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Coronary anatomy: Difference between revisions
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→Intra-aortic balloon counterpulsation
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[[File:IntraAortic_figure1.jpg]] | [[File:IntraAortic_figure1.jpg]] | ||
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Figure 1: intra-aortic location of IABP | Figure 1: intra-aortic location of IABP | ||
[[File:IntraAortic_figure2.jpg]] | [[File:IntraAortic_figure2.jpg]] | ||
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Figure 2: balloon pressure curve. | Figure 2: balloon pressure curve. | ||
''Technique'' | ''Technique'' | ||
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The balloon pump system consists of a balloon-tipped catheter (polyurethane, 10cm, 40ml, dual lumen) that is positioned in the descending aorta 1 to 2 cm beyond the origin of the left subclavian artery and is inserted percuteaneously through a 8-9 French sheath. The balloon is inflated in with helium after aortic valve closure (triggered on the R wave of surface ECG), and maintained until just before the beginning of systolic ejection when the helium is abruptly withdrawn. When appropriately timed, the effect of the IABP is to reduce ventricular afterload and increase cardiac output. | The balloon pump system consists of a balloon-tipped catheter (polyurethane, 10cm, 40ml, dual lumen) that is positioned in the descending aorta 1 to 2 cm beyond the origin of the left subclavian artery and is inserted percuteaneously through a 8-9 French sheath. The balloon is inflated in with helium after aortic valve closure (triggered on the R wave of surface ECG), and maintained until just before the beginning of systolic ejection when the helium is abruptly withdrawn. When appropriately timed, the effect of the IABP is to reduce ventricular afterload and increase cardiac output. | ||
''Indication'' | ''Indication'' | ||
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*Severe arrhythmia owing to refractory ischemia | *Severe arrhythmia owing to refractory ischemia | ||
*Prophylactic high risk intervention (high risk PCI due to LV dysfunction or large territory at risk, severe multivessel disease, left main disease) | *Prophylactic high risk intervention (high risk PCI due to LV dysfunction or large territory at risk, severe multivessel disease, left main disease) | ||
Contra-indications are: | Contra-indications are: | ||
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*High risk of bleeding | *High risk of bleeding | ||
*Bilateral femoral-popliteal bypass grafts | *Bilateral femoral-popliteal bypass grafts | ||
''Precautions'' | ''Precautions'' | ||
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The level of anticoagulation should be monitored daily, with aPTT maintained 50-70 seconds to prevent thrombotic or embolic complications. Evalutions of the limbs and peripheral circulation should be checked regularly. Before removal, patients are weaned by decreasing the counterpulsation (to 1:2/1:3). The incidence of major complications is 2.8%. Common complications are limb ischemia, access site bleeding and balloon leak. Risk factors for complications are female sex, older age (>75 years), BSA < 1.65m2 and peripheral vascular disease. | The level of anticoagulation should be monitored daily, with aPTT maintained 50-70 seconds to prevent thrombotic or embolic complications. Evalutions of the limbs and peripheral circulation should be checked regularly. Before removal, patients are weaned by decreasing the counterpulsation (to 1:2/1:3). The incidence of major complications is 2.8%. Common complications are limb ischemia, access site bleeding and balloon leak. Risk factors for complications are female sex, older age (>75 years), BSA < 1.65m2 and peripheral vascular disease. | ||
''Clinical results'' | ''Clinical results'' | ||
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In one meta-analyses including 7 randomized trials with STEMI patients with cardiogenic shock, IABP showed neither a 30-day survival benefit nor improved left ventricular ejection fraction, and was associatied with more complications (higher stroke, higher bleeding rates). Another meta-analysis included 9 cohorts with STEMI patients with cardiogenic shock, and showed that IABP was associated with an 18% decrease in 30 day mortality, but with significantly higher revascularization rates and higher mortality in the PCI group<cite>EurHeart2</cite>. In the randomized controlled trial Shock II, publiced in the NEJM in 2012, the use of IABP did not significantly reduce the 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned<cite>Thiele</cite>. | In one meta-analyses including 7 randomized trials with STEMI patients with cardiogenic shock, IABP showed neither a 30-day survival benefit nor improved left ventricular ejection fraction, and was associatied with more complications (higher stroke, higher bleeding rates). Another meta-analysis included 9 cohorts with STEMI patients with cardiogenic shock, and showed that IABP was associated with an 18% decrease in 30 day mortality, but with significantly higher revascularization rates and higher mortality in the PCI group<cite>EurHeart2</cite>. In the randomized controlled trial Shock II, publiced in the NEJM in 2012, the use of IABP did not significantly reduce the 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned<cite>Thiele</cite>. | ||
= References = | = References = | ||