Intra-Aortic Balloon Pumps

Matthew D. Kauffmann
CCEMT-P
Abbott EMS
Cardiogenic shock is a deadly complication of myocardial infarction or cardiac arrhythmias.
Intra-aortic balloon pumps can be lifesaving devices for these fragile patients. In this brief
paper, we will detail the function of the intra-aortic balloon pump. We will discuss the cardiac
physiology, general usage guidelines & principles, and indications & contraindications, and
transport considerations for intra-aortic balloon pumps.

Shock, or hypoperfusion, is hypoxia at the cellular level. This can happen for one of three
reasons. It is either a problem with the fluid, the pump, or the container. There can be a lack of
fluid, in the cases of trauma or exsanguinations. There can be a problem with the container, in
the case of sepsis or a neurogenic problem that causes vasodilation. There can be a problem
with the pump – inefficient or insufficient pumping by the myocardium, often caused by
myocardial infarction or arrhythmias. Each type of shock has a specific treatment. Fluid
problems are usually treated with replacement fluids, whether isotonic crystalloid solutions or
replacement blood. In the case of septic shock treatment is a combination of removing the
infection and vasoconstrictors such as Levophed. In the case of a pump problem, treatment is
aimed at preserving myocardium and continuing the important function of perfusing the rest of
the body. This is accomplished with two primary methods: medication and intra-aortic balloon
pumps.

Before we delve into the specifics of intra-aortic balloon pumps, it is relevant to discuss a bit of
cardiac physiology. The heart is comprised of four chambers, each with an important function.
The right artrium collects unoxygenated blood from the body and pushes it into the right
ventricle. From the right ventricle, the blood goes into the lungs to collect oxygen molecules.
From the lungs, the blood returns to the heart and collects in the left atrium. From the left
atrium into the powerful left ventricle; from the left ventricle back out to the body. This
happens with a familiar lub-dub pattern approximately eighty times per minute.

The cardiac cycle is a complex cycle of contractions of the four chambers of the heart controlled
by the Sino-Atrial node. While all parts of the cycle are important, for the rest of the body the
most important part is the contraction of the left ventricle – which expels blood to perfuses the
body during the period known as systole. During diastole, the heart returns to a period of rest.
To the casual observer, it would seem that diastole is not as important, HOEWEVER, it is during
diastole that the myocardium receives its perfusion. We will see why this is important as we
explore the mechanism of the intra-aortic balloon pump.

In order to understand the function of an intra-aortic balloon pump, it is important to

understand the cardiac equation: cardiac output is equal to stroke volume multiplied by rate.
Stroke volume is influenced by contractility, preload, and afterload. Contractility is the ability
and force at which the myocardial fibers squeeze blood from the heart. Preload is a function of
venous return – it is the amount of blood available for the heart to pump. Afterload is the
tension against which the ventricle must expel blood from the heart or systemic vascular
resistance. In order to overcome cardiogenic shock, one must increase cardiac output. This can
be done by increasing stroke volume or by increasing rate. Rate seems easiest. However, as we
said above the heart receives perfusion during diastole. Therefore, by increasing the rate we
decrease diastolic time causing a decreasing in perfusion to the heart, which is why
tachydysrhythmias are so dangerous. That being said, in order to efficiently increase cardiac
output, we must increase stroke volume. To increase contractility would be a function of a
positive intropic medication such as Dopamine or Dobutamine. The downside of this is that
they themselves increase myocardial oxygen demand, thus worsening the myocardial damage.
They can also cause tachycardias which as we have said increase myocardial oxygen demand.
The second way would be to increase preload. This can be done by increasing systemic blood
pressure, which unfortunately increases afterload and makes the heart work harder creating
more myocardial oxygen demand and potentially worsening the myocardial damange. The third
way to increase cardiac output would be to decrease afterload. This is done by lowering
systemic blood pressure, which is dangerous beyond certain levels. We seem to have an
unwinnable game.

Enter intra-aortic balloon pumps. A balloon is inserted into the aorta and controlled by a
computer and pump outside the body. Intra-aortic balloon pumps work by counter-pulsation.
The computer syncs with the heart’s natural beating pattern to pulse in time but opposite the
heart. The inflation is timed to deflate just before the beginning of systole. This creates the
previously mentioned vacuum that pulls blood from the left ventricle thereby reducing
afterload and indirectly increasing preload. As the left ventricle is emptied, diastole begins and
the aortic valve closes, the intra-aortic balloon pump inflates, which augments the heart’s own
work and increasing preload. More importantly, because the aortic valve is closed and the
chordae tendineae are preventing its collapse, the blood is also pushed backwards into
myocardial circulation to perfuse the heart itself.

The most important consideration when operating an intra-aortic balloon pump is timing. As
one can imagine, the inflation and deflation of the balloon must be precisely timed to work
effectively (at best) lest it become dangerous to the patient (at worst). Timing is generally
controlled by a computer, but is monitored by a technologist who observes waveforms.
Generally speaking, the intra-aortic balloon pump will coincide with the electrocardiogram.
However, the electrocardiogram waveform is not important to calibrating or monitoring the
intra-aortic balloon pump. The waveform of an intra-aortic balloon pump is a pressure wave,
with a distinct mark at the closing of the aortic valve, known as the dichrotic notch. If the
counter-pulsation of the intra-aortic balloon pump is timed correctly, the resulting wave form
will have a higher peak and a lower valley to coincide with the pulsed beats. Most often, the
intra-aortic balloon pumps are used with every other heartbeat.

The most dangerous timing errors are early inflation or late deflation. Either of these errors
causes the balloon to be inflated as the heart is trying to push blood against it, creating an
impossibly high afterload and virtually eliminating cardiac output. This timing error can be seen
in the wave form as a low peak or high valley. The errors of timing the balloon to deflate early
or inflate late are not as serious, but the result is sub-optimal benefit of the device. Late
inflation causes poor coronary perfusion. Early deflation results in reduced coronary perfusion and
the potential for retrograde coronary blood flow. If the patient is improving and not needing as
much help it is better to set the intra-aortic balloon pump to pulse on fewer beats, rather than
to have it pulse for a shorter duration.

These are example waveforms, courtesy of

http://www.aic.cuhk.edu.hk/web8/IABP%20pressure%20waveforms.htm

Normal Waveform
Early Inflation

Late Inflation
Early

Deflation
 Late Deflation

Intra-
aortic
balloon
pumps
are
used for patients who are in left ventricular failure who have a chance for recovery. They are
often used on high-risk patients who are post myocardial infarction or who are awaiting a heart
transplant. As good as they seem, intra-aortic balloon pumps cannot be used on all patients.
They absolutely cannot be used in cases of a weak aorta or previous aortic dissection, due to
the increased pressure on the aortic walls. It is also important to consider the risks of using an
intra-aortic balloon pump. These include the creation of an embolus, infection, limb ischemia,
or the formation of a thrombus on a malfunctioning balloon. There is also a great risk in the
balloon shifting. If the balloon shifts up, it can puncture the aorta. If it shifts down, it can block
the important renal arteries. As we can see, the benefits greatly outweigh the risks, and there
are very few patients who cannot benefit from this therapy.

Transporting an intra-aortic balloon pump is never a matter to be taken lightly. Certainly, these
patients should be regarded as unstable even with the best of circumstances. In addition to the
considerations for the intra-aortic balloon pump itself, these patients also often require
mechanical ventilation and multiple medication infusions. The most important consideration
for transporting a patient on an intra-aortic balloon pump is positioning – of the pump and of
the patient. The patient needs to be maintained in a very secure position to prevent the balloon
from shifting within them, which as we described above can cause dangerous side effects. The
pump must also be tended to. They are generally heavy and require a conscious effort to lift
and move them – not only for the safety of the lifters, but to keep them close to the patient
and not disconnect the lines. Further, as many intra-aortic balloon pumps are timed from the
electrocardiograph reading, it is important to maintain a smooth transport as to allow the
sensor to accurately read the patient. Finally, it is always important to read the wave form and
ensure the intra-aortic balloon pump is compliant with the patient.

Intra-aortic balloon pumps are life-saving devices for patients in cardiogenic shock. In this brief
paper, we have detailed the function of the intra-aortic balloon pump. We have discussed the
cardiac physiology, general usage guidelines & principles, and indications & contraindications,
and transport considerations for intra-aortic balloon pumps.

These sources were consulted prior to writing:

Gilmore, WS. “Intra-Aortic Balloon Counterpulsation Therapy.” Abbott EMS SCT Quarterly
Training. St. Louis, Missouri. 20 February 2010.

(September 2006).Intra-Aortic Balloon Pump Refresher. Retrieved 15 February 2010 from

www.icufaqs.org/IABPFAQ.doc.