAugmentation

Assisted Aortic Assisted Aortic EndEnd--Diastolic Diastolic

PressurePressure

Unassisted Aortic Unassisted Aortic EndEnd--Diastolic Diastolic

PressurePressure

Premature deflation of the IAB during Premature deflation of the IAB during the diastolic phasethe diastolic phase

Waveform Characteristics:Waveform Characteristics:•• Deflation of IAB is seen as a sharp Deflation of IAB is seen as a sharp

drop following diastolic drop following diastolic augmentationaugmentation

•• SubSub--optimal diastolic augmentationoptimal diastolic augmentation•• Assisted aortic endAssisted aortic end--diastolic pressure diastolic pressure

may be equal to or less than the may be equal to or less than the unassisted aortic endunassisted aortic end--diastolic diastolic

pressurepressure•• Assisted systolic pressure may riseAssisted systolic pressure may rise

Physiologic Effects:Physiologic Effects:•• SubSub--optimal coronary perfusionoptimal coronary perfusion•• Potential for retrograde coronary and Potential for retrograde coronary and

carotid blood flowcarotid blood flow•• Angina may occur as a result of Angina may occur as a result of

retrograde coronary blood flowretrograde coronary blood flow•• SubSub--optimal optimal afterloadafterload reductionreduction•• Increased MVOIncreased MVO22 demanddemand

Timing Errors Timing Errors -- Late DeflationLate Deflation

Diastolic Diastolic AugmentationAugmentation

Assisted Aortic Assisted Aortic EndEnd--Diastolic Diastolic

PressurePressure

Unassisted Unassisted SystoleSystole

Widened Widened AppearanceAppearance

Prolonged Rate of Rise of

Assisted Systole

Deflation of the IAB as the aortic valve is beginning to open

Waveform Characteristics:• Assisted aortic end-diastolic pressure

may be equal to the unassisted aortic end-diastolic pressure

• Rate of rise of assisted systole is prolonged

• Diastolic augmentation may appear widened

Physiologic Effects:• Afterload reduction is essentially

absent• Increased MVO2 consumption due to the

left ventricle ejecting against a greater resistance and a prolonged isovolumetriccontraction phase

• IAB may impede left ventricular ejection and increase the afterload