Weaning From IABP

 Ri 王昭閎
IntraAortic Balloon Pump

Settings: catheter-mounted,
balloon volume 30-50 ml, central
lumen, helium, synchronization.
Net effect: myocardial oxygen
supply/demand ratio with a small
increase in systemic perfusion
(≦0.5L/min)
Timing: Pre-,Peri-,Post-op
IABP Waveforms
IABP Waveforms

Early Inflation Late Inflation

IABP Waveforms

Early Deflation Late Deflation

 Indications
 Cardiogenic shock
 Mechanical complication of AMI
 In association with CABG
 In association with nonsurgical revascularization
 Stabilization of cardiac transplant recipient
before insertion of ventricular assist device
 Postinfarction angina
 Ventricular arrhythmias related to ischemia
 Contraindications
 Absolute Contraindications
 Aortic valve insufficiency; Aortic dissection
 Relative Contraindications
 Femoral arterial insertion: Abdominal aortic
aneurysm; Severe calcific aortoiliac or femoral
arterial disease

Percutaneous insertion: Recent ipsilateral
groin incision; Morbid obesity
 Complications
 Complication rate: 5-47%
 Limb ischemia; aortic dissection; aortoiliac
laceration; perforation; deep wound
infection
 Bleeding at insertion site; superficial
wound infections; asymptomatic loss of
peripheral pulse; lymphocele
 Weaning from IABP
 Continued satisfactory LV performance
 Augmentation curve remains < SBP
 No further increase in CO at 1:1 assist rate in
comparinson with 1:2
 Weaning from IABP
 No experimental or clinical studies have
been done to evaluate the most effective
weaning
 Traditional method: reduce the assist rate
from 1:1 to 1:2, etc, because all consoles
are equipped with it.
 The method of weaning is, at best,
selected arbitrarily.
 Weaning from IABP
 Traditional method:↓Assist rate while maintaining
augmentation.
 New method: ↓Augmentation while rate at 1:1
 Goal: assure satisfactory cardiac performance
independent of balloon pump assist.
 Weaning is done in a gradual fashion over a
preset time interval (in two phases)
 Criteria for initiation of IABP weaning: a patient
must be in hemodynamic class I (Shock box)
Weaning from IABP
Shock Box
 Left Ventricular Stroke Work
Index
 LVSWI = (SV/BSA)*(MAP-
PCWP)*(0.0136)
 Normal = 45-75
 Class I: Minimal failure group
 Class II: Hypovolemic group
 Class III: Hypervolemic-
Hyperdynamic group
 Class IV: Classic cardiogenic
shock (Hypervolemic-
Hypodynamic group)
 Protocols

 Initial set of hemodynamic data

 Phase I: 1:2 + 100% V.S. 75% + 1:1
 Appropriate therapeutic measure
 Parameters:↓LVSWI or↑PWP > 20%
 If not class I, 1:1 + 100% for more 12-24 hr
 Phase II: 1:3 + 100% V.S. 50% + 1:1
 Flutter mode (<25%) for 10-15 min; Prevent clot
 Augmentation(%) adjustment by pressure;
variable balloon volume changes
 Results

 75% + 1:1 similar to 1:2 + 100%

 Class I p’t in Phase II: min. change between phases
 Phase II as balloon “off” or “flutter”
 Combined methods is safe and reliable
 IABP < 3-4 hrs, weaning may be shortened to 1-2 hrs
 Average time from class IV to I: 48 hrs
One Patient’s Data
 Criteria for Variant Condition

 Preoperatively or acute ventricular dysfunction

 ~1 hr devided into two 30-minute phases
 Criteria for Variant Condition

 Emergency basis (at the completion of a cardiac

operation),
 IABP should not be DC early after satisfactory response
 Maybe 12-18 hours later in ICU
Criteria for Variant Condition
 Weaning in Special Situations
 Prolonged Respiratory Support
 Never weaning simultaneously
 DC respiratory support first, if possible

12-24 hr later, weaning may be attempted

COPD or ARDS, IABP may be weaned first
 Pressor Therapy
 Vasopressor to the lowest level before weaning
 Exception: Leg ischemia. Early removal or change site
 Change all the pressor drugs to dopamine or dobutamine
 Decrease to <5mcg/kg/min, then weaning
 Within 12-24 hr after DC IABP, decrease in conc. and DC
 DC pressor but keep IABP as bridge to trans.
Thanks for Your Attention
 References
 Clinical Application of Intra-Aortic
Balloon Pump, Third Edition.
Hooshang Bolooki.
 Counterpulsation: historical
background, technical
improvements, hemodynamic and
metabolic effects," which appears
in Volume 84 (1994) of the journal
Cardiology (pp. 156-167).
 Braunwald: Heart Disease: A
Textbook of Cardiovascular
Medicine, 6th ed.