Bedside Topline

What It Does: A helium balloon in the descending aorta inflates in diastole to raise coronary perfusion and deflates just before systole to lower afterload.
Key Settings & Targets: Trigger: ECG or arterial pressure
Ratio: 1:1 to start, then step down
Inflate at the dicrotic notch; deflate before systole
MAP target ≥65 mmHg
Check Every Hour: Distal pulses and perfusion in both legs, left radial pulse and neuro check, insertion site, console timing and augmentation, helium level, MAP and urine output.
Top Alarm → First Move: Loss of trigger or pressure: check leads or transducer, then switch to the arterial trigger if the trace is clear.
Never: Run the pump with blood in the gas line
Leave the balloon static in blood
Reduce fill volume to wean
Clamp or pull the catheter without an order
Escalate Now If: Blood in the helium line or gas loss
Cool, pale or painful leg
New neurologic deficit
Late deflation not fixed by timing

Overview & How It Works

An intra-aortic balloon pump (IABP) is temporary mechanical support. A helium-filled balloon on a catheter sits in the descending thoracic aorta. It inflates in diastole and deflates just before systole. Inflation raises diastolic pressure and coronary perfusion. Deflation lowers the afterload the left ventricle has to eject against.

Key Components

Component	Where It Sits	What It Does
Balloon catheter	Descending thoracic aorta; tip about 1–2 cm distal to the left subclavian origin (per manufacturer IFU; confirm on chest X-ray)	Displaces aortic blood during inflation and empties during deflation
Sheath and femoral access	Common femoral artery (usual route)	Introduces the catheter; the leg stays straight while in place
Console	Bedside cart or stand	Times inflation and deflation, shows ECG, arterial and balloon traces, and sets the assist ratio
Helium supply	Cylinder on the console	Fills and empties the balloon quickly; helium is inert and diffuses out rapidly if it leaks
Pressure lumen	Central lumen of the catheter and its tubing	Measures arterial pressure at the balloon for the console display and timing
Trigger input	ECG leads or arterial pressure line	Gives the console the cardiac cycle signal it times each beat from

Flow Path

The console watches for a trigger: an ECG R-wave, an arterial upstroke or a pacer signal.
Helium fills the balloon at the dicrotic notch. That is when the aortic valve closes.
The balloon stays full through diastole, pushing blood toward the coronary arteries.
The balloon empties just before the next systolic upstroke. The left ventricle ejects against lower aortic pressure.

Key Point: The benefit rides on three things: the rhythm, the LV still squeezing, and timing you get right. Routine use in cardiogenic shock has not reduced mortality (see Indications, Contraindications & Evidence).

Physiology & Hemodynamic Effects

What It Does

Parameter	Effect	Why It Matters
Diastolic aortic pressure	↑	Raises coronary perfusion pressure during diastole, when coronary flow occurs
LV afterload	↓	Less pressure to eject against; lower wall stress
Isovolumetric contraction	↓	Shorter time at high LV pressure lowers myocardial O₂ demand
Stroke volume and cardiac output	↑ (usually modest)	Benefit depends on rhythm, native LV function and timing
Left-sided filling pressures	↓ (variable)	Offloading the LV can lower wedge and LA pressures in some patients
Systemic vascular resistance	↓ (functional)	Afterload reduction lowers SVR, so MAP can rise only if flow also improves

What It Depends On

Rhythm: you need an organized rhythm with a trigger you can use. Ventricular fibrillation or pulseless ventricular tachycardia gives little or no benefit.
Native LV function: the biggest effect shows up when the ventricle still ejects.
Timing: inflate at the dicrotic notch and deflate before systole. Timing errors reduce the benefit or reverse it.
Balloon volume and position: a poorly filled or misplaced balloon augments weakly.
Aortic compliance and pressure: stiff aortas and hypertension blunt the augmented diastolic pressure.

Why Helium

Helium is light, so the balloon fills and empties fast. It is also inert, but it is absorbed fast once it reaches the circulation. A rupture with gas loss, or blood in the gas line, is an emergency.

Clinical Pearl: Weak augmentation? Check the trigger, the timing and the fill first. Then think about more vasoactive drugs.

Types, Modes & Configurations

Type / Mode	Route / Configuration	Support or Output	Best For	Key Limitation / Risk
Femoral IABP (standard)	Femoral artery; balloon in the descending thoracic aorta	Modest augmentation; modest rise in cardiac output	Short-term bridge in selected cardiogenic shock with an organized rhythm, or a bridge for a mechanical complication of MI	Limb ischemia, bleeding, thrombosis, balloon rupture; no routine mortality benefit in shock
Asynchronous (internal) IABP	Same catheter; console fires on a fixed internal rate	No true counterpulsation; keeps the balloon moving	Only when there is no usable ECG or pressure trigger, such as during arrest	Timing is not linked to the heartbeat, so it can worsen afterload

Trigger Modes

ECG (R-wave): the usual trigger, as long as the QRS is tall and consistent.
Arterial pressure: reads the arterial upstroke. It helps with atrial fibrillation, ectopy or a noisy ECG.
Pacer: for paced rhythms. Pick ventricular or atrial pacer input per the console setting.
Internal (asynchronous): the last resort, for when neither ECG nor pressure gives a reliable trigger. It is not true counterpulsation.

Assist Ratios

1:1: the balloon inflates every beat. Start here for shock and transport.
1:2: every second beat is assisted. You use it to compare assisted and unassisted beats, and early in weaning.
1:3: minimal support. A late weaning step in stable patients.

Indications, Contraindications & Evidence

Indications

Cardiogenic shock complicating acute MI: it may bridge you while the cause is treated. Current guidelines do not recommend routine use (see Key Evidence).
Mechanical complication of MI: acute severe mitral regurgitation or ventricular septal rupture. It is a bridge to surgery or definitive therapy.
Refractory ischemia: ischemia that continues despite medical therapy while you wait for revascularization. Selected patients only.
Post-cardiotomy low output: trouble weaning off cardiopulmonary bypass, or low output after cardiac surgery. Practice varies by center.
Bridge: to another support device (LVAD, ECMO or a microaxial pump) or to surgery. The team decides.

Contraindications

Absolute	Relative
Moderate to severe aortic regurgitation	Uncontrolled bleeding or severe coagulopathy (insertion and removal risk)
Aortic dissection	Severe peripheral arterial or iliac occlusive disease that prevents safe insertion
Thoracic or abdominal aortic aneurysm that the balloon cannot safely traverse or sit in	Thrombocytopenia or heparin-induced thrombocytopenia
	Sepsis or uncontrolled bacteremia (device infection risk)
	Sustained tachyarrhythmia or a rhythm that prevents reliable triggering
	Irreversible end-stage disease with no recovery, transplant or LVAD option

Warning: Severe aortic regurgitation is the commonly missed contraindication. Each inflation adds to regurgitant volume and can worsen the lesion.

Limitations

Needs an organized ventricular rhythm. Little benefit in ventricular fibrillation or pulseless ventricular tachycardia.
Does not directly support the right ventricle.
Augmentation stays modest next to ECMO or microaxial pumps.
Benefit depends on timing. Rhythm changes and ectopy reduce effectiveness.
In IABP-SHOCK II, routine use in cardiogenic shock did not improve survival.

Key Evidence

Trial / Guideline (Year)	Population	Bottom Line
IABP-SHOCK II (2012; 12-month 2013; 6-year 2019)	Randomized patients with acute MI and cardiogenic shock; IABP with standard care versus standard care alone	No reduction in 30-day mortality; no difference at 12 months or 6 years
BCIS-1 (2010; long-term follow-up 2013)	Randomized patients with ejection fraction under 30% and severe coronary disease undergoing high-risk PCI; elective IABP versus no planned IABP	No difference in major adverse cardiac and cerebrovascular events (MACCE) at hospital discharge. At a median of 51 months, all-cause mortality was lower with elective IABP (HR 0.66, 95% CI 0.44–0.98), a long-term follow-up finding
DanGer Shock (2024)	Patients with STEMI-related cardiogenic shock; microaxial flow pump (Impella CP) plus standard care versus standard care alone	Microaxial pump plus standard care in the selected trial population lowered 180-day all-cause mortality (45.8% vs 58.5%; HR 0.74) but caused more serious adverse events (composite 24.0% vs 6.2%: severe bleeding, limb ischemia, hemolysis, device failure or worsening aortic regurgitation). See the Impella page
2023 ESC ACS guideline	Acute coronary syndrome, including cardiogenic shock	States that routine IABP is not recommended for cardiogenic shock complicating AMI, unless a mechanical complication is present
2025 ACC/AHA ACS guideline	Acute coronary syndrome, including cardiogenic shock	Routine IABP in AMI-related cardiogenic shock is not recommended (Class 3, no benefit; downgraded from Class 2a in 2013). The same guideline gives microaxial flow pumps Class 2a (reasonable) for selected STEMI patients with severe or refractory shock. Class wording as summarized in the JACC companion editorial

The SCAI SHOCK classification stages shock severity, from stage A to stage E. The stage tells you when and how to escalate support.

Setup, Settings & Targets

Targets

Parameter	Typical Target	If Below	If Above
MAP	≥65 mmHg	Check augmentation, fill and rhythm; team decides on vasoactive support	Usually acceptable; check afterload and vasoactive dose
Augmented diastolic pressure	Taller than the unassisted systolic peak	Check timing, fill and balloon position	Not usually a problem; recheck if waveform looks wrong
Assisted systolic pressure	Slightly lower than unassisted systolic	Expected finding with good afterload reduction	Equal to or above unassisted: suspect early deflation (no afterload reduction)
Assisted end-diastolic pressure	Lower than unassisted end-diastolic	Expected finding; a sharp U-shaped dip after the augmented peak suggests early deflation	Equal to or above unassisted: suspect late deflation

Initial Settings

Trigger: ECG when the R-wave is clean and tall. Arterial pressure for atrial fibrillation, ectopy or pacing.
Ratio: start at 1:1. Step down only after the patient is stable.
Timing: inflate at the dicrotic notch. Deflate before the next systolic upstroke. Adjust with the console timing controls.
Fill and helium: check fill status and gas level on the console at each check.

Sizing & Positioning

Balloon volume: matched to patient height on the manufacturer chart (per manufacturer IFU).
Tip position: about 1–2 cm distal to the left subclavian origin. Confirm it on chest X-ray (per manufacturer IFU).

Anticoagulation

The team sets anticoagulation targets. You will find them in the Anticoagulation & Hematology section.

Calculations & Derived Values

Mean arterial pressure

MAP = DBP + ⅓ (SBP − DBP)

Cardiac power output

CPO (W) = MAP × CO ÷ 451

Variable	Formula	Why You Care
MAP	DBP + ⅓ (SBP − DBP)	Perfusion target (≥65 mmHg) and the pressure the balloon must support
Cardiac power output	MAP × CO ÷ 451	Combines pressure and flow; a low value signals shock severity and prompts an escalation discussion
Cardiac index	CO ÷ BSA (L/min/m²)	Used as a readiness threshold for weaning (protocol-dependent)

Clinical Pearl: Take a MAP of 60 mmHg and a cardiac output of 4 L/min. CPO = 60 × 4 ÷ 451 = 0.53 W. A number like that should send the team back to the support plan, not just the pump settings.

Waveforms & Console Interpretation

Normal

Inflation: a sharp V at the dicrotic notch. The augmented diastolic peak follows right after it.
Augmented diastolic peak: taller than the unassisted systolic peak.
Assisted end-diastolic pressure: lower than the unassisted end-diastolic pressure. It is measured just before the next upstroke.
Assisted systolic pressure: slightly lower than the unassisted systolic peak.

Abnormal Patterns

Pattern	What You See	Cause	Fix
Early inflation	Balloon inflates before the dicrotic notch; augmented peak merges with systolic	Inflation timed before aortic valve closure	Delay inflation to the dicrotic notch
Late inflation	Dicrotic notch visible before the augmented peak; small augmented peak	Inflation timed after the notch	Advance inflation so it starts at the notch
Early deflation	Assisted systolic pressure equal to or above unassisted (no afterload reduction); sharp drop after the augmented peak; assisted end-diastolic pressure equal to or below unassisted (U-shaped dip)	Balloon empties before end-diastole; can cause retrograde coronary and carotid flow	Delay deflation so it ends at end-diastole, just before the systolic upstroke
Late deflation (among the most harmful)	Assisted end-diastolic pressure equal to or above unassisted; widened augmented diastolic peak; slowed assisted systolic upstroke as the balloon is still deflating into systole	Balloon is still inflated after the aortic valve opens, raising afterload	Advance deflation so the balloon is empty by end-diastole, before ejection

Warning: Both late deflation and early inflation push up LV afterload and myocardial O₂ demand. The pump exists to do the opposite. Fix the timing before anything else.

Monitoring & Ongoing Care

Frequency	What to Check	Expected / Action
Hourly	Distal pulses, color, temperature, capillary refill, sensation and movement in both legs	Symmetric perfusion; any new change needs immediate assessment and provider notice
Hourly	Left radial pulse, left arm BP and color; neuro check (speech, facial symmetry, limb strength)	Symmetric arm perfusion and neuro exam; a weak or absent left radial pulse, lower left arm BP or a new deficit suggests upward migration: notify the provider now
Hourly	Augmented peak, timing, trigger, fill and helium level on the console	Augmentation present on every assisted beat; loss of augmentation needs troubleshooting
Hourly	MAP, heart rate and rhythm	MAP ≥65 mmHg; new rhythm changes need a timing review
Hourly	Insertion site for bleeding or hematoma; urine output	Stable site; urine output per unit target; falling output needs review
Per unit protocol	CBC and platelets; aPTT or ACT per heparin protocol	Per order and protocol. A platelet fall of 50% or more from baseline during heparin exposure: notify the team for heparin-induced thrombocytopenia evaluation
Per unit protocol	Creatinine, plasma free hemoglobin and LDH when hemolysis is suspected; chest X-ray if position is in question	Rising values or a moved catheter need provider review

Positioning & Mobility

Keep the leg with the femoral catheter straight and limit hip flexion per unit protocol.
Keep head-of-bed elevation at or below 30 degrees for femoral access (higher angles can strain or kink the catheter); log-roll rather than sit the patient up when possible.
Expect no ambulation with a femoral catheter. Passive range of motion on the unaffected leg, per team.

Clinical Pearl: Check distal perfusion every time the patient is moved. The scheduled check is not enough on its own.

Anticoagulation & Hematology

Strategy / Agent	Typical Target	Monitoring	Watch For
Unfractionated heparin High-alert	Set by team protocol (no universal target)	ACT or aPTT per protocol	Bleeding; balloon thrombosis when flow is poor; heparin-induced thrombocytopenia
Bivalirudin or argatroban High-alert	Per protocol	aPTT per protocol	Used when heparin cannot be given, such as heparin-induced thrombocytopenia

Hemolysis

Signs: dark or tea-colored urine, rising LDH, falling haptoglobin, rising plasma free hemoglobin, rising bilirubin.

Bleeding & Platelets

Falling platelet count with heparin exposure: consider heparin-induced thrombocytopenia and notify the team before further heparin.
Protamine reverses heparin only under provider order. It can cause severe hypotension, cardiovascular collapse, pulmonary vasoconstriction or anaphylactoid reactions, especially with rapid infusion.

Links: heparin, protamine, aPTT, platelets.

Key Medications & Drug Considerations

Medication	Role Here	Typical Adult Dose / Target	Device-Specific Notes
Heparin High-alert	Prevents thrombus on the catheter	Per protocol; ACT or aPTT target set by team (no fixed IABP target)	Dose and monitoring follow the unit protocol; bleeding and thrombocytopenia checks apply
Norepinephrine High-alert	Vasopressor when the pump alone does not hold MAP	Typical 0.05–0.5 mcg/kg/min IV infusion; titrate to MAP target (≥65 mmHg) per protocol	Excess vasoconstriction raises afterload and works against the pump
Dobutamine High-alert	Inotrope for low output	2–20 mcg/kg/min IV infusion (usual; maximum per protocol)	Can increase heart rate and ectopy, which makes timing harder
Milrinone High-alert	Inodilator for low output	Label: 50 mcg/kg IV over 10 min, then 0.375–0.75 mcg/kg/min IV infusion	Vasodilation can lower MAP; renally cleared, so reduce in renal impairment per label
Amiodarone High-alert	Antiarrhythmic for VT or VF	Pulseless VF/VT: initial 300 mg IV/IO push, then repeat 150 mg once (ACLS); stable VT: 150 mg IV over 10 min	Treat the rhythm first; a balloon does not replace ACLS care

Doses vary by protocol; follow local protocols and medical direction. Pediatric dosing is in Special Populations.

Alarms & Troubleshooting

Alarm / Problem	What You See	Likely Causes	First Actions
Blood in helium line	Red or pink fluid in the gas tubing	Balloon rupture	1) Stop the pump per protocol. 2) Notify the provider immediately. 3) Do not restart without an order.
Rapid helium loss	Falling gas level; repeated fill alarms	Balloon rupture or a leak at a connection	1) Check tubing and connections for kinks or disconnections. 2) If loss continues, treat as balloon rupture.
Loss of trigger	No trigger; erratic or missing inflation	Lead off, poor R-wave, lead or cable fault	1) Check leads and cables. 2) Switch to arterial trigger if the arterial trace is clear.
Loss of pressure waveform	Flat or absent arterial or balloon trace	Kinked or clotted line, air in tubing, transducer level or zero	1) Check the pressure bag, tubing and stopcocks. 2) Re-zero and level the transducer. 3) Use an alternate arterial line if available.
Poor augmentation	Low augmented peak; no clear V-notch	Wrong timing, low fill, rhythm change, catheter migration	1) Check trigger and timing. 2) Check fill and helium. 3) Review rhythm and tell the team.
Timing error	Early or late inflation or deflation pattern	Timing settings out of step after a rhythm or heart rate change	Adjust timing per the waveform table; recheck the next several beats.

Never:

Never run the pump with blood in the gas line.
Never leave the balloon static unless the team has ordered it stopped.
Never reduce balloon fill volume to wean.
Never move, clamp or disconnect the catheter without a provider order.

Clinical Pearl: Alarm going off? Look at the patient first. Then trace the circuit, tubing first, console second, settings last.

Complications & Red Flags

Complication	How You Recognize It	Immediate Action	Prevention
Aortic injury or dissection (insertion)	Sudden back or chest pain; pulse or BP difference	Stop the procedure; notify the team immediately	Gentle advancement; check the aortic anatomy before insertion
Bleeding or hematoma (insertion and during use)	Oozing or swelling at the sheath site; falling hemoglobin	Apply pressure; notify the provider	Site checks per protocol; anticoagulation per protocol
Limb ischemia (during use)	Cool, pale, painful leg; loss of distal pulses	Notify the provider now; check the leg straight and pulses	Keep the leg straight; hourly distal checks
Balloon rupture and gas embolism (during use)	Blood in the helium line; gas loss; new neurologic change	Stop the pump; notify the provider immediately	Check tubing and connections; avoid kinks during transfers
Thrombosis or embolism (during use)	New neurologic deficit; cold limb; loss of augmentation from a clotted balloon	Notify the provider; assess neurologic status	Anticoagulation per protocol; keep the balloon moving
Hemolysis and thrombocytopenia (during use)	Dark urine; rising LDH or plasma free hemoglobin; falling platelets	Notify the team; labs per order	Lab monitoring; check position
Downward migration: renal or mesenteric compromise (during use)	Falling urine output; rising creatinine; new abdominal pain or distension	Notify the team now; position check by imaging	Confirm tip position on X-ray after insertion and after any suspected movement
Upward migration: left arm ischemia or stroke (during use)	Weak or absent left radial pulse; lower left arm BP; cool or pale left arm; new neurologic deficit	Notify the provider now; position check by imaging; treat a neurologic change per stroke protocol	Confirm tip position on X-ray; hourly left arm pulse, BP and neuro checks
Infection (during use)	Fever; redness or drainage at the site	Culture and notify the provider	Aseptic site care; remove as soon as clinically appropriate
Pseudoaneurysm or AV fistula (removal)	Pulsatile mass; bruit; pain at the site	Notify the provider; site evaluation	Hemostasis per protocol after removal
Catheter entrapment (removal)	Resistance during removal	Do not force; notify the team	Remove only under provider order

Red Flags: Call Immediately

Blood in the helium line or unexplained gas loss.
Weak or absent left radial pulse, or lower left arm BP.
Cool, pale, pulseless or painful leg.
New neurologic deficit.
Sudden loss of augmentation or a waveform change not fixed by timing adjustment.
Falling MAP or urine output despite the pump.

Emergencies: Arrest, Power Loss & Device Failure

Cardiac Arrest or VF on the IABP

Start CPR and defibrillate per the AHA 2025 adult ACLS algorithm. Do not delay life-saving care for the pump.
Defibrillate per ACLS; follow your console's IFU for the pump during defibrillation. Do not delay shocks for the pump.
Set the trigger for CPR: use the pressure trigger only if compressions produce a usable arterial waveform; otherwise use internal (asynchronous) mode per the console instructions.
Notify the MCS team and document the trigger and timing change.

Power or Console Failure

Keep the patient alive first. Assess perfusion and rhythm.
Switch to battery or the backup console if the unit has one; check the battery charge.
Follow the manufacturer IFU and the MCS team for manual or backup operation. A balloon left static in blood risks thrombus: restore pumping quickly or escalate.

Dislodgement or Catheter Migration

Stop the pump and check the site and distal perfusion.
Do not advance, withdraw or clamp the catheter without an order.
Call the MCS team for imaging and repositioning.

Balloon Rupture or Air in the Circuit

Stop the pump per the device instructions.
Watch for gas embolism signs: new neurologic change, chest pain or hypotension.
Notify the provider immediately and prepare for transfer to the MCS team.

Weaning & Discontinuation

Readiness Criteria

MAP ≥65 mmHg on low or no vasopressor support.
Cardiac index about 2.2 L/min/m² or higher (protocol-dependent).
Lactate normalizing; perfusion improving.
Improving LV function on echo; cause of shock treated.

Weaning Steps

Confirm readiness with the team.
Reduce the ratio stepwise: 1:1 to 1:2 to 1:3, keeping the balloon fill unchanged.
Reassess MAP, perfusion, lactate and urine output at each step.
If MAP, perfusion or symptoms worsen, step back to the prior ratio.
Remove only after a stable period on the lowest support level, per protocol.

Failure Criteria: Step Back Up

Falling MAP or new vasopressor need.
Rising lactate or falling urine output.
New arrhythmia or loss of augmentation.

Removal & Post-Removal Care

The team removes it, under order. Heparin is held and coagulation is checked per protocol before removal.
After removal: manual pressure at the site for the protocol-defined time, then hemostasis, distal pulse and limb checks, and bed rest per protocol.
A balloon must not sit static in blood past the manufacturer time limit. If the pump cannot be restarted, escalate to the team.

Protocol Varies: Centers differ on weaning steps, readiness thresholds and bed rest after removal. Follow your unit protocol.

Transport Considerations

Before You Move

Check battery charge and confirm backup power is available.
Check the helium cylinder supply and how long it will last.
Secure the catheter, tubing and cables.
Pack spare tubing, a spare pressure bag and the backup console or manual protocol.
Confirm trained personnel are with the patient and the receiving team has been briefed.

If You Are Not the Device Specialist

Watch: distal perfusion of the catheter leg, the arterial trace, and the console alarm screen.
Never touch: trigger, ratio or timing settings unless trained; never clamp or pull the catheter.
Call: the MCS team or provider for any waveform change, blood in the gas line or limb change.
CPR and defibrillation: follow ACLS; see Emergencies for the device-specific steps.

During Transport

Keep the catheter leg straight and the tubing secured through every transfer.
Recheck distal perfusion after each move.

Air Medical & Altitude

Helium expands as ambient pressure falls (Boyle's law). So after every altitude change, check balloon fill and console status. Confirm with the flight team per the device IFU.

Handoff

Mode, trigger, ratio, timing and fill settings.
Latest labs, anticoagulation and platelet trend.
Recent alarms or complications.
Access sites, distal limb checks and the last time they were done.
Goals of care and the device plan.

Transport Pearl: Know the battery time and the helium supply before you leave. Check the leg before and after every move.

Special Populations

Pediatric & Neonatal

Only specialized centers place balloon pumps in children. Catheter size follows the child's vessels, set by manufacturer and center protocol. For pediatric shock support and vascular access, see pediatric shock and vascular access. Weight-based dosing governs the pediatric doses of the medications above. Look them up on the medication pages.

Other

Older adults and peripheral arterial disease: higher risk of access-site and limb complications. Check pulses before insertion.
Pregnancy: data are limited. The decision rests with the team.

Bedside Pearls & Teaching Script

Systematic Walk-Through

Indication: why the balloon is in place and whether it is a bridge.
Mode: trigger, ratio and whether augmentation is visible.
Settings: inflation and deflation timing, fill and helium level.
Anticoagulation: target and latest platelets and aPTT.
Complications: limb, site, hemolysis and neurologic check.
Today's goal: weaning, escalation or transfer.

Pearls

A taller augmented peak and a lower assisted end-diastolic pressure: that is what good timing looks like.
Of the timing errors, late deflation and early inflation are among the most harmful.
A static balloon is a thrombus risk. Keep the pump running unless it is stopped on order.
Severe aortic regurgitation: the contraindication most often missed.
Routine IABP in cardiogenic shock has not improved survival. The goal is a bridge.

References

Thiele H, et al. (2012). Intraaortic balloon support for myocardial infarction with cardiogenic shock. New England Journal of Medicine, 367, 1287–1296. https://doi.org/10.1056/NEJMoa1208410
Thiele H, et al. (2013). Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet, 382, 1638–1645. https://doi.org/10.1016/S0140-6736(13)61783-3
Perera D, et al. (2013). Long-term mortality data from the balloon pump-assisted coronary intervention study (BCIS-1): a randomized, controlled trial of elective balloon counterpulsation during high-risk percutaneous coronary intervention. Circulation, 127(2), 207–212. https://doi.org/10.1161/CIRCULATIONAHA.112.132209
Thiele H, et al. (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, 395–403. https://doi.org/10.1161/CIRCULATIONAHA.118.038201
Perera D, et al. (2010). Elective intra-aortic balloon counterpulsation during high-risk percutaneous coronary intervention: a randomized controlled trial. JAMA, 304(8), 867–874. https://doi.org/10.1001/jama.2010.1190
Møller JE, et al. (2024). Microaxial flow pump or standard care in infarct-related cardiogenic shock (DanGer Shock). New England Journal of Medicine, 390(15), 1382–1393. https://doi.org/10.1056/NEJMoa2312572
Byrne RA, et al. (2023). 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal: Acute Cardiovascular Care, 13(1), 55–161. https://doi.org/10.1093/ehjacc/zuad107
Rao SV, et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes. Journal of the American College of Cardiology, 85, 2135–2237. https://doi.org/10.1016/j.jacc.2024.11.009
Murugiah K, McDonagh TA, Cohen DJ, Dhruva SS. (2025). Mechanical circulatory support in acute myocardial infarction-cardiogenic shock: 2025 acute coronary syndrome guideline in context. Journal of the American College of Cardiology, 85(22), 2103–2106. https://doi.org/10.1016/j.jacc.2025.04.025
Naidu SS, et al. (2022). SCAI SHOCK stage classification expert consensus update: a review and incorporation of validation studies. Journal of the American College of Cardiology, 79(9), 933–946. https://doi.org/10.1016/j.jacc.2022.01.018
Motia N, Marko V, Karlsen MW. (2024). Complications associated with intra-aortic balloon pump treatment in critically ill patients: a systematic review. Nursing in Critical Care, 29(6), 1768–1780. https://doi.org/10.1111/nicc.13163
American Heart Association (2025). Part 1: Executive Summary: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. https://doi.org/10.1161/cir.0000000000001372

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Intra-Aortic Balloon Pump (IABP)