Is it best to place an Intra-Aortic Balloon Pump (IABP) on standby during X-ray imaging?

From the Guidelines

Yes, it is correct to place an Intra-Aortic Balloon Pump (IABP) on standby mode during X-ray imaging. When obtaining a chest X-ray for a patient with an IABP, the device should be temporarily placed on standby mode just before the image is taken. This pause in balloon inflation and deflation, which typically lasts only 10-15 seconds, helps prevent motion artifact that would otherwise blur the image and reduce diagnostic quality. Motion artifact occurs because the rapidly moving balloon (inflating and deflating at 40-120 times per minute) cannot be captured clearly by the X-ray exposure. After the X-ray is completed, the IABP should be immediately returned to its therapeutic mode to continue providing hemodynamic support. This brief interruption in IABP therapy is generally well-tolerated by most patients. However, for hemodynamically unstable patients who cannot tolerate even brief IABP interruption, the clinical team may need to accept a lower quality image or consider alternative imaging approaches.

The management of patients with IABP is crucial, and guidelines recommend its use in specific scenarios, such as cardiogenic shock not quickly reversed with pharmacological therapy 1. Recent studies have focused on the invasive management of acute myocardial infarction complicated by cardiogenic shock, highlighting the role of mechanical circulatory support (MCS) devices, including IABP 1. While the IABP-Shock II trial did not support the routine use of IABP in cardiogenic shock, it is essential to consider the timing of device insertion and the severity of shock in individual patients 1.

Key considerations for IABP management include:

• Temporarily placing the IABP on standby mode during X-ray imaging to prevent motion artifact
• Immediately returning the IABP to its therapeutic mode after the X-ray is completed
• Monitoring hemodynamically unstable patients closely during IABP interruption
• Considering alternative imaging approaches for patients who cannot tolerate brief IABP interruption

Overall, the use of IABP in clinical practice requires careful consideration of the individual patient's needs and circumstances, as well as adherence to established guidelines and protocols 1.

From the Research

Intra-Aortic Balloon Pump (IABP) Placement for Imaging

When obtaining an X-ray for IABP, it is essential to consider the optimal placement of the IABP for imaging purposes. The available evidence does not directly address the best practice for IABP placement during X-ray imaging.

Landmarks for IABP Placement

• The aortic knob is thought to be a useful radiographic landmark for positioning the IABP tip 2.
• However, the carina may be a more reliable landmark for positioning the IABP than the aortic knob, with 95.3% of patients having the origin of the left subclavian artery 35-55 mm above the carina 2.
• The distance from the level of the left subclavian artery origin to the level of the carina was measured using three-dimensional computed tomography in 150 patients, with a median distance of 42 mm (range: 30-63 mm) 2.

IABP Placement and Clinical Outcomes

• The use of IABP has been associated with improved clinical outcomes, including reduced pulmonary oedema and increased time off mechanical ventilation 3.
• IABP can be used as a bridge to heart transplant, with acceptable postoperative results, but with significant rates of adverse clinical events during support 4.
• Bedside IABP insertion under echocardiographic guidance may be a feasible and safe option for selected patients with cardiogenic shock, with similar rates of correct IABP positioning and IABP-related complications compared to fluoroscopic-guided insertion in the Catheterization Laboratory 5.

IABP and Mortality

• The use of IABP has been associated with lower in-hospital mortality in patients with cardiogenic shock, across different Society for Cardiovascular Angiography and Intervention (SCAI) shock stages 6.