IABP

IABP Troubleshooting Tool

Device / waveform issue

Clinical trajectory

Complications present

Bedside checks

Recommendation

Likely issue

    Immediate actions

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        Disposition

          Inflation

          • Occurs in early diastole
          • Raises aortic diastolic pressure
          • Improves coronary perfusion

          Deflation

          • Occurs immediately before systole
          • Lowers LV afterload
          • Decreases LV wall stress and myocardial O2 demand
          • May modestly improve cardiac output

          Most useful when there is

          • LV-predominant failure
          • Active ischemia
          • Need for modest LV unloading
          • Mechanical complication of MI
          • Bridge to PCI, CABG, valve surgery, recovery, escalation, or goals/decision

          Common indications

          • Refractory ischemia or unstable angina as bridge to revascularization
          • Mechanical complications of MI:
            • Acute MR from papillary muscle rupture
            • Post-MI VSD
          • Selected high-risk PCI
          • Post-cardiotomy low output state
          • Selected cardiogenic shock with active ischemia
          • Selected acute decompensated HFrEF with low output

          Contraindications

          Type Contraindication Why it matters
          Absolute / major Moderate-to-severe aortic regurgitation Diastolic inflation worsens regurgitant flow and LV volume overload.
          Absolute / major Aortic dissection Balloon movement can extend the dissection or cause rupture.
          Absolute / major Severe PAD preventing safe access High risk of limb ischemia, vascular injury, or failed placement.
          Relative Uncontrolled bleeding or severe coagulopathy Large-bore arterial access and anticoagulation can worsen bleeding.
          Relative Aortic aneurysm with mural thrombus Risk of embolization or aortic injury.
          Relative Severe vasodilatory shock or sepsis IABP provides limited benefit when low SVR is the dominant problem.
          Relative Severe uncontrolled HTN Higher vascular and aortic complication risk.

          Correct position

          • Proximal tip 2-3 cm distal to left subclavian artery
          • Distal balloon above renal arteries
          • CXR marker near aortic knob/carina level

          Too proximal

          • Can obstruct left subclavian
          • Left arm ischemia/weak left radial pulse

          Too distal

          • Can compromise renal, mesenteric, or visceral flow
          • Rising Cr, low UOP, abdominal pain

          Good timing

          • Inflate at dicrotic notch
          • Deflate just before systole
          • Augmented diastolic pressure should exceed native systolic pressure
          • Assisted systolic pressure should be lower than unassisted systolic pressure
          • Assisted end-diastolic pressure should be lower than unassisted EDP

          Timing problems

          Late inflation

          • Low diastolic augmentation
          • Poor coronary perfusion
          • Fix: inflate earlier

          Early inflation

          • Balloon inflates before systole ends
          • Increases afterload
          • Fix: delay inflation

          Late deflation

          • High assisted EDP
          • Delayed/widened systolic upstroke
          • Increases afterload and myocardial O2 demand
          • Fix: deflate earlier

          Early deflation

          • Loss of diastolic augmentation
          • Less afterload reduction
          • Fix: delay deflation slightly

          Daily management questions

          • Why is the IABP still in?
          • Is MAP, lactate, UOP, ischemia, and end-organ function improving?
          • Is timing appropriate?
          • Is there limb ischemia or bleeding?
          • Is anticoagulation appropriate?
          • Should we continue, wean, remove, or escalate?

          Monitoring

          Category What to monitor Why it matters
          Hemodynamics MAP
          Augmented pressure
          Assist ratio
          Pressor/inotrope needs
          CI/PCWP/SVR if PA catheter present           		Tracks whether the IABP is improving forward flow and reducing shock severity.
          Perfusion Lactate
          UOP
          Mental status
          Renal/liver function
          Extremity temperature           		Worsening lactate, urine output, or end-organ function suggests inadequate support and possible need for escalation.
          Access / limb Groin site
          DP/PT pulses
          Color/temp
          Cap refill
          Motor/sensory exam
          Hematoma           		Femoral access can cause limb ischemia, bleeding, hematoma, or vascular injury.
          Labs CBC
          Platelets
          BMP/Mg
          Coags per anticoagulation plan
          Hemolysis labs if suspected           		Screens for bleeding, thrombocytopenia, renal injury, electrolyte issues, and hemolysis.
          Major complications Limb ischemia
          Access-site bleeding/hematoma
          Retroperitoneal bleed
          Aortic/iliac injury or dissection
          Stroke/systemic embolism
          Thrombocytopenia
          Hemolysis
          Infection
          Balloon rupture
          Renal/mesenteric ischemia from malposition           		These can be limb-threatening or life-threatening and require early recognition.
          Balloon rupture Blood in tubing
          Sudden loss of augmentation/alarm
          Stop pump
          Clamp catheter
          Urgent removal/exchange           		Blood in the tubing should be treated as balloon rupture until proven otherwise.

          IABP is not enough if

          • Persistent hypotension
          • Rising lactate
          • Worsening renal/liver function
          • Escalating pressors/inotropes
          • Persistent pulmonary edema
          • Low CI or high filling pressures despite support
          • Ongoing ischemia
          • Recurrent malignant arrhythmias from low output

          Escalation options

          • LV-predominant shock: consider Impella/stronger LV support
          • Biventricular failure or severe hypoxemia: consider VA-ECMO/combined support
          • RV-predominant shock: RV support strategy, treat underlying cause
          • Unclear shock: PA catheter + shock team

          Weaning

          Criteria

          • Stable MAP without escalating pressors/inotropes
          • Improving lactate
          • Improving UOP/end-organ function
          • No active ischemia
          • Definitive therapy completed or no longer needed
          • Stable respiratory status
          • Acceptable filling pressures/CO if PA catheter present

          Typical wean

          • 1:1 = full support
          • 1:2 = initial wean
          • 1:3 = minimal support
          • Remove if perfusion remains stable

          Watch during wean

          • MAP
          • Lactate
          • UOP
          • Ischemia
          • Pressor/inotrope needs
          • Filling pressures/CI if available

          References

          1. Kantrowitz, A., Tjonneland, S., Freed, P. S., Phillips, S. J., Butner, A. N., & Sherman, J. L. (1968). Initial clinical experience with intraaortic balloon pumping in cardiogenic shock. JAMA, 203(2), 113–118. https://doi.org/10.1001/jama.1968.03140020075014
          2. Thiele, H., Zeymer, U., Neumann, F. J., Ferenc, M., Olbrich, H. G., Hausleiter, J., Richardt, G., Hennersdorf, M., Empen, K., Fuernau, G., Desch, S., Eitel, I., Hambrecht, R., Lauer, B., Böhm, M., Ebelt, H., Schneider, S., Schuler, G., Werdan, K., & IABP-SHOCK II Trial Investigators. (2012). Intraaortic balloon support for myocardial infarction with cardiogenic shock. New England Journal of Medicine, 367(14), 1287–1296. https://doi.org/10.1056/NEJMoa1208410
          3. Thiele, H., Zeymer, U., Thelemann, N., Neumann, F. J., Hausleiter, J., Abdel-Wahab, M., Meyer-Saraei, R., Fuernau, G., Eitel, I., Hambrecht, R., Böhm, M., Werdan, K., Felix, S. B., Hennersdorf, M., Schneider, S., Ouarrak, T., Desch, S., & IABP-SHOCK II Trial Investigators. (2019). Intraaortic balloon pump in cardiogenic shock complicating acute myocardial infarction: Long-term 6-year outcome of the randomized IABP-SHOCK II trial. Circulation, 139(3), 395–403. https://doi.org/10.1161/CIRCULATIONAHA.118.038201
          4. Ferguson, J. J., Cohen, M., Freedman, R. J., Stone, G. W., Miller, M. F., Joseph, D. L., & Ohman, E. M. (2001). The current practice of intra-aortic balloon counterpulsation: Results from the Benchmark Registry. Journal of the American College of Cardiology, 38(5), 1456–1462. https://doi.org/10.1016/S0735-1097(01)01553-4
          5. Parissis, H., Graham, V., Lampridis, S., Lau, M., Hooks, G., & Mhandu, P. C. (2016). IABP: History-evolution-pathophysiology-indications: What we need to know. Journal of Cardiothoracic Surgery, 11, 122. https://doi.org/10.1186/s13019-016-0513-0
          6. Naidu, S. S., Baran, D. A., Jentzer, J. C., Hollenberg, S. M., van Diepen, S., Basir, M. B., Grines, C. L., Diercks, D. B., Hall, S., Kapur, N. K., Kent, W., Sinha, S. S., Thiele, H., Zweck, E., & Henry, T. D. (2022). SCAI SHOCK stage classification expert consensus update: A review and incorporation of validation studies. Journal of the Society for Cardiovascular Angiography & Interventions, 1(1), 100008. https://doi.org/10.1016/j.jscai.2021.100008
          7. Gillespie, L. E., Grunau, B., & Reynolds, J. C. (2024). The intra-aortic balloon pump: A focused review of physiology, indications, complications, and transport considerations. Journal of the Society for Cardiovascular Angiography & Interventions, 3(8), 101063. https://doi.org/10.1016/j.jscai.2024.101063