Transcript IABP… - 365医学网

主动脉球囊反搏在心脏危
重症中的临床应用
Intra Aortic Balloon Pump
张瑞岩
上海交通大学医学院附属瑞金医院心脏科
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Case No.1
 Male ，71y
 Acute STEMI, Cardiogenic Shock
 Coronary risk: Hypertension, smoking
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Immediate Coronary Angiography
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Primary PCI with IABP support
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Case No.2
• Female, 67y
• Acute Non-STEMI, Cardiogenic Shock
• Coronary risk: hypertension
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Coronary Angiography
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Immediate PCI with IABP Support
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History of IABP
• 1952, Adrian and Arthur Kantrowitz: principle
tested in experimental animals
• 1962, Moulopoulos et al. developed an intraaortic device
• 1968, Kantrowitz et al. reported the use of IABP
in 2 pts with cardiogenic shock
• 1980, Bregman et al. described percutaneous
insertion of IABP
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Innovation in Industry
KONTRON
MODEL 10 IABP
AVCO MODEL 7 IABP
Prototype Pump
ACAT® 1
PLUS IABP
KAAT AND K 2000 IABPs
TransAct® IABP
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Hemodynamic Principles of IABP
A: cardiac diastole - inflation
• Diastolic pressure↑
• Coronary artery flow↑
• Great vessel & renal artery
flow↑
B: cardiac systole - deflation
• Forward flow to the aorta
and periphery↑
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Hemodynamic Effects
• Diastolic inflation---augmentation of DBP
 Increase coronary and systemic perfusion
 Increase in myocardial oxygen supply
• Systolic deflation---afterload reduced
 Reduce LV wall stress
 Decrease myocardial oxygen demand
 Increase in cardiac output
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Device Components and Selection
•
•
Components: (1) a double-lumen
8F~9.5F catheter with a 25~50ml
balloon at its distal end; (2) a console
with a pump to deliver gas to the
balloon
Selection of the balloon: fully expanded
balloon diameter ≤85%~90% of the
diameter of the patient’s descending
thoracic aorta
>183cm:50ml
163~183cm: 40ml
152~162cm:30ml
<152cm: 25ml
The tip of the catheter should be positioned 2~3cm distal to the origin of the LSA
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Triggers & Interpretation of IABP
•
Triggers: EKG waveform & systemic arterial pressure
•
Depending on the patient’s status (1:1, 1:2, 1:4,1:8)
•
Optimal arterial wave forms with IABP

Peak diastolic augmentation should be greater than the
unassisted systolic pressure

The 2 assisted pressures should be less than the unassisted
values
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Timing
D>C;
B+C>D+E
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Interpretations
• Optimal arterial
waveform
 Diastolic augmentation
>unassisted systolic
pressure
 2 assisted pressures
<the unassisted values
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Interpretations
•
Balloon inflation occurs
too early (before aortic
valve closure)
 LV afterload↑
 Myocardial oxygen
consumption↑
 LV systolic function↓
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Interpretations
• Balloon inflation occurs
too late (well after the
beginning of diastole)
 Minimizing the diastolic
augmentation
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Interpretations
•
Balloon deflation occurs too
early (before the end of
diastole)
 Diastolic pressure
augmentation period↓
 Transient decrease in aortic
pressure may promote
retrograde arterial flow from
the carotid or coronary
arteries
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Interpretations
•
Balloon deflation occurs too
late (after the end of diastole)
 As early balloon inflation
 LV afterload↑
 Myocardial oxygen
consumption ↑
 LV Systolic function↓
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Indications for Use
• Cardiogenic shock (complicated AMI, RV failure)
• Cardiogenic shock due to VSR or papillary muscle rupture, with
resultant mitral regurgitation (mechanical complications of AMI or
trauma)
• Intractable ventricular arrhythmias
• Post-MI angina or unstable angina refractory to medical therapy
• Severe CAD with hemodynamic compromise (left main disease)
• Heart failure refractory to medical therapy
• Hemodynamic support for “high-risk” coronary intervention
• Hemodynamic support for high-risk CABG
• Bridge to heart transplantation
• Septic shock
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Shock Registry
in-hospital mortality by IABP/Lytic use
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The use of IABP in patients with cardiogenic
shock complicating AMI: data from the
National Registry of Myocardial Infarction 2
• Retrospective analysis of 23,180 AMI patients
complicated by cardiogenic shock
• IABP was used in 7,268 patients
Barron HV, et al. AHJ 2001;141:933
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PAMI-2 Trial
Study Design
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PAMI-2 Trial Conclusions
• IABP was associated with fewer ischemic events,
repeat interventions, re-infarction, and
congestive heart failure episodes
• The vascular complication rate was low in IABP
group (2.2%)
• No benefit of IABP was observed among low risk
patients with AMI
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ACC/AHA IABP Practice Guidelines
Clinical situation
ACC/AHA
recommendation
Level of
evidence
IIa
C
I
C
I
B
IIb
C
IIa
B
Unstable angina
(refractory to intensive medical care, for hemodynamic
instability in pts pre- and post- coronary intervention)
Recurrent ischemia/infarction
(hemodynamic instability, poor LV function, or a large
area of myocardium at risk)
Cardiogenic shock
(not quickly reversed with pharmacological therapy)
CHF
(w/ refractory pulmonary congestion)
Polymorphic VT
(refractory to medical management)
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ACC/AHA Guidelines for STEMI 2004
Treatment of low-output state/cardiogenic shock
•
Class I
 Fluids, inotropic support, IABP…
 Mechanical reperfusion with PCI or CABG if age<75y, early shock (<18hrs)
 Surgical correction of mechanical defects
 Fibrinolytic therapy if not suitable for invasive approach
•
Class IIa
 Early revasc. in selected patients >=75yrs old, if good prior functinal status
and present early
•
Class III – not recommended or contraindicated
 Beta-blockers
 Calcium channel antagonists
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Contraindications to IABP
• Aortic regurgitation
• Suspected or known aortic dissection
• Sizable abdominal aneurysm
• Severe peripheral vascular disease
• Uncontrolled septicemia or a bleeding diathesis
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Concomitant Medications,
Weaning and Removal
• UFH to maintain APTT 50s~70s
• An immobile IABP should be removed within 30 minutes
• Discontinue heparin >= 2 hours before removal
• Periodically inflating IABP to prevent hemostasis and thrombosis
• If a patient tolerates a 1:3 ratio, the IABP can be removed
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Complications of IABP
• Vascular complications
 bleeding, systemic embolization, limb ischemia and
amputation, aortic dissection
• Mechanical complications
 balloon rupture, inadequate inflation, inadequate
diastolic augmentation
• Infection
• Death
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Complication Frequency
7.00%
6.00%
4.00%
0.80%
0.90%
limbthreatening
ischemia
2.00%
major
bleeding
2.60%
0.10%
limb
amputation
major
total
0.00%
0.05%
death
8.00%
Age>=75y
PVD
DM
Female
BSA<1.65m2
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Hematologic Effects
• Hemoglobin and hematocrit often decrease modestly
(hemolysis from mechanical damage to erythrocytes and
bleeding at the vascular access site)
• Thrombocytopenia (mechanical destruction of platelet,
heparin administration)
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Daily Evaluation after IABP
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Sepsis
Thrombocytopenia
Blood loss
Hemolysis
Vascular obstruction
Thrombus
Embolus
Dissection
APTT
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Conclusions
•
IABP is one of the most versatile support device used in the
management of patients suffering from complications of acute
cardiovascular disease
•
Relative ease and quick use of IABP leads to its application as
a first line intervention among critically unstable patients
•
Improved risk-benefit ratio has achieved with the improvement
in technology and refined percutaneous insertion techniques
•
IABP should probably be applied more often in certain clincal
situations to enhance patient outcomes
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Thanks !
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