IABP Therapie - Die Basics

Donnerstag, 6. August 2009 

Curriculum Medizinische Intensivtherapie 

IABP Therapie - Die Basics 

Robert M. Radke 

Medizinische Klinik C 

Universitätsklinikum Münster


Themen 

• Grundprinzip der IABP 

• Indikationen, Kontraindikationen 

• Einführung in das Gerät 

• Katheteranlage und optimale 

Kreislaufunterstützung 

• Komplikationen 

• Evidenz


IABP System 

IABP-Katheter 

Pumpe


Katheterposition und Funktion


Physiologischer Herzzyklus 

Vorhofsystole 

Aortendruck 

Druck in der 

linken Kammer 

Druck im 

linken Vorhof 

zentraler Venendruck 

(ZVD) 

Volumen des 

linken Ventrikels 

1mV 

120 

mmHg 

0 

2 

mmHg 

0 

120 

ml 

40 

0 

a 

IVc I IIa IIb III IVa IVb 

1 

2 

3 

4 

Q 

R 

S 

Kammersystole Kammerdiastole 

c 

enddiastolisches 

Volumen 

(EDV) 

x 

T 

Inzisur 

v 

Schlagvolumen 

(SV) 

EKG 

Restvolumen (ESV) 

y 

P 

IVc 

Q 

a 

Vorhofkontraktion


Myokardiale Sauerstoffversorgung 

Angebot 

•Koronaranatomie 

•Diastolischer Druck 

•Diastolendauer 

•O2 Transport 

(Hb, PaO2) 

Verbrauch 

•Herzfrequenz 

•Afterload 

•Preload 

•Kontraktilität


Myokardiale Sauerstoffversorgung 

DPTI / TTI = Angebot / Nachfrage

EKG 

IABP - Prinzip 

Aortendruck 

IABP 


nicht 

assistierte Systole 

nicht assistierter 

enddiastolischer Druck 

diastolische 

nicht 

Augmentation 

assistierte Systole 

assistierte 

Systole 

assistierter 

enddiastolischer Druck


IABP - Prinzip


IABP - Physiologische Effekte 

Aortaler 

Druck 

Kardiale 

Last 

! Systolisch ! Nachlast 

" Diastolisch ! Vorlast 

Blutfluss LV Drücke LV 

" Koronarer 

Blutfluss 

" Cardiac 

Output 

" Renaler 

Blutfluss 

! Systolisch ! Volumen 

! Enddiastolisch 

! Arbeit 

! Wandspannung 

Maccioli GA et al. 1988


Indikationen - Kardiologie 

• Hypotension oder Low Output nach 

akutem Myokardinfarkt 

(AHA : I, B ESC: I, B) 

• Infarkt-VSD, Papillarmuskelabriss 

• Polymorphe VTs nach MI 

• Patienten vor operativer Notfall 

Myokardrevaskularisation 

(AHA : IIa, B) 

• Supportiv bei Thrombolyse 

• ggf. Überbrückung zur Transplantation 

bei Herzinsuffizienz


Indikationen - Anästhesiologie 

• Notfall-Myokardrevaskularisationen 

• Prophylaktischer Einsatz bei 

Hochrisikopatienten mit reduzierter 

linksventrikulärer Pumpfunktion 

• Low Output beim Weaning von der 

HLM


Indikationen - Zukunft? 

• Septischer Schock mit schlechter 

Pumpfunktion und gutem peripheren 

Wiederstand? 

Solomon SB, Critical Care Medicine, 2009


Kontraindikationen 

• Schwere Aorteninsuffizienz 

• Aortenaneurysma 

• Gefäßprothese der A. femoralis 

• schwerste pAVK


Anlage des IABP Katheters 

• Anlage Schleuse im Seldingerverfahren 

• Vorschieben des Führungsdrahtes unter 

Sicht bis zum Erreichen des Aortenbogens


Anlage des IABP Katheters 

• IABP Katheterspitze kurz unterhalb des 

Bogens positionieren. Sollte am unteren 

Rand des Aortenknopfes sein. 

• Fixieren. Bein gestreckt lassen. 

• Röntgenthoraxkontrolle. Alternativ im OP 

per TEE. 

• Vollheparinisierung. 

• Keine Pausen über 30 min!

Donnerstag, 6. August 2009



Unsere IABPs (Datascope CS100) 

• Automatische Analyse der 

optimalen Triggerquelle 

und Ableitung 

• Automatisches Timing 

• Druckmonitoring über das 

Katheterlumen


Aufbau


Anschlüsse 

• Helium Anschluss 

• EKG Buchse 

• Druck Buchse


Überblick Display


Überblick Bedienfeld


Therapie Starten - I 

• Alles konnektieren 

• IABP Einschalten: „Mains On“ und „IABP 

On“ 

• Heliumflasche aufdrehen, Druck 

kontrollieren 

• Transducer nullen: 3W-Hahn auf Luft 

drehen. „Zero Pressure“ für 2 Sekunden 

drücken. 3W-Hahn zurückdrehen.


Therapie Starten II 

• Operation Mode „Auto“ einstellen. 

• 1:2 Modus Einstellen. 

• „Start“ drücken. (Füllung und Pumpen beginnt) 

• Kontrolle der Druckkurven und Finetuning des 

Entlüftungstiming (Inflationstiming im Auto 

Modus nicht beeinflussbar) 

• 1:1 Modus auswählen 

• Setzten des Augmentationsalarms auf ca. 

10mmHg unter der Augmentierten astolischen 

Druck.


Aspekte des Automatik Modus 

• Trigger wird automatisch ausgesucht. Wenn 

EKG, dann automatisch die beste Ableitung. 

• Timing wird automatisch eingestellt, 

Deflation veränderbar 

• Timing wird an HF und Rhythmus angepasst

• 

• 

• 

• 

• 

• 


!"#$%&%'(#()%*+##,-,-.,##/0/1#23##24(+#5 

Optimierung der Druckkurven - Idealbild 

Beurteilung in 1:2 Modus 

Scharfes A = One V complete sicher nach dem 

cardiac cycle 

Klappenschluss (A) 

B = Unassisted aortic 

end diastolic pressure 

Diastolische C = Unassisted Augmentation, die 

systolic pressure 

idelaerweise über der 

D = Diastolic 

normalen augmentation Systole liegt (D) 

E = Reduced aortic 

end diastolic pressure 

Verminderter enddiastolischer 

F = Reduced 

Druck (max. systolic pressure um 10mmHg) (E) 

Verminderung des darauf 

folgenden systolischen Drucks 

(F) 

Anstieg der MAP 

P 

Q 

B 

R 

S 

T 

Correct IABP Timing 

C 

A 

D 

E 

F

Unassisted 

systole 

Zu frühe Inflation 

• 

• 


Incorrect IABP Timing 

Assisted Aortic End 

Diastolic Pressure 

Effekte: 

Diastolic 

Augmentation 

Assisted Systole 

• 

• 

Inflation vor dem 

Aortenklappenschluss 

Verschmelzung von 

diastolischer Augmentation 

und Systole 

Verfrühter Aortenklappenschluss. Ggf. Anstieg von LVEDP. 

Anstieg des Afterloads, Erhöhter O2 Bedarf

Zu späte Inflation 

LATE INFLATION 

tion of the IAB markedly after 

re of the aortic valve. 

form Characteristics: 

• Inflation 

deutlich nach 

lation of IAB after the dicrotic notch. 

sence of sharp V. 

iologic Effects: 

der Inzisur 

b-optimal coronary artery perfusion. 


• Kein scharfes 

V! 

Effekt: 

Dicrotic Notch 

Diastolic Augmentation 



• Sub-optimale Koronarperfusion 

Assisted Systole

eform Characteristics: 

Zu späte Deflation 

LATE DEFLATION 

sisted aortic end diastolic pressure 

ay be equal to the unassisted 

rtic end diastolic pressure. 

• Assistierter 

enddiastolischer Druck 

ate of rise of assisted systole 

prolonged. 

nicht tiefer als normal 

iastolic augmentation may appear 

idened. 

• Druckanstieg der 

assistierten Systole, 

siologic Effects: 

terload reduction is essentially 

sent 

flacher als normal. 

creased MV02 consumption due to 

e left ventricle ejecting against a 

eater resistance and a prolonged 

ovolumetric contraction phase 

• Diastolische 

Augmentation 

B may impede 

verbreitert. 

left ventricular 

ection and increase the afterload 

Effekt: 


Unassisted Systole 

Widened 

Appearance 

Prolonged Rate 

of rise of Assisted 

Systole 



• LV pumpt z.T. gegen geschlossenen Ballon. Erhöhte 

Nachlast und O2 Bedarf.

Zu frühe Deflation 

Diastolic 

Augmentation 


Diastolic Pressure Unassisted Aortic 

End Diastolic Pressure 

Effekt: 


Incorrect IABP Timing 

Assisted Systole 

• Sub-optimale Koronarperfusion und 

Nachlastminderung 

• Deflation führt zu sehr 

scharfem Abfall des 

diastolischen Drucks 

• Suboptimale 

diastolische 

Augmentation 

• Assistierte systolischer 

Druck zu hoch.


Keine supersystolische Diastole - Andere 

Gründe 

• Patient 

• 

• 

• 

• Katheter 

• 

• 

• 

• 

• 

Tachykardie. Zu wenig Zeit zum Aufblasen. 

Hypovolämie. Zu geringes Schlagvolumen. 

Hypotonie. Diastole unter 40mmHg 

Ballon noch in der Schleuse? 

Katheter abgeknickt? 

Falsche Katheter Größe? 

Falsche Katheterlage 

Helium Leck

IABP - Die Risiken 

Komplikation Inzidenz (%) 

Beinischämie 5-18 

Schwerwiegende vaskuläre Komplikation 1-4 

Mesenteriale Ischämie 1 

Fehlplatzierung 1-5 

Ballonleck 1-5 

Aortenperforation


Überwachung der Therapie 

• Antikoagulation sicherstellen. 

• Klinische Untersuchung (Extremität 

durchblutet? Pulse? Farbe? Blutung?) 

• Röntgen Thorax zur Lagekontrolle 

• CK-Kontrolle (Ischämie der Extremität?) 

• Überwachung von Urinausscheidung und 

Retentionsparametern.


Weaning 

• Keine Richtlinien für die Therapie-Dauer. 

• Abhängig von Klinik. Typisch 3-5 Tage. 

• Weaning durch stufenweises reduzieren in 

Abhängigkeit vom Katecholaminbedarf über 

Stunden oder Tage.


Leitlinien - IABP und STEMI 

• Kardiogener Schock, nicht unmittelbar 

ansprechend auf Volumen und 

Pharmakotherapie (AHA : I, B ESC: I, B) 

• Low Output (AHA: I, B ESC IIa, B) 

• Evidenz?

IABP bei high-risk STEMI 

ized clinical trials of IABP therapy in STEMI. All meta-analyses show effect estimates for the individual trials, 

and for the overall analysis. The size of each square is proportional to the weight of the individual trial. (A) 

lity. (B) The mean differences in left ventricular ejection fraction (LVEF). (C and D) The risk differences in 

P, intra-aortic balloon counterpulsation; PCI, percutaneous coronary intervention. 

difference for three trials that 

. Overall, IABP support in the 

d with a change in LVEF at 

95% CI, 22.2 to 2.0%; P ¼ 

absolute numbers of stroke 

, together with the respective 

ial. Overall, the use of IABP 

stroke rate of 2% (95% CI, 

leeding rate of 6% (95% CI, 

ype of reperfusion therapy 

the comprehensive analyses. 

neity across the seven trials. 

ewed distributions, suggesting 

. 


K.D. Sjauw et al. 

464 

Meta-analysis of cohort studies of 

intra-aortic balloon pump therapy in 

STEMI patients with cardiogenic shock 

Nine cohort studies of IABP therapy in STEMI patients with cardiogenic 

shock included a total of 10 529 patients. 20 – 29 Table 4 shows 

the study characteristics. Patients in the IABP group were younger 

(66 vs. 73 years) and more often male (63 vs. 53%). Figure 3A 

shows the absolute numbers of deaths in each treatment group, 

with the absolute risk difference for each cohort study. The thrombolysis 

studies showed adjunctive IABP therapy to be associated 

with an absolute decrease in 30 day mortality of 18% (95% CI, 

16–20%; P , 0.0001). Contrariwise, the primary PCI studies 

showed IABP therapy to be associated with an absolute increase 

464 

Figure 2 Meta-analysis of randomized clinical trials of IABP therapy in STEMI. All meta-analyses show effect estimates for the individual trials, 

for each type of reperfusion therapy and for the overall analysis. The size of each square is proportional to the weight of the individual trial. (A) 

The risk differences in 30 day mortality. (B) The mean differences in left ventricular ejection fraction (LVEF). (C and D) The risk differences in 

stroke and major bleeding rate. IABP, intra-aortic balloon counterpulsation; PCI, percutaneous coronary intervention. 

each treatment group, with the mean difference for three trials that 

reported on left ventricular function. Overall, IABP support in the 

setting of STEMI was not associated with a change in LVEF at 

follow up (mean difference 20.1%; 95% CI, 22.2 to 2.0%; P ¼ 

0.93). Figure 2C and D shows the absolute numbers of stroke 

and bleeding in each treatment group, together with the respective 

absolute risk differences for each trial. Overall, the use of IABP 

was associated with an increased stroke rate of 2% (95% CI, 

0–4%; P ¼ 0.03) and an increased bleeding rate of 6% (95% CI, 

1–11%; P ¼ 0.02). Analyses by type of reperfusion therapy 

yielded similar results to those of the comprehensive analyses. 

There was no evidence of heterogeneity across the seven trials. 

None of the funnel plots showed skewed distributions, suggesting 

that no publication bias was involved. 

each treatment group, with the mean difference for three trials that 

reported on left ventricular function. Overall, IABP support in the 

setting of STEMI was not associated with a change in LVEF at 

follow up (mean difference 20.1%; 95% CI, 22.2 to 2.0%; P ¼ 

0.93). Figure 2C and D shows the absolute numbers of stroke 

and bleeding in each treatment group, together with the respective 

absolute risk differences for each trial. Overall, the use of IABP 

was associated with an increased stroke rate of 2% (95% CI, 

0–4%; P ¼ 0.03) and an increased bleeding rate of 6% (95% CI, 

1–11%; P ¼ 0.02). Analyses by type of reperfusion therapy 

yielded similar results to those of the comprehensive analyses. 










studies showed adjunctive IABP therapy to be associated 

with an absolute decrease in 30 day mortality of 18% (95% CI, 

16–20%; P , 0.0001). Contrariwise, the primary PCI studies 

showed IABP therapy to be associated with an absolute increase 

K.D. Sjauw et al. 

Figure 2 Meta-analysis of randomized clinical trials of IABP therapy in STEMI. All meta-analyses show effect estimates for the individual trials, 

for each type of reperfusion therapy and for the overall analysis. The size of each square is proportional to the weight of the individual trial. (A) 

The risk differences in 30 day mortality. (B) The mean differences in left ventricular ejection fraction (LVEF). (C and D) The risk differences in 

stroke and major bleeding rate. IABP, intra-aortic balloon counterpulsation; PCI, percutaneous coronary intervention. 




Sjauw, EHJ 2009 







studies showed adjunctive IABP therapy to be associated


466 

STEMI mit Kardiogenem Schock 

Keine randomisierten Studien! 

the hypothesis that IA 

therapy in STEMI pat 

coronary perfusion. 32 

explanations for the o 

in this setting. First, th 

years younger and th 

known from the curre 

by 49–60% for every 

a lower clinical risk pr 

of cardiogenic shock 

co-treatment with c 

more frequent in pa 

patients who did no 

clearly showed that r 

in cardiogenic shock p 

SHOCK trial in the em 

vative medical treatme 

tive risk 3.4), whereas 

groups. In comparison 

thrombolysis studies f 

IABP group were 39 a 

in the thrombolysis stu 

sidered too ill to bene 

Sjauw, EHJ 2009


Vielen Dank


Wenn nichts mehr hilft... 

• RTFM

hythm changes. 

• With sustained unpredictable rhythms, R-wave deflation is automatically selected. 

Semi-Automatik Modus 

The message “Auto R-Wave Deflate” will be displayed. 

The system will return to predictive timing once the rhythm becomes 

predictable. 

SEMI AUTO Operation Mode 

• Operator selects the most appropriate trigger source. 

• Operator establishes initial timing and thereafter, software algorithms 

automatically track changes in patient heart rate or rhythm and adjusts 

timing accordingly. 

• Changing the trigger source will cause the pump to go to Standby. Pumping will 

resume when the START key is pressed. 

• Leads I, II, III, AVR, AVL, AVF, V or External ECG source can be selected. 

• With sustained unpredictable rhythms and a valid ECG Trigger, R-wave 

deflation is automatically selected. The message “Auto R-Wave Deflate” will be 

displayed. The system will return to predictive timing once the rhythm becomes 

predictable. 

• Loss of trigger causes an alarm and pumping will stop. 

Manual Operation Mode 

• Trigger source and timing of IAB inflation and deflation is determined by 

the operator. 


esume when the START key is pressed. 


Manueller Modus 

• With sustained unpredictable rhythms and a valid ECG Trigger, R-wave 

deflation is automatically selected. The message “Auto R-Wave Deflate” will be 

displayed. The system will return to predictive timing once the rhythm becomes 

predictable. 


Manual Operation Mode 

• Trigger source and timing of IAB inflation and deflation is determined by 

the operator. 

• Changing the trigger source will cause the pump to go to Standby. Pumping will 

resume when the START key is pressed. 


• Timing must be readjusted by the operator if heart rate or rhythm changes. 


• Manual timing is typically used for pediatric IABP patients. 

WARNING: The CS100 must be in Semi-Auto Operational mode whenever no aortic pulse is 

present, and IAB assist is desired. For example, whenever circulatory bypass or a laminar flow, 

left ventricular assist device is in use.

IABP Therapie - Die Basics

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