What is an Intra-Aortic Balloon Pump (IABP)?

From the Guidelines

Intra-Aortic Balloon Pump (IABP) is a mechanical circulatory support device used to help patients with severe heart failure or cardiogenic shock, and its use is recommended only in the presence of haemodynamic impairment, as stated in the guidelines on myocardial revascularization 1. The device consists of a balloon catheter that is inserted into the descending thoracic aorta, typically via the femoral artery. The IABP works by inflating during diastole (when the heart relaxes) and deflating during systole (when the heart contracts). This counterpulsation mechanism increases coronary blood flow by augmenting diastolic pressure and reduces cardiac workload by decreasing afterload during systole. Some key points to consider when using an IABP include:

• Conventional indications for IABP are to support the circulation before surgical correction of specific acute mechanical problems, during severe acute myocarditis, and in selected patients with acute myocardial ischaemia or infarction before, during, and after percutaneous or surgical revascularization, as outlined in the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 1.
• IABPs are commonly used in patients with acute myocardial infarction complicated by cardiogenic shock, refractory unstable angina, or as a bridge to cardiac surgery or heart transplantation.
• Potential complications include limb ischemia, bleeding, infection, and vascular injury.
• Patients on IABP require continuous monitoring in an intensive care setting, with regular assessment of hemodynamic parameters, distal pulses, and device function.
• Anticoagulation with heparin is usually maintained during IABP therapy to prevent thrombus formation, with a target activated clotting time of 160-180 seconds or aPTT of 50-70 seconds. It is essential to weigh the benefits of IABP against device-related complications, mostly vascular and more frequently observed in small stature patients and/or females, patients with peripheral arterial disease (PAD), and diabetics, as noted in the guidelines on myocardial revascularization 1. The use of IABP should be balanced against the risks, and alternative mechanical circulatory assistance devices may be considered in patients who continue to deteriorate and cardiac function cannot maintain adequate circulation to prevent end-organ failure 1.

From the Research

Definition and Function of IABP

• The Intra-Aortic Balloon Pump (IABP) is a type of mechanical circulatory support device used to manage cardiogenic shock 2.
• It works by external counterpulsation, using systolic unloading and diastolic augmentation of aortic pressure to improve hemodynamics 2.
• IABP is one of the earliest and most widely used types of mechanical circulatory support, providing less hemodynamic support compared to newer devices but is still preferred in certain situations due to its simplicity, smaller size, and better safety profile 2.

Clinical Applications and Evidence

• IABP is frequently used to support severely compromised ventricles in critically ill patients, with the current ACC/AHA recommendations maintaining a Class 2A for its use in shock 3.
• However, the evidence supporting the use of IABP is equivocal, and its effectiveness in certain clinical situations, such as perioperative support during high-risk cardiac surgery, remains largely unproven due to limited data 3.
• IABP has been used in combination with other devices, such as extracorporeal membrane oxygenation (ECMO), to provide temporary support in patients with refractory cardiogenic shock 4.
• A network meta-analysis of randomized controlled trials and propensity score-matched studies found that ECMO-IABP may reduce mortality in patients with cardiogenic shock, while other mechanical circulatory support devices did not show a significant reduction in mortality 5.

Indications and Considerations

• IABP is indicated for use in cardiogenic shock, particularly in patients who are refractory to medical therapy or require temporary support 2, 3.
• The device can be used as a bridge to recovery or as a bridge to left ventricular assist device (LVAD) implantation or transplant 4.
• The choice of IABP or other mechanical circulatory support devices depends on the patient's specific hemodynamic profile and clinical situation, with the goal of tailoring therapy to individual needs 6.