Cardiovascular Critical Care I
Short to Intermediate Term
Intra-aortic balloon
pump (IABP)
counterpulsation
| • | Placed by femoral arterial catheter or percutaneously through the axillary artery and |
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advanced up to the aorta
| • | Inflation enables diastolic augmentation of systemic blood pressure to improve vital |
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organ and coronary perfusion pressures
| • | Deflation facilitates selective afterload during systole through a vacuum effect of the |
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balloon deflation to ease cardiac output (does not technically increase cardiac output)
| • | Can be set to trigger from ECG, pacer, or arterial line pressure, or can be manually set |
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| • | Tachyarrhythmias and aortic regurgitation/insufficiency are not well supported with this |
means of MCS
| • | Level of support coincides with timing of inflation/deflation per related heartbeat; for |
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example:
1:1 = one inflation/deflation per every heartbeat (maximal support)
1:4 = one inflation/deflation for every fourth heartbeat (less support)
| • | When setting duration in deflated state increases (providing less support), |
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the thrombosis risk associated with the IABP increases, commonly requiring
anticoagulation
| • | Complications may include limb and visceral ischemia (distal pulses must be monitored |
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three times a day), thrombocytopenia, hemolysis, balloon rupture.
Percutaneous VAD
| • | One common example is Impella: intraluminal axial support that provides varying |
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degrees of LV output support (CP and 5.5) and RV output support (RP)
| • | Another example is TandemHeart: left atrium-to-femoral artery bypass using |
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transseptal cannulation
| • | To date, only 1 trial has shown benefit in the management of post-MI congenital shock |
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with temporary MCS (DANGER-SHOCK); all previous Impella and IABP have been
negative (N Engl J Med. 2024;390(15):1382-1393)
| • | May be considered in cardiogenic shock or as temporary support during high-risk PCI |
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| • | Impella devices require a purge solution to run through the pump to prevent backflow |
of blood into the motor. This solution can be either heparin based or bicarbonate based.
Sodium bicarbonate–based purge solution is an emerging alternative for patients with
the base must always be mixed in dextrose 5% water. This purge solution should
generally be used in combination with systemic anticoagulation
| • | Anticoagulation regimen is a common topic of debate and medication safety discussion. |
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In general, UFH is accepted as the standard anticoagulant for percutaneous VADs, and
bivalirudin and argatroban can be used in patients with a history of or concern for HIT.
| • | Complications may include hemolysis/bleeding, arrhythmias, and migration and/or |
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malposition of the catheter/cannula
Extracorporeal or
paracorporeal VAD
Examples include CentriMag, BVS 5000, and AB5000 ventricle