IABP Class Final

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Determinants of MVO2 :
Myocardial wall tension
Heart rate
Contractility
Others e.g.-basal energy
metabolism(25% of MVO2)
External work performance
Energy for electrical activation
NB: Pressure work requires
more O2 consumption than
volume work
Work of RV is 1/7th of LV
Heart cannot develop O2 debt-
all aerobic metabolism.
MVO2-MYOCARDIAL OXYGEN CONSUMPTION
Any increase in MVO2 must be
met with increase perfusion
THEORY OF COUNTERPULSATION IABP
Primary Goal of IABP Therapy

IAB Inflation:
Increases supply of oxygen to myocardium
How it works
•Balloon inflates at
onset of diastole
(when aortic valve
closes)
•Displaces blood,
causing an increase
in aortic pressure
What are the effects of IABC therapy on

the following?
 Coronary perfusion
 Cardiac output
 Heart rate
 PAWP
 SVR
 Systolic BP
 Diastolic pressure with balloon
inflation
 End diastolic BP
 MAP
 Systemic perfusion (neurologic,
respiratory, renal, vascular)
TIMING & TIMING ERRORS IABP
Synchronization with the cardiac cycle
ECG
TRIGGER
Arterial Pressure
TIMING
IAB Inflated
IABP
IABP
IABP
IABP
MAP-Mean RA/C.O=SVR in wood

unit, conversion isx80 to
dynes/s/cm-5
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IAB CATHETER SIZING & PLACEMENT IABP
Intra-Aortic Balloon
New Clinical Reference Sizing Guide
IABP
• The IAB Should be selected according to the

following chart (chart located on every box).
Note: The 50cc balloons are no longer made by Datascope

IABP
• Introducer needle
• Guide wire
• Vessel dilators
• Sheath
• IABP (34 or 40cc)
• Gas tubing
• 60-mL syringe
• Three-way stopcock
• Arterial pressure tubing (not in kit)
IABP
IABP
TECHNICAL ASPECTS – IAB CATHETER IABP
Conventional Catheter Components
Proximal Marker Distal Marker

Balloon Membrane
Gas Lumen
& Inner Lumen
Universal
Sheath Seal
Suture Pads
STAT-GARD Sleeve
Y-fitting
Stylet
Extracorporeal Tubing
Fiber-optic Catheter Components

Fiber-optic
Pressure Sensor
Fiber-optic
Cable
Tubing Clips
STATLOCK® Stabilization Device
®
STATLOCK
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FACTORS AFFECTING DIASTOLIC AUGMENTATION IABP
IAB Catheter
 IAB in sheath
 IAB not unfurled
 IAB position
 IAB size
 Kink in IAB catheter
 IAB leak
 Low helium concentration
FACTORS AFFECTING DIASTOLIC AUGMENTATION IABP
Intra-aortic Balloon Pump

 Timing
- Late inflation
- Early deflation
 Position of the IAB augmentation control
Timing
Refers to the positioning of inflate and deflate
points on the arterial pressure waveform
Proper IABP Timing
Inflation
 Occurs at the dicrotic notch
 Appears as a sharp “V”
 Ideally diastolic augmentation
rises above systole
Deflation
 Occurs just prior to systolic ejection
 Results in a reduction in assisted
end diastolic pressure
 Results in a reduction in assisted
systolic pressure
Timing Assessment
A: Unassisted End
D
Diastolic Pressure
B: Unassisted Systole B
F
C: IAB Inflation
Dicrotic
Notch
D: Diastolic Augmentation
E: Assisted End
Diastolic Pressure C
F: Assisted Systole A
E
Timing Assessment
116
102 98
52
43
Mean Arterial Pressure Calculation
 IABP samples BP every 4msec on

pressure waveform, then averages
measurements
 IAB increases MAP due to augmentation
of blood pressure during diastole
1:1 Frequency
Diastolic Augmentation
Assisted Systole
Assisted End
One Cardiac Cycle
Diastolic Pressure
1:2 Frequency
Diastolic
Augmentation
Unassisted Assisted
Systole Systole
Unassisted End
One Cardiac Cycle Diastolic Pressure Assisted End
Diastolic Pressure
1:3 Frequency
Diastolic Augmentation
Unassisted Assisted
Systole Systole
One Cardiac Cycle Unassisted End Assisted End

Diastolic Pressure Diastolic Pressure
Timing Error – Early Inflation

Inflation of IAB prior to aortic valve closure
Waveform Characteristics
 Inflation of IAB prior to dicrotic notch
 Diastolic augmentation encroaches onto
systole (may be unable to distinguish)
Physiologic Effects
 Potential premature closure of aortic valve
 Potential increase in LVEDV/LVEDP/PCWP
 Increased left ventricular wall stress
or afterload
 Aortic regurgitation
 Increased MVO2 demand
Timing Error – Late Inflation

Inflation of IAB markedly after closure of aortic valve
 Inflation of IAB after dicrotic notch
 Absence of sharp “V”
 Sub-optimal diastolic augmentation
Physiologic Effects
 Sub-optimal coronary artery perfusion
Timing Error – Early Deflation

Premature deflation of IAB during diastolic phase
 Deflation of IAB is seen as a sharp
drop following diastolic augmentation
 Sub-optimal diastolic augmentation
 Assisted end diastolic pressure may
be equal to or less than unassisted
 Assisted systolic pressure may rise
Physiologic Effects
 Sub-optimal coronary perfusion
 Potential for retrograde coronary
and carotid blood flow, which may
result in angina
 Sub-optimal afterload reduction
 Increased MVO2 demand
Timing Error – Late Deflation

Deflation of IAB after aortic valve has opened
 Assisted end diastolic pressure may
be equal to or higher than unassisted
 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 left
ventricle ejecting against a greater resistance
and a prolonged isovolumetric contraction phase
 IAB may impede left ventricular ejection
and increase afterload
IABP
IABP
IABP
IABP
TECHNICAL ASPECTS – CARDIOSAVE IABP IABP
Variations in Balloon Pressure Waveform
Bradycardia Tachycardia Irregular Rhythm

Variations in Balloon Pressure Waveform
Catheter Restriction Gas Loss

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OVERVIEW OF CARDIAC PERFORMANCE IABP
Oxygen Supply - Coronary Anatomy
Normal Autoregulation
Coronary Arteries 70% or < occlusion

Oxygen Supply - Diastolic Time/Pressure
Diastolic Phase Diastolic Phase

60 BPM 130 BPM
 Decreased diastolic filling time = decreased stroke volume

 Decreased diastolic pressure = decreased myocardial oxygen supply
Oxygen Supply - Hgb & PaO2

Oxygen Demand - Heart Rate
Diastolic Phase Diastolic Phase

60 BPM 130 BPM
 Increased heart rate = increased demand for myocardial oxygen

Oxygen Demand - Afterload (Left Side)

Resistance left ventricle has to overcome
to eject blood from heart
 Measured by Systemic Vascular
Resistance (SVR)
– Normal values: 900 - 1400 dynes/s/cm-5
Klein DG. AACN Procedure Manual for Critical Care. 6th Edition 2011; 578-579
Oxygen Demand - Preload (Left Side)

Volume of blood in left ventricle at end of
diastole, creating a “stretch” in muscle fibers
 Measured by Pulmonary Artery Wedge
Pressure (PAWP)
– Normal values: 4-12mmHg
Oxygen Demand - Contractility

Ability of muscle fibers to contract in
order to eject blood into the circulation
Measured by Ejection Fraction (EF)
– Normal values: 60% - 75%
Proper placement of IAB catheter

 Tip of IAB catheter
– Positioned approximately 1 to 2cm
distal to the left subclavian artery
 Base of balloon
– Positioned above renal arteries
Verification of proper placement

Important tips to remember

 Whenever possible, use fluoroscopy
 If fluoroscopy is not used, a CXR should
be taken as soon as possible after
insertion to identify placement
 Place IABP in Standby when obtaining
CXR to enhance visualization of IAB tip
TRIGGERS IABP
Triggering
 A Trigger is the signal that CARDIOSAVE
uses to identify the beginning of the next
cardiac cycle
 When CARDIOSAVE recognizes the trigger
event, it will deflate the balloon if not already
deflated
TRIGGERS IABP
ECG Trigger
Trigger Event
 R-Wave
Applications
 Preferred trigger (must have reliable
R-Wave)
 Recommended for patients with
arrhythmias
 Recommended for paced rhythms
(demand or asynchronous pacing)
TRIGGERS IABP
Pressure Trigger
Trigger Event
 Systolic upstroke of arterial waveform
Applications
 Backup trigger when ECG trigger is not
appropriate
 Reoccurring ECG artifact
 Electrocautery interference in OR
 Low voltage R-Wave
 Cardiac arrest/CPR
TRIGGERS IABP
Pacer V/A-V
Trigger Event
 Ventricular pacer spike
Applications
 Used with V or AV paced rhythms
 Used when 100% paced and NO
reliable R-Wave
 Low voltage R-Wave
 Only available in Semi-Auto
operation mode
TRIGGERS IABP
Pacer A
Trigger Event
 R-Wave
Applications
 If pacer tails are present, they can cause
the IABP to trigger inappropriately on the
pacer tail, instead of the R-Wave
(in ECG trigger)
 Primarily used in open heart patients
who have a temporary atrial pacemaker
 Never use Pacer A trigger in the presence
of a ventricular paced rhythm
operation mode
TRIGGERS IABP
Internal Trigger
Trigger Event
 Asynchronous
 Balloon inflates/deflates at a set rate
of 80 BPM
 Internal rate is adjustable
Applications
 Only use when patient is not generating
a cardiac output on their own
 Cardiac arrest
 Cardiopulmonary bypass
operation mode
SIDE EFFECTS & COMPLICATIONS/PATIENT ASSESSMENT IABP
How are balloon leaks diagnosed?
Balloon Leak
What causes a balloon leak?
 Majority are caused by plaque abrasion
What is the treatment?
 Stop pumping and notify physician
 Remove IAB catheter
• Blood appears in
extracorporeal tubing or helium
extender tubing
• Be suspicious with any “Gas
Loss in IAB Circuit” alarm
SIDE EFFECTS & COMPLICATIONS/PATIENT ASSESSMENT IABP
Patient Assessment
Assessment Corrective Action
Radial pulses Check position of
Left radial pulse weak IAB
or left arm ischemia
Insertion site Apply pressure,
Excessive bleeding ensure distal flow
from insertion site
Pedal pulses Consider removing
Limb ischemia IAB, consider
detected insertion via opposite
limb
IAB inner lumen Aspirate inner lumen.
flush line If line patent, flush
Pressure waveform for 15 seconds (with
damped (if using a IABP on Standby)
conventional IAB)
Urine output Check position of
Urine output low IAB
IAB catheter tubing STOP pumping and
Blood observed in prepare for IAB
catheter tubing removal
Proper Care of Inner Lumen

 Minimize length of pressure tubing
 Use only low compliance pressure tubing
 Elevate flush bag at least 3’ (91.44cm)
above transducer
 A 3cc/hour continuous flow through inner
lumen is recommended
 If inner lumen becomes damped:
– Aspirate and discard 3cc of blood
– If unable to aspirate blood, consider
inner lumen clotted, cap lumen, provide
alternate pressure source
– If able to aspirate blood, fast flush to
clear pressure tubing for at least 15 seconds
(with IABP on Standby)
 Do not sample blood from inner lumen
Top Panel
A: Helium Pressure Gauge
B: Battery Charging LED
C: AC Connected LED
A
B C
Doppler
Storage Compartment
Helium Tank
Back Panel
Back Panel – With a Fiber-optic IAB

Back Panel – With a Conventional IAB

Back Panel – With ECG External Monitor Interfacing

Back Panel – Hot Swappable Lithium Ion Batteries

Back Panel – Retractable Power Cord

Transport Configuration
CARDIOSAVE Initial Set-Up
Connect ECG cable
Connect fiber-optic IAB:

for MAQUET/Datascope
fiber-optic IAB
Press POWER button

to turn IABP ON
Connect pressure cable:
for conventional IAB
Open helium tank (if

not already opened)
Connect IAB
Initial set-up using a MAQUET/Datascope fiber-optic IAB (continued)
Verify Aug. Alarm is set 10mmHg

below patient’s augmented
diastolic pressure (approx. 3 min.
after initiation of assist)
Pressing the START key

 Automatically purges and fills IAB
 Automatically performs an in vivo calibration
 Automatically selects most appropriate lead and trigger
 Automatically sets inflation and deflation timing
Initial set-up using a conventional IAB (continued)
Verify Aug. Alarm is set 10mmHg

below patient’s augmented
diastolic pressure (approx. 3 min.
after initiation of assist)
Pressing the START key

 Automatically purges and fills IAB
 Automatically selects most appropriate lead and trigger
 Automatically sets inflation and deflation timing
Monitor Display
Normal Balloon Pressure Waveform

Battery Status (Examples)

Auto Operation Mode

 Automatic lead and trigger selection
 Automatic and continuous inflation
and deflation timing management
- User has ability to fine-tune deflation
timing
 Automatic management of irregular
rhythms
 Automatic in vivo calibration
(when using a MAQUET/Datascope
fiber-optic IAB)
Semi-Auto Operation Mode

 Operator selects most appropriate
lead and trigger source Touchscreen
 Operator establishes timing, then
CARDIOSAVE automatically adjusts
timing with heart rate and rhythm changes
 Automatic management of irregular
rhythms
 Automatic in vivo calibration
(when using a MAQUET/Datascope
fiber-optic IAB)
Touchscreen
Lock Screen Feature
Touchscreen Unlocked Touchscreen Locked
Touchscreen will Lock: Touchscreen will Unlock:

 Automatically after 2 min. of inactivity  Automatically with any Technical,
 When operator presses LOCK High, Medium, or Low Priority Alarm
SCREEN key for 2 sec.  When operator presses UNLOCK
SCREEN key
Touchscreen with Preferences menu opened

Touchscreen with Help Screen displayed

HANDS-ON/TROUBLESHOOTING IABP
Alarms
Augmentation Below Limit Set Autofill Failure
Probable Cause Corrective Action

IAB disconnected Attach IAB
Probable Cause Corrective
catheter
Action
Helium tank is Open helium tank
Hemodynamic Attempt to
closed
status has optimize
changed patient’s Helium tank is Change helium
hemody- empty tank
namic status Incorrect IAB Ensure only one
Alarm limit set too Press AUG. catheter extender IAB catheter
high ALARM key, tubing length extender tubing is
decrease limit connected
Alarms
IAB Catheter Restriction IAB Disconnected

Restriction in IAB Relieve restriction if
catheter or tubing possible, press Corrective
START Probable Cause
Action
Membrane has not Manually inflate and
completely deflate IAB IAB catheter or Reattach IAB,
unfolded
IAB remains in Check markings on
extender tubing is press
sheath IAB and if IAB has disconnected START
not exited sheath,
refer
to IFU to reposition
sheath
Alarms
Prolonged Time in Standby Gas Loss in IAB Circuit
Probable Corrective Probable Cause Corrective Action

Cause Action A helium loss has been If blood observed -
detected in IAB circuit STOP pumping and
IABP has Verify prepare for removal
been in whether it
Standby for is If blood not observed -
verify connections are
at least 10 appropriate
tight
minutes to
resume If appropriate, perform
pumping an
Autofill, then press
START
Alarms
Unable to Update Timing

Poor waveform Check cable connections, verify transducer was not left vented, if in
quality use
If transducer is in use, aspirate and flush arterial pressure line
If problem persists, switch operation mode to SEMI-AUTO, verify

TRIGGER
SOURCE, adjust timing, resume pumping
Sustained heart rate Switch to SEMI-AUTO, verify TRIGGER SOURCE, adjust timing,
is less than 30 or resume pumping
greater than 150
BPM
Poor diastolic If diastolic augmentation is poor, when AUG level is set to MAX,
augmentation attempt to improve patient’s hemodynamic status
Alarms
Unable to Calibrate Fiber-Optic Sensor
Probable Corrective Action

Cause
Patient’s When patient’s pulse pressure improves,
pulse press CALIBRATE PRESSURE
pressure is key for 2 seconds while IABP is assisting
inadequate for
calibration Provide alternate A.P. source (i.e.: radial)
Extender Relieve restriction
tubing or
balloon Attempt calibration by pressing
catheter may CALIBRATE PRESSURE key for 2
be restricted seconds while IABP is assisting
Alarms
Fiber-Optic Sensor Calibration Postponed

A non-scheduled calibration Assess patient to determine if a brief
update has been intentionally pause in assist
postponed because either would be tolerated, and if so, press
patient’s mean arterial pressure CALIBRATE
may be too low to pause assist PRESSURE key for 2 seconds while
or less than 15 minutes have IABP is
elapsed since last calibration assisting
Provide alternate A.P. source (i.e.:

radial)
Pump is in STANDBY Resume pumping, then press
CALIBRATE
PRESSURE key for 2 seconds to
initiate a calibration
Alarms
Fiber-Optic Sensor Module Failure

There has been a If a MAQUET/Datascope fiber-optic IAB is NOT
failure of the internal in use, continue
Fiber-Optic Sensor normal IAB use
Module in the IABP
If a MAQUET/Datascope fiber-optic IAB is in use,
replace IABP
with another MAQUET/Datascope IABP that
supports the fiber-
optic IAB
If a replacement IABP is not available, provide

alternate A.P. source
(i.e.: radial)
Contact MAQUET Service for Fiber-Optic Sensor

Module repair
Alarms
Fiber-Optic Sensor Failure

There is a failure in Unplug Fiber-Optic Sensor Connector and
communication of the reconnect
fiber-optic sensor
signal with the IABP Relieve any visible kinks in orange Fiber-Optic
Cable
If problem persists, disconnect Fiber-Optic

Sensor Connector
and provide alternate A.P. source (i.e.: radial)

IABP Class Final

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IABP Class Final

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IABP

Primary Goal of IABP Therapy

What are the effects of IABC therapy on

Synchronization with the cardiac cycle

MAP-Mean RA/C.O=SVR in wood

• The IAB Should be selected according to the

Note: The 50cc balloons are no longer made by Datascope

Conventional Catheter Components

Proximal Marker Distal Marker

Conventional Catheter Components

Conventional Catheter Components

Conventional Catheter Components

Conventional Catheter Components

Conventional Catheter Components

Conventional Catheter Components

Conventional Catheter Components

Conventional Catheter Components

Fiber-optic Catheter Components

Fiber-optic Catheter Components

Fiber-optic Catheter Components

STATLOCK® Stabilization Device

Intra-aortic Balloon Pump

Proper IABP Timing

Mean Arterial Pressure Calculation

 IABP samples BP every 4msec on

One Cardiac Cycle Unassisted End Assisted End

Timing Error – Early Inflation

Timing Error – Late Inflation

Timing Error – Early Deflation

Timing Error – Late Deflation

Variations in Balloon Pressure Waveform

Bradycardia Tachycardia Irregular Rhythm

Variations in Balloon Pressure Waveform

Catheter Restriction Gas Loss

Oxygen Supply - Coronary Anatomy

Coronary Arteries 70% or < occlusion

Oxygen Supply - Diastolic Time/Pressure

Diastolic Phase Diastolic Phase

 Decreased diastolic filling time = decreased stroke volume

Oxygen Supply - Hgb & PaO2

Oxygen Demand - Heart Rate

Diastolic Phase Diastolic Phase

 Increased heart rate = increased demand for myocardial oxygen

Oxygen Demand - Afterload (Left Side)

Oxygen Demand - Preload (Left Side)

Oxygen Demand - Contractility

Proper placement of IAB catheter

Verification of proper placement

Important tips to remember

Proper Care of Inner Lumen

Back Panel – With a Fiber-optic IAB

Back Panel – With a Conventional IAB

Back Panel – With ECG External Monitor Interfacing

Back Panel – Hot Swappable Lithium Ion Batteries

Back Panel – Retractable Power Cord

CARDIOSAVE Initial Set-Up

Connect ECG cable

Connect fiber-optic IAB:

Press POWER button

Open helium tank (if

Initial set-up using a MAQUET/Datascope fiber-optic IAB (continued)

Verify Aug. Alarm is set 10mmHg

Pressing the START key