Intra-aortic balloon pump
Encyclopedia
The Intra-aortic balloon pump (IABP) is a mechanical device that increases myocardial oxygen
perfusion while at the same time increasing cardiac output
. Increasing cardiac output increases coronary blood
flow and therefore myocardial oxygen delivery. It consists of a cylindrical polyethylene balloon that sits in the aorta
, approximately 2 centimetre (0.78740157480315 in) from the left subclavian artery
and counterpulsates. That is, it actively deflates in systole
, increasing forward blood flow by reducing afterload
. It actively inflates in diastole
, increasing blood flow to the coronary arteries. These actions combine to decrease myocardial oxygen demand and increase myocardial oxygen supply.
A computer-controlled mechanism inflates the balloon with helium
from a cylinder during diastole, usually linked to either an electrocardiogram
(ECG) or a pressure transducer
at the distal tip of the catheter
; some IABPs, such as the Datascope System 98XT, allow asynchronous counterpulsation at a set rate, though this setting is rarely used. Helium is used because its low viscosity allows it to travel quickly through the long connecting tubes, and has a lower risk of causing an embolism
should the balloon rupture.
Dr. Adrian Kantrowitz
and his team. The device was developed for use in heart surgery by Dr. David Bregman in 1976 at NewYork-Presbyterian Hospital
in New York City
.
The first clinical implant was performed at Maimonides Medical Center
, Brooklyn, N.Y. in Oct., 1967. The patient, a 48 year old woman, was in cardiogenic shock and unresponsive to traditional therapy. An IABP was inserted by a cut down on the left femoral artery
. Pumping was performed for approximately 6 hours. Shock reversed and the patient was discharged.
The size of the original balloon was 15 French
but eventually 9 and 8 French
balloons were developed. A second operation removed the balloon. Since 1979 the placement of the balloon has been modified using the Seldinger technique.
and aorta it could provoke ischemia
, and compartment syndrome
. The leg is at highest risk of becoming ischemic if femoral artery it is supplied becomes obstructed. Placing the balloon too distal from the arcus aortae
may induce occlusion of the renal artery
and subsequent renal failure
. Other possible complications are cerebral embolism during insertion, infection, dissection
of the aorta or iliac artery
, perforation of the artery and hemorrhage in the mediastinum
. Mechanical failure of the balloon itself is also a risk which entails vascular surgery to remove under that circumstance. After balloon removal there is also a risk of 'embolic shower' from micro clots that have formed on the surface of the balloon, and can lead to peripheral thrombosis, myocardial ischemia
, hemodynamic decompensation, and late pseudoaneurysm
.
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
perfusion while at the same time increasing cardiac output
Cardiac output
Cardiac output is the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute. CO may be measured in many ways, for example dm3/min...
. Increasing cardiac output increases coronary blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....
flow and therefore myocardial oxygen delivery. It consists of a cylindrical polyethylene balloon that sits in the aorta
Aorta
The aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries...
, approximately 2 centimetre (0.78740157480315 in) from the left subclavian artery
Subclavian artery
In human anatomy, the subclavian arteries are two major arteries of the upper thorax , below the clavicle . They receive blood from the top of the aorta...
and counterpulsates. That is, it actively deflates in systole
Systole (medicine)
Systole is the contraction of the heart. Used alone, it usually means the contraction of the left ventricle.In all mammals, the heart has 4 chambers. The left and right ventricles pump together. The atria and ventricles pump in sequence...
, increasing forward blood flow by reducing afterload
Afterload
Afterload is the tension or stress developed in the wall of the left ventricle during ejection. Following Laplace's law, the tension upon the muscle fibers in the heart wall is the product of the pressure within the ventricle, multiplied by the volume within the ventricle, divided by the wall...
. It actively inflates in diastole
Diastole
Diastole is the period of time when the heart fills with blood after systole . Ventricular diastole is the period during which the ventricles are relaxing, while atrial diastole is the period during which the atria are relaxing...
, increasing blood flow to the coronary arteries. These actions combine to decrease myocardial oxygen demand and increase myocardial oxygen supply.
A computer-controlled mechanism inflates the balloon with helium
Helium
Helium is the chemical element with atomic number 2 and an atomic weight of 4.002602, which is represented by the symbol He. It is a colorless, odorless, tasteless, non-toxic, inert, monatomic gas that heads the noble gas group in the periodic table...
from a cylinder during diastole, usually linked to either an electrocardiogram
Electrocardiogram
Electrocardiography is a transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body...
(ECG) or a pressure transducer
Transducer
A transducer is a device that converts one type of energy to another. Energy types include electrical, mechanical, electromagnetic , chemical, acoustic or thermal energy. While the term transducer commonly implies the use of a sensor/detector, any device which converts energy can be considered a...
at the distal tip of the catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
; some IABPs, such as the Datascope System 98XT, allow asynchronous counterpulsation at a set rate, though this setting is rarely used. Helium is used because its low viscosity allows it to travel quickly through the long connecting tubes, and has a lower risk of causing an embolism
Embolism
In medicine, an embolism is the event of lodging of an embolus into a narrow capillary vessel of an arterial bed which causes a blockage in a distant part of the body.Embolization is...
should the balloon rupture.
History
The IABP device was pioneered at Grace Sinai Hospital in Detroit during the early 1960s byDr. Adrian Kantrowitz
Adrian Kantrowitz
Adrian Kantrowitz was an American cardiac surgeon who performed the world's first pediatric heart transplant at Maimonides Medical Center in Brooklyn on December 6, 1967...
and his team. The device was developed for use in heart surgery by Dr. David Bregman in 1976 at NewYork-Presbyterian Hospital
NewYork-Presbyterian Hospital
NewYork–Presbyterian Hospital is a prominent university hospital in New York City affiliated with two Ivy League medical schools: Columbia University's College of Physicians and Surgeons and Cornell University's Weill Medical College. It is composed of two distinct medical centers, Columbia...
in New York City
New York City
New York is the most populous city in the United States and the center of the New York Metropolitan Area, one of the most populous metropolitan areas in the world. New York exerts a significant impact upon global commerce, finance, media, art, fashion, research, technology, education, and...
.
The first clinical implant was performed at Maimonides Medical Center
Maimonides Medical Center
Maimonides Medical Center is a non-profit, non-sectarian hospital located in Borough Park, Brooklyn. Maimonides is both a treatment facility and academic medical center with 705 beds, and more than 70 primary care and sub-specialty programs...
, Brooklyn, N.Y. in Oct., 1967. The patient, a 48 year old woman, was in cardiogenic shock and unresponsive to traditional therapy. An IABP was inserted by a cut down on the left femoral artery
Femoral artery
The femoral artery is a general term comprising a few large arteries in the thigh. They begin at the inguinal ligament and end just above the knee at adductor canal or Hunter's canal traversing the extent of the femur bone....
. Pumping was performed for approximately 6 hours. Shock reversed and the patient was discharged.
The size of the original balloon was 15 French
French catheter scale
The French scale or French gauge system is commonly used to measure the size of a catheter. It is most often abbreviated as Fr, but can often abbreviated as FR or F. It may also be abbreviated as CH or Ch in French speaking countries...
but eventually 9 and 8 French
French catheter scale
The French scale or French gauge system is commonly used to measure the size of a catheter. It is most often abbreviated as Fr, but can often abbreviated as FR or F. It may also be abbreviated as CH or Ch in French speaking countries...
balloons were developed. A second operation removed the balloon. Since 1979 the placement of the balloon has been modified using the Seldinger technique.
Indications
The following situations may benefit from this device.- Cardiogenic shockCardiogenic shockCardiogenic shock is based upon an inadequate circulation of blood due to primary failure of the ventricles of the heart to function effectively....
when used alone as treatment for myocardial infarctionMyocardial infarctionMyocardial infarction or acute myocardial infarction , commonly known as a heart attack, results from the interruption of blood supply to a part of the heart, causing heart cells to die...
. 9-22% survive the first year. - Reversible intracardialHeartThe heart is a myogenic muscular organ found in all animals with a circulatory system , that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions...
mechanical defects complicating infarction, i.e. acute mitralMitral valveThe mitral valve is a dual-flap valve in the heart that lies between the left atrium and the left ventricle...
regurgitation and septal perforation. - Unstable angina pectoris benefits from counterpulsation.
- Post cardiothoracic surgeryCardiothoracic SurgeryCardiothoracic surgery is the field of medicine involved in surgical treatment of diseases affecting organs inside the thorax —generally treatment of conditions of the heart and lungs .-Cardiac / Thoracic:...
—most common and useful is counterpulsation in weaning patients from cardiopulmonary bypass after continued perioperative injury to myocardial tissue. - Preoperative use is suggested for high-risk patients such as those with unstable anginaAnginaAngina pectoris, commonly known as angina, is chest pain due to ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries . Coronary artery disease, the main cause of angina, is due to atherosclerosis of the cardiac arteries...
with stenosisStenosisA stenosis is an abnormal narrowing in a blood vessel or other tubular organ or structure.It is also sometimes called a stricture ....
greater than 70% of main coronary artery, in ventricular dysfunction with an ejection fractionEjection fractionIn cardiovascular physiology, ejection fraction is the fraction of Blood pumped out of the Right Ventricle of the heart to the Pulmonary Circulation and Left Ventricle of the heart to the Systemic Circulation with each Heart beat or Cardiac cycle...
less than 35%. - Percutaneous coronary angioplastyPTCAPTCA may refer to:* Percutaneous transluminal coronary angioplasty, a type of angioplasty* Percutaneous transhepatic cholangiography...
- In high risk coronary artery bypass graft surgery where cardiopulmonary bypass time was shortened, as well as during intubation period and hospital stay.
- Thrombolytic therapy of acute myocardial infarction.
Absolute contraindication
The following conditions will always exclude patients for treatment:- Severe aortic valveAortic valveThe aortic valve is one of the valves of the heart. It is normally tricuspid , although in 1% of the population it is found to be congenitally bicuspid . It lies between the left ventricle and the aorta....
insufficiency - Aortic dissectionAortic dissectionAortic dissection occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta and force the layers apart. The dissection typically extends anterograde, but can extend retrograde from the site of the intimal tear. Aortic dissection is a medical...
- Severe aortoiliac occlusive disease
Relative contraindication
The following conditions could, under pressing circumstances, indicate IABP therapy:- Prosthetic vascularVascularVascular in zoology and medicine means "related to blood vessels", which are part of the circulatory system. An organ or tissue that is vascularized is heavily endowed with blood vessels and thus richly supplied with blood....
grafts in the aortaAortaThe aorta is the largest artery in the body, originating from the left ventricle of the heart and extending down to the abdomen, where it branches off into two smaller arteries... - Aortic aneurysmAneurysmAn aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart...
- Aortofemoral grafts
Complications
Since the device is placed in the femoral arteryFemoral artery
The femoral artery is a general term comprising a few large arteries in the thigh. They begin at the inguinal ligament and end just above the knee at adductor canal or Hunter's canal traversing the extent of the femur bone....
and aorta it could provoke ischemia
Ischemia
In medicine, ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue. It may also be spelled ischaemia or ischæmia...
, and compartment syndrome
Compartment syndrome
Compartment syndrome is a limb threatening and life threatening condition, defined as the compression of nerves, blood vessels, and muscle inside a closed space within the body . This leads to tissue death from lack of oxygenation due to the blood vessels being compressed by the raised pressure...
. The leg is at highest risk of becoming ischemic if femoral artery it is supplied becomes obstructed. Placing the balloon too distal from the arcus aortae
Aortic arch
The arch of the aorta or the transverse aortic arch is the part of the aorta that begins at the level of the upper border of the second sternocostal articulation of the right side, and runs at first upward, backward, and to the left in front of the trachea; it is then directed backward on the left...
may induce occlusion of the renal artery
Renal artery
The renal arteries normally arise off the side of the abdominal aorta, immediately below the superior mesenteric artery, and supply the kidneys with blood. Each is directed across the crus of the diaphragm, so as to form nearly a right angle with the aorta....
and subsequent renal failure
Renal failure
Renal failure or kidney failure describes a medical condition in which the kidneys fail to adequately filter toxins and waste products from the blood...
. Other possible complications are cerebral embolism during insertion, infection, dissection
Dissection
Dissection is usually the process of disassembling and observing something to determine its internal structure and as an aid to discerning the functions and relationships of its components....
of the aorta or iliac artery
Iliac artery
In human anatomy, iliac artery refers to several anatomical structures located in the pelvis:*Common iliac artery - forms at terminus of the aorta...
, perforation of the artery and hemorrhage in the mediastinum
Mediastinum
The mediastinum is a non-delineated group of structures in the thorax, surrounded by loose connective tissue. It is the central compartment of the thoracic cavity...
. Mechanical failure of the balloon itself is also a risk which entails vascular surgery to remove under that circumstance. After balloon removal there is also a risk of 'embolic shower' from micro clots that have formed on the surface of the balloon, and can lead to peripheral thrombosis, myocardial ischemia
Myocardial ischemia
Myocardial ischemia is an imbalance between myocardial oxygen supply and demand. Left untreated, it results in angina pectoris, myocardial stunning, myocardial hibernation, ischemic preconditioning, postconditioning, or under the most severe instances, acute coronary syndrome and myocardial...
, hemodynamic decompensation, and late pseudoaneurysm
Pseudoaneurysm
A pseudoaneurysm, also known as a false aneurysm, is a hematoma that forms as the result of a leaking hole in an artery. Note that the hematoma forms outside the arterial wall, so it is contained by the surrounding tissues. Also it must continue to communicate with the artery to be considered a...
.
External links
- Intra-italheartj.org/pdf_files/20050080.pdf Images in cardiovascular medicine The missing intra-aortic balloon pump catheter by Pasquale Totaro, Nello Degno, John Smith, Vincenzo Argano, Cardiac Surgery Department, Regional Cardiac Center, Morriston Hospital, Swansea, UK, Ital Heart J 2005; 6 (4): 361-362)