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Dharam Prakash Saran
1
2
Intra aortic balloon counter pulsation( IABP):
Most common and widely available methods of mechanical
circulatory suppor...
3
Indications for IABP
1. Cardiogenic shock:
2. In association with CABG :
Preoperative insertion
- Patients with severe L...
4
CONTRAINDICATIONS
Absolute-
▫ Significant aortic regurgitation
▫ Aortic dissection
▫ Aortic stents
▫ Bilateral femoral pop...
6
7
8
Interpreting IABP waveforms
9
IABP –instrumentation and
techniques
10
The IAB Counter pulsation system
- two principal parts
 A flexible catheter -2 lumen
• first - for distal aspiration/f...
11
12
Expected changes with IABP support in hemodynamic profile in
patients with Cardiogenic shock
- Decrease in SBP by 20 %
...
13
IABP catheter:
 10-20 cm long polyurethane bladder
 25cc to 50cc capacity
 Optimal 85% of aorta occluded (not 100%)
...
14
Intra Aortic Balloon
15
Balloon sizing
 Sizing based on patients
height
 Four common balloon
sizes
 Balloon length and
diameter increases wi...
16
Benefits of larger volume IABs
• More blood volume displacement
• More diastolic augmentation
• More systolic unloading
17
Introducer needle
• Guide wire
• Vessel dilators
• Sheath
• IABP (34 or 40cc)
• Gas tubing
• 60-mL syringe
• Three-way ...
18
Connect ECG
Set up pressure lines
Femoral access – followed by insertion of the supplied
sheath
0.030 inch supplied...
19
Take the entire catheter and T handle as one unit
(DO NOT disconnect one-way
valve when removing the
extracorporeal tub...
20
• Remove stylet/aspirate/Flush
• Insert the balloon only over the guide wire
• Hold the catheter close to skin insertio...
21
- The end of the balloon should be just distal (1-2 cm) to the takeoff of the
left subclavian artery
- Position should ...
22
Connecting to console:
- Connect helium gas tube to the console via a long extender
- Open helium tank.
- The central l...
23
24
25
Trigger modes
Trigger :
- Event the pump uses to identify the onset of cardiac cycle (systole)
- Pump must have consist...
26
ECG signal – most common
• Inflation
- middle of T wave
• Deflation
– peak of R wave
• Pacer (v/a)
• Arterial waveform
...
27
28
29
30
Increased coronary
perfusion
The “normal” augmented waveform
31
Not all Sub optimal augmentation is due to Timing
errors/kinks
32
Factors affecting diastolic augmentation
Patient
- Heart rate
- Mean arterial pressure
- Stroke volume
- Systemic vascu...
33
How to check waveform is acceptable ?
 First change from 1:1 to 1:2 augmentation
 Check the dicrotic notch
 See if a...
34
How to check waveform is acceptable ?
 First change from 1:1 to 1:2 augmentation
 Check the dicrotic notch
 See if a...
35
How to check waveform is acceptable ?
 First change from 1:1 to 1:2 augmentation
 Check the dicrotic notch
 See if a...
36
37
Late Inflation
 Inflation of the IAB markedly after closure of the aortic valve.
 Waveform Characteristics:
• Inflati...
38
Early Deflation
 Premature deflation of the IAB during the diastolic phase.
39
Late Deflation
 Late deflation of the IAB during the diastolic phase.
 Waveform Characteristics:
• Assisted aortic en...
40
41
Variation in balloon pressure wave forms
Increased duration of
plateau due to longer
diastolic phase
Decreased duration...
42
Variation in balloon pressure wave forms
Varying R-R intervals
result in irregular
plateau durations
43
Variation in balloon pressure wave forms
Increased height
or amplitude of
the waveform
Decreased height
or amplitude of...
44
Variation in balloon pressure wave forms
Gas leak
Leak in the closed system causing the
balloon pressure waveform to fa...
45
Catheter Kink
Rounded balloon pressure waveform
- Loss of plateau resulting from a kink or
obstruction of shuttle gas
-...
46
“Balloon too
large”
syndrome
47
Patient Management During IABP support
 Anticoagulation-- maintain apTT at 50 to 70 seconds
 CXR daily – to R/O IAB m...
48
 Never leave in standby by mode for more than 20 minutes >
thrombus formation
 Daily
– Haemoglobin (risk of bleeding ...
49
50
Weaning of IABP
Timing of weaning:
- Patient should be stable for 12 – 24 hours
- Decrease inotropic support
- Decrease...
51
IABP Removal
-Discontinue heparin 1 hour prior to removal
-Disconnect the IAB catheter from the IAB pump
- Patient bloo...
ACC/AHA 2013Practice Guidelines (ESC
2012- IIb)
52
ESC 2014 GUIDELINES
53
IABP IN UA/NSTEMI (2007, 2012
update)
(Current Practices)(Class IIa LOE-©)
54
The placement of an IABP could be useful in
...
TRIALS OF IABP
55
Benchmark registry
• n = 17,000( june 1996- aug 2000)
• 203 hospitals- 90% US
• 18.8% of IABP used for cardiogenic shock
•...
Balloon-pump assisted Coronary Intervention
Study (BCIS-1):
• The first randomized controlled trial of elective
Intra-Aort...
58IABP in high risk PCI(BCIS-1 TRIAL)
N= 301 Elective IABP(
151)
No elective
IABP(150)
P VALUE
MACE 15.2% 16% 0.85
All cau...
59
Conclusions of long term results of
BCIS1 trial(2012-2013)
In patients with severe ischemic cardiomyopathy treated
with...
60
Counterpulsation Reduces Infarct Size Acute Myocardial
Infarction (CRISP AMI) trial.
Intra-aortic balloon pump counterp...
Shock trial and registry
61
62
N-302 pts
N- 152 pts N- 150 pts
63
SHOCK Trial
Primary and Secondary Endpoints
0
20
40
60
80
30 Days 6 months
Immediate
Revascularization
Strategy
Medical...
64
Impact of thrombolysis, intra-aortic balloon
pump counterpulsation, and their
combination in cardiogenic shock
complica...
65
SHOCK Registry: Impact of Thrombolytics
and IABP
0
20
40
60
80
47%
52%
%
P<0.0001
63%
77%
Thrombolytics
+ IABP
No
Throm...
66
Intraaortic Balloon Support for
Myocardial Infarction with
Cardiogenic Shock
IABP Shock II Trial
Conclusion
• The use of intraaortic balloon counterpulsation
did not significantly reduce 30-day mortality in
patients wit...
MCQs
68
• 1. Major physiological effects of counter pulsation
include?
▫ A) increased coronary artery perfusion, increased preload...
2. The dicrotic notch on the arterial wave form
reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric ...
3. Expected changes with IABP support in hemodynamic
profile in patients with Cardiogenic shock include all
except?
A) Dec...
4. late inflation of the balloon can result in?
A) premature augmentation
B) increased augmentation
C) decreased augmentat...
5. A rounded balloon pressure wave form
indicate?
A) helium leak
B) power failure
C) hypovolemia
D) balloon occluding the ...
6. width of balloon pressure wave form
corresponds to
A) length of systole
B) length of diastole
C) arterial pressure
D) h...
7. true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso
v...
8. true statement
A) pacing spikes are automatically rejected in ECG
triggered modes
B) pacing trigger modes can be used i...
9. Identify the tracing abnormality
77
10. Identify the tracing abnormality
78
79
• 1. Major physiological effects of counter pulsation
include?
▫ A) increased coronary artery perfusion, increased preload...
2. the dicrotic notch on the arterial wave form
reflects
A) aortic valve opening
B) aortic valve closure
C) isovolumetric ...
3. Expected changes with IABP support in hemodynamic
profile in patients with Cardiogenic shock include all
except?
•A) De...
4. late inflation of the balloon can result in?
• A) premature augmentation
• B) increased augmentation
• C) decreased aug...
5. A rounded balloon pressure wave form
indicate?
• A) helium leak
• B) power failure
• C) hypovolemia
• D) balloon occlud...
6. width of balloon pressure wave form
corresponds to
• A) length of systole
• B) length of diastole
• C) arterial pressur...
7. true statement
a) Dicrotic notch- land mark used to set deflation
b) Deflation is timed to occur during period of iso
v...
8. true statement
A) pacing spikes are automatically rejected in ECG
triggered modes
B) pacing trigger modes can be used i...
9.
88
10.
89
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IABP

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IABP

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IABP

  1. 1. Dharam Prakash Saran 1
  2. 2. 2 Intra aortic balloon counter pulsation( IABP): Most common and widely available methods of mechanical circulatory support Temporary support for the left ventricle by mechanically displacing blood within the aorta Concepts: - Systolic unloading - Diastolic augmentation Traditionally used in surgical and non surgical patients with cardiogenic shock
  3. 3. 3 Indications for IABP 1. Cardiogenic shock: 2. In association with CABG : Preoperative insertion - Patients with severe LV dysfunction - Patients with intractable ischemic arrhythmias Postoperative insertion - Postcardiotomy cardiogenic shock - Associated with acute MI - Mechanical complications of MI - MR , VSD 3. In association with nonsurgical revascularization: -Hemodynamically unstable infarct patients -High risk coronary interventions - severe LV dysfunction, LMCA, complex coronary artery disease 4. Stabilization of cardiac transplant recipient before insertion of VAD Post infarction angina Ventricular arrhythmias relathed to ischemia
  4. 4. 4
  5. 5. CONTRAINDICATIONS Absolute- ▫ Significant aortic regurgitation ▫ Aortic dissection ▫ Aortic stents ▫ Bilateral femoral popliteal bypass grafts for severe PVD Relative - ▫ Abdominal aortic aneurysm ▫ Uncontrolled septicemia ▫ Uncontrolled bleeding diathesis ▫ Severe bilateral peripheral vascular disease
  6. 6. 6
  7. 7. 7
  8. 8. 8 Interpreting IABP waveforms
  9. 9. 9 IABP –instrumentation and techniques
  10. 10. 10 The IAB Counter pulsation system - two principal parts  A flexible catheter -2 lumen • first - for distal aspiration/flushing or pressure monitoring • second - for the periodic delivery and removal of helium gas to a closed balloon.  A mobile console • system for helium transfer • computer for control of the inflation and deflation cycle
  11. 11. 11
  12. 12. 12 Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock - Decrease in SBP by 20 % - Increase in aortic Diastolic Press. by 30 % ( raise coronary blood flow) - Increase in MAP - Reduction of the HR by 20% -Decrease in the mean PCWP by 20 % - Elevation in the COP by 20%
  13. 13. 13 IABP catheter:  10-20 cm long polyurethane bladder  25cc to 50cc capacity  Optimal 85% of aorta occluded (not 100%)  The shaft of the balloon catheter contains 2 lumens: - one allows for gas exchange from console to balloon - second lumen - for catheter delivery over a guide wire - for monitoring of central aortic pressure after installation.
  14. 14. 14 Intra Aortic Balloon
  15. 15. 15 Balloon sizing  Sizing based on patients height  Four common balloon sizes  Balloon length and diameter increases with each larger size  40 cm³ balloon is most commonly used  Paediatric balloons also available : sizes 2.5, 5.0, 12.0 and 20 cm³ Balloon size Height 50 cm³ > 6 feet 40 cm³ 5 feet 4 inch to 6 feet 34 cm³ 5 feet to 5 feet 4 inch 25 cm³ < 5 feet
  16. 16. 16 Benefits of larger volume IABs • More blood volume displacement • More diastolic augmentation • More systolic unloading
  17. 17. 17 Introducer needle • Guide wire • Vessel dilators • Sheath • IABP (34 or 40cc) • Gas tubing • 60-mL syringe • Three-way stopcock IABP Kit Contents
  18. 18. 18 Connect ECG Set up pressure lines Femoral access – followed by insertion of the supplied sheath 0.030 inch supplied J-shaped guide wire to the level of the aortic arch (LAO view) - IABP insertion
  19. 19. 19 Take the entire catheter and T handle as one unit (DO NOT disconnect one-way valve when removing the extracorporeal tubing from the tray.) Pull out the T- handle only as shown
  20. 20. 20 • Remove stylet/aspirate/Flush • Insert the balloon only over the guide wire • Hold the catheter close to skin insertion point • Advance in small steps of 1 to 2 cm at a time and stop if any resistance. • The IABP should advance freely Inserting the Balloon catheter - Many vascular complications occur during insertion itself - Resistance during insertion either indicates PVOD, or dissection - Kinking of IABP » improper inflation/deflation
  21. 21. 21 - The end of the balloon should be just distal (1-2 cm) to the takeoff of the left subclavian artery - Position should be confirmed by fluoroscopy or chest x-ray Positioning
  22. 22. 22 Connecting to console: - Connect helium gas tube to the console via a long extender - Open helium tank. - The central lumen of the catheter is flushed and connected to pressure tubing with 3 way and then to a pressure transducer to allow for monitoring of central aortic pressure. - Zero the transducer Initial set-up: - Once connected properly the console would show ECG and pressure waveforms. - Check Basal mean pressure - Make sure the setting is at “auto” - Usually IABP started at 1:1 or 1:2 augmentation - Usually Augmentation is kept at maxim
  23. 23. 23
  24. 24. 24
  25. 25. 25 Trigger modes Trigger : - Event the pump uses to identify the onset of cardiac cycle (systole) - Pump must have consistent trigger in order to provide patient assist - If selected trigger not detected, counter pulsation will interrupted 1.ECG - uses the slope of QR segment to detect triggering point 2. AP(Arterial pressure wave) - Systolic upstroke of the arterial pressure wave form is the trigger
  26. 26. 26 ECG signal – most common • Inflation - middle of T wave • Deflation – peak of R wave • Pacer (v/a) • Arterial waveform • An intrinsic pump rate (VF, CPB)
  27. 27. 27
  28. 28. 28
  29. 29. 29
  30. 30. 30 Increased coronary perfusion The “normal” augmented waveform
  31. 31. 31 Not all Sub optimal augmentation is due to Timing errors/kinks
  32. 32. 32 Factors affecting diastolic augmentation Patient - Heart rate - Mean arterial pressure - Stroke volume - Systemic vascular resistance Intra aortic balloon catheter - IAB in sheath - IAB not unfolded - IAB position - Kink in the IAB catheter - IAB leak - Low helium concentration Intra aortic balloon pump - Timing - Position of IAB augmentation control
  33. 33. 33 How to check waveform is acceptable ?  First change from 1:1 to 1:2 augmentation  Check the dicrotic notch  See if augmentation starts at that point This should produce a sharp “V” at inflation.
  34. 34. 34 How to check waveform is acceptable ?  First change from 1:1 to 1:2 augmentation  Check the dicrotic notch  See if augmentation starts at that point This should produce a sharp “V” at inflation.  Check if diastolic augmented wave is › systolic wave
  35. 35. 35 How to check waveform is acceptable ?  First change from 1:1 to 1:2 augmentation  Check the dicrotic notch  See if augmentation starts at that point This should produce a sharp “V” at inflation.  Check if diastolic augmented wave is › systolic wave  Confirm if end diastolic wave following the augmented wave is less than an non augmented wave.  Is Deflation slope ok
  36. 36. 36
  37. 37. 37 Late Inflation  Inflation of the IAB markedly after closure of the aortic valve.  Waveform Characteristics: • Inflation of IAB after the dicrotic notch. • Absence of sharp V. • Sub optimal diastolic augmentation
  38. 38. 38 Early Deflation  Premature deflation of the IAB during the diastolic phase.
  39. 39. 39 Late Deflation  Late deflation of the IAB during the diastolic phase.  Waveform Characteristics: • Assisted aortic end diastolic pressure may be equal to the unassisted aortic end diastolic pressure. • Rate of rise of assisted systole is prolonged. • Diastolic augmentation may appear widened
  40. 40. 40
  41. 41. 41 Variation in balloon pressure wave forms Increased duration of plateau due to longer diastolic phase Decreased duration of plateau due to shortened diastolic phase
  42. 42. 42 Variation in balloon pressure wave forms Varying R-R intervals result in irregular plateau durations
  43. 43. 43 Variation in balloon pressure wave forms Increased height or amplitude of the waveform Decreased height or amplitude of the waveform
  44. 44. 44 Variation in balloon pressure wave forms Gas leak Leak in the closed system causing the balloon pressure waveform to fall below zero baseline.. - due to a loose connection - a leak in the IAB catheter - H2O condensation in the external tubing - a patient who is tachycardiac and febrile which causes increased gas diffusion through the IAB membrane
  45. 45. 45 Catheter Kink Rounded balloon pressure waveform - Loss of plateau resulting from a kink or obstruction of shuttle gas - Kink in the catheter tubing - Improper IAB catheter position - Sheath not being pulled back to allow inflation of the IAB - IAB is too large for the aorta - IAB is not fully unwrapped - H2O condensation in the external tubing
  46. 46. 46 “Balloon too large” syndrome
  47. 47. 47 Patient Management During IABP support  Anticoagulation-- maintain apTT at 50 to 70 seconds  CXR daily – to R/O IAB migration  Check lower limb pulses - 2 hourly. - If not palpable » ? - vascular obstruction - thrombus, embolus, or dissection (urgent surgical consultation)  Prophylactic antibiotics NOT INDICATED  Hip flexion is restricted, and the head of the bed should not be elevated beyond 30°.
  48. 48. 48  Never leave in standby by mode for more than 20 minutes > thrombus formation  Daily – Haemoglobin (risk of bleeding or haemolysis) – Platelet count (risk of thrombocytopenia) – Renal function (risk of acute kidney injury secondary to distal migration of IABP catheter)  Wean off the IABP as early as possible as longer duration is associated with higher incidence of limb complications Patient Management During IABP support
  49. 49. 49
  50. 50. 50 Weaning of IABP Timing of weaning: - Patient should be stable for 12 – 24 hours - Decrease inotropic support - Decrease pump ratio – From 1:1 to 1:2 or 1:3 - Decrease augmentation - Monitor patient closely – If patient becomes unstable, weaning should be immediately discontinued
  51. 51. 51 IABP Removal -Discontinue heparin 1 hour prior to removal -Disconnect the IAB catheter from the IAB pump - Patient blood pressure will collapse the balloon membrane for withdrawal - Withdraw the IAB catheter through the introducer sheath until resistance is met. - NEVER attempt to withdraw the balloon membrane through the introducer sheath. -Remove the IAB catheter and the introducer sheath as a unit - Check for adequacy of limb perfusion after hemostasis is achieved.
  52. 52. ACC/AHA 2013Practice Guidelines (ESC 2012- IIb) 52
  53. 53. ESC 2014 GUIDELINES 53
  54. 54. IABP IN UA/NSTEMI (2007, 2012 update) (Current Practices)(Class IIa LOE-©) 54 The placement of an IABP could be useful in patients with recurrent ischemia despite maximal medical management and in those with hemodynamic instability until coronary angiography and revascularization can be completed.
  55. 55. TRIALS OF IABP 55
  56. 56. Benchmark registry • n = 17,000( june 1996- aug 2000) • 203 hospitals- 90% US • 18.8% of IABP used for cardiogenic shock • Device related death – 0.5% • Major complication – 2.6% • Minor complication – 4.2% 56
  57. 57. Balloon-pump assisted Coronary Intervention Study (BCIS-1): • The first randomized controlled trial of elective Intra-Aortic Balloon Pump (IABP) insertion prior to high-risk PCI vs. PCI with no planned IABP use • 17 UK centres • n=301 (150 in each arm) 57
  58. 58. 58IABP in high risk PCI(BCIS-1 TRIAL) N= 301 Elective IABP( 151) No elective IABP(150) P VALUE MACE 15.2% 16% 0.85 All cause mortality at 6 mths 4.6% 7.4% 0.32 Major procedural complications 1.3% 10.7% <0.001 Major or minor bleeding 19.2% 11.3% 0.06 Access site complications 3.3% 0% 0.06 Patients (n = 301) had severe left ventricular dysfunction (ejection fraction ≤ 30%) and extensive coronary disease (Jeopardy Score ≥ 8/12); those with contraindications to or class I indications for IABP therapy were excluded JAMA. 2010;304(8):867-874
  59. 59. 59 Conclusions of long term results of BCIS1 trial(2012-2013) In patients with severe ischemic cardiomyopathy treated with PCI, all cause-mortality was 33% at 51 months (median) Elective IABP use during PCI was associated with an observed 34% reduction in long-term all-cause mortality
  60. 60. 60 Counterpulsation Reduces Infarct Size Acute Myocardial Infarction (CRISP AMI) trial. Intra-aortic balloon pump counterpulsation prior to PCI in patients with ST segment elevation MI without shock does not reduce infarct size as measured by MRI
  61. 61. Shock trial and registry 61
  62. 62. 62 N-302 pts N- 152 pts N- 150 pts
  63. 63. 63 SHOCK Trial Primary and Secondary Endpoints 0 20 40 60 80 30 Days 6 months Immediate Revascularization Strategy Medical Stabilization as an Initial Strategy Primary Endpoint Secondary Endpoint Mortality(%) 46.7 % 56.0 % 50.3 % 63.1 % P=.11 P= .027 Hochman et al, NEJM 1999; 341:625.
  64. 64. 64 Impact of thrombolysis, intra-aortic balloon pump counterpulsation, and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry
  65. 65. 65 SHOCK Registry: Impact of Thrombolytics and IABP 0 20 40 60 80 47% 52% % P<0.0001 63% 77% Thrombolytics + IABP No Thrombolytics + IABP Thrombolytics + No IABP Neither Hochman et al, NEJM 1999; 341:625
  66. 66. 66 Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock IABP Shock II Trial
  67. 67. Conclusion • The use of intraaortic balloon counterpulsation did not significantly reduce 30-day mortality in patients with cardiogenic shock complicating acute myocardial infarction for whom an early revascularization strategy was planned. 67
  68. 68. MCQs 68
  69. 69. • 1. Major physiological effects of counter pulsation include? ▫ A) increased coronary artery perfusion, increased preload, decreased after load, decreased myocardial oxygen consumption ▫ B) increased coronary artery perfusion, increased preload, increased after load, decreased myocardial oxygen consumption ▫ C) increased coronary artery perfusion, decreased preload, decreased after load, increased myocardial oxygen consumption ▫ D) increased coronary artery perfusion, decreased preload, decreased after load, decreased myocardial oxygen consumption 69
  70. 70. 2. The dicrotic notch on the arterial wave form reflects A) aortic valve opening B) aortic valve closure C) isovolumetric contraction D)rapid ejection 70
  71. 71. 3. Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except? A) Decrease in SBP by 20 % B) Increase in aortic DP by 30 % C) Decrease in MAP by 10% D) Reduction of the HR by 20% E)Decrease in the mean PCWP by 20 % 71
  72. 72. 4. late inflation of the balloon can result in? A) premature augmentation B) increased augmentation C) decreased augmentation D) increased coronary perfusion 72
  73. 73. 5. A rounded balloon pressure wave form indicate? A) helium leak B) power failure C) hypovolemia D) balloon occluding the aorta 73
  74. 74. 6. width of balloon pressure wave form corresponds to A) length of systole B) length of diastole C) arterial pressure D) helium level 74
  75. 75. 7. true statement a) Dicrotic notch- land mark used to set deflation b) Deflation is timed to occur during period of iso volumetric contraction c) Most common trigger used is arterial pressure wave method d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm 75
  76. 76. 8. true statement A) pacing spikes are automatically rejected in ECG triggered modes B) pacing trigger modes can be used in a patient of 50% paced rhythm C) Varying R-R interval result in regular plateau durations in Balloon pressureWave form 76
  77. 77. 9. Identify the tracing abnormality 77
  78. 78. 10. Identify the tracing abnormality 78
  79. 79. 79
  80. 80. • 1. Major physiological effects of counter pulsation include? ▫ A) increased coronary artery perfusion, increased preload, decreased after load, decreased myocardial oxygen consumption ▫ B) increased coronary artery perfusion, increased preload, increased after load, decreased myocardial oxygen consumption ▫ C) increased coronary artery perfusion, decreased preload, decreased after load, increased myocardial oxygen consumption ▫ D) increased coronary artery perfusion, decreased preload, decreased after load, decreased myocardial oxygen consumption 80
  81. 81. 2. the dicrotic notch on the arterial wave form reflects A) aortic valve opening B) aortic valve closure C) isovolumetric contraction D)rapid ejection 81
  82. 82. 3. Expected changes with IABP support in hemodynamic profile in patients with Cardiogenic shock include all except? •A) Decrease in SBP by 20 % •B) Increase in aortic DP by 30 % •C) Decrease in MAP by 10% •D) Reduction of the HR by 20% •E)Decrease in the mean PCWP by 20 % 82
  83. 83. 4. late inflation of the balloon can result in? • A) premature augmentation • B) increased augmentation • C) decreased augmentation • D) increased coronary perfusion 83
  84. 84. 5. A rounded balloon pressure wave form indicate? • A) helium leak • B) power failure • C) hypovolemia • D) balloon occluding the aorta 84
  85. 85. 6. width of balloon pressure wave form corresponds to • A) length of systole • B) length of diastole • C) arterial pressure • D) helium level 85
  86. 86. 7. true statement a) Dicrotic notch- land mark used to set deflation b) Deflation is timed to occur during period of iso volumetric contraction c) Most common trigger used is arterial pressure wave method d) Internal trigger mode is acceptable to use in a patient with normal sinus rhythm 86
  87. 87. 8. true statement A) pacing spikes are automatically rejected in ECG triggered modes B) pacing trigger modes can be used in a patient of 50% paced rhyth C) Varying R-R interval result in regular plateau durations in Balloon press. Wave form 87
  88. 88. 9. 88
  89. 89. 10. 89

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