Maquet Fiber Optic Iabp Series Of Wins
In October, according to a press release.That’s the latest in a series of wins for Wayne, N.J.-based Maquet. The company in June won CE Mark approval for its Intergard Synergy vascular graft, which is made with anti-microbial compounds to prevent vascular graft infections.In May Maquet won 510(k) for new sizes of its Mega intra-aortic balloon catheters."Over the last 12 months, Maquet has launched 2 new families of IAB catheters, as well as a new balloon pump, Cardiosave – all of which are designed to revolutionize counterpulsation therapy, from both an efficacy and safety perspective," president & CEO Christian Keller said in prepared remarks. "As a global leader in hemodynamic support, we are dedicated to developing and marketing new and innovative products that continuously improve the therapy needs of hemodynamically compromised patients thereby improving patient outcomes."Maquet has, however, seen some bad luck in recent months.
She underwent stenting of the left anterior descending (LAD) coronary artery, but continued to have ongoing severe chest pain. Case 1The patient is a female in her 60s who presented to an outside hospital with chest pain and was found to have an anterior ST elevation MI (STEMI). Two recent Air Care patients highlight this need. As such, prehospital and ED providers must become comfortable with the management of these patients and be aware of complications from these devices. Patients with IABPs are frequently transferred to tertiary referral hospitals via helicopter emergency medical services (HEMS) transport. Placed in critically-ill patients with cardiogenic shock, it increases coronary blood flow and decreases afterload.
The patient’s diastolic pressure was augmented into the 130s. The IABP was set to ECG trigger, 1:1 assist ratio and had good capture on the monitor. On Air Care arrival, she was alert and hemodynamically stable with a heart rate in the 80s and a blood pressure 120s over 70s.The patient was transitioned to Air Care’s IABP portable console while still on the cath lab table. As such, an IABP was placed secondary to persistent unstable angina.
A bedside echocardiogram revealed severe mitral regurgitation and thrombus in the left ventricle.The patient was taken back to the cath lab and found to have papillary muscle rupture. Upon repeat presentation, the patient reported continuing shortness of breath and chest pain since being discharged. However, revascularization was unsuccessful, and he was treated with medical management. Of note, coronary angiography at that time revealed chronic total occlusion of the right coronary artery. Case 2The patient is a male in his late 40s who presented to an outside hospital five days after an inferior STEMI. The IABP was removed within 24 hours, as she remained hemodynamically stable and reported improvement in chest pain.
However, once in the aircraft, the patient went into ventricular tachycardia with thready pulses before quickly proceeding into asystole. Push-dose epinephrine was administered with improvement in his heart rate. Exam was notable for a holosystolic murmur, thready distal pulses, diffuse crackles in all lung fields with pink, frothy ETT secretions and significant JVD.As the patient was being loaded into the aircraft, he became bradycardic to the 30s. The IABP was set to pressure trigger at 1:1 assist ratio. On Air Care arrival, vitals were notable for a blood pressure of 90s/50s with a heart rate in the 90s. An IABP was then placed and Air Care was called for emergent transport to our hospital for operative repair of the valve.
These assist devices are indicated for use in patients with acute cardiogenic shock, failure to wean off cardiopulmonary bypass after cardiothoracic surgery, refractory unstable angina, or ventricular arrhythmias. DiscussionThese cases illustrate two extremes of patients that prehospital HEMS and Emergency Medicine providers may encounter with IABPs. Cardiology and Cardiothoracic Surgery evaluated the patient at bedside in the ED and agreed with terminating efforts based on down time and prognosis. Resuscitative efforts continued on arrival in the ED for an additional 25 minutes without ROSC.
Helium is used as it is an inert gas which is easily absorbed into blood in the rare event of balloon rupture. This is connected to a console with a helium tank used to inflate the balloon. The pumps are contraindicated in those with aortic dissection or severe aortic regurgitation, and are cautiously used in those with severe peripheral vascular disease or coagulopathies.The IABP is composed of a catheter with a distal cylindrical balloon sized by patient height.
For most patients, this is done by placing the balloon pump in the ECG trigger mode, which is based off the R-wave, marking the beginning of systole. These physiologic alterations serve to benefit both those in acute cardiogenic shock and those with acute myocardial infarction.As discussed previously, the balloon is triggered to inflate and deflate based on the cardiac cycle. This creates a vacuum effect, reducing cardiac afterload by decreasing aortic end-DBP and decreasing myocardial demand. Deflation occurs in early systole, just before the aortic valve opens. A balloon sits in the proximal descending aorta, approximately 1 cm distal to the left subclavian artery, and is triggered to inflate and deflate at different phases of the cardiac cycle (Figure 1).The balloon is triggered to inflate in early diastole, which causes an increase in the early diastolic blood pressure (DBP), subsequently increasing coronary perfusion. Newer models augment the traditional arterial line with a fiberoptic cable built into the balloon catheter itself, allowing for auto-calibration of timing.The purpose of the IABP is to increase coronary perfusion and myocardial oxygen supply while decreasing myocardial oxygen demand by several mechanisms.
Assist ratio is the number of assisted cycles to the number of intrinsic beats. Regardless of the trigger mode, the arterial waveform is used to determine if the timing with the cardiac cycle is accurate.In addition to the trigger mode, the operator must also set the assist ratio. ECG mode will work, however, for the majority of paced patients that have good capture. Pacer mode is used for patients with 100% AV/V pacing where there are no reliable R-waves to trigger the ECG mode. The trigger in this case is the systolic upstroke of the arterial waveform. Pressure mode may be used for backup when ECG leads are not reading, there is significant artifact or the patient is in arrest.
Maquet Fiber Optic Iabp Free Resources Available
Any report of sudden change in the quality or degree of pain should raise concern for dissection and the vascular exam should be repeated immediately. The largest study to date of IABP complications found that the most common complications included limb ischemia (2.9%), bleeding from the access site or from aorto-iliac dissection (2.4%), balloon rupture (1.0%) and death attributable to balloon pump (0.05%).Prior to transport, the HEMS provider should always perform a neurovascular exam and check the access site for hematoma or active bleeding. The newer models, including the Maquet Cardiosave HybridTM that are carried on Air Care, are equipped with an “auto-mode” that automatically fills the balloon, performs calibration using fiber-optic cable, selects the most appropriate lead and trigger, and sets the appropriate inflation timing.While Emergency Medicine physicians must have an understanding of which patients are candidates for urgent IABP placement and how these devices function, it is essential for those involved in prehospital care and those at quaternary referral centers to know the basics of managing a patient who already has one of these devices in place. There are several free resources available with scenarios of poorly timed waveforms and their solutions that may be helpful. The goal is to have appropriate timing of inflation and deflation with the cardiac cycle in order to most effectively improve hemodynamics. The 1:2 and 1:3 ratios are most often used for weaning from the IABP in the postoperative period or in extremely tachycardic patients.Figure 2 illustrates the optimized arterial pressure waveform with IABP augmentation.
This prevents the machine from sensing R-waves from artifact and impeding systemic and cardiac perfusion when compressions are being done. Secondly, when set to “auto-mode,” the newer machines will automatically switch between ECG and pressure trigger mode depending on the signal quality. First, CPR should be performed as usual in these patients without fear of damaging the balloon. There are a few pertinent points to be aware of if the patient that experiences cardiac arrest. Clamping the line with a Kelly clamp or hemostat can temporize this complication.Another issue that arises in the emergent care of these patients is represented by the second case above.
The machine is grounded, but everyone should stand clear of the machine to prevent being shocked if it is not plugged into a wall outlet.
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