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Ann Thorac Surg 1996;62:401-409
© 1996 The Society of Thoracic Surgeons
Department of Cardiovascular and Thoracic Surgery, Geisinger Medical Center, Danville, Pennsylvania
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. Between January 1991 and December 1995, 163 consecutive patients with a left ventricular ejection fraction of 0.25 or less underwent isolated coronary artery bypass grafting. An intraaortic balloon pump was inserted before operation in 37 patients (group A). The remaining 126 patients underwent operation without preoperative insertion of the device (group B). Preoperatively, 91.9% (34/37) of group A patients and 54.8% (69/126) of group B patients were in New York Heart Association functional class III or IV (p < 0.001).
Results. The 30-day mortality rate was 2.7% (1/37) and 11.9% (15/126) for groups A and B, respectively (p < 0.005). All deaths occurred in patients in functional class III or IV. In group B, 28 patients (22.2%) required an intraaortic balloon pump after cardiotomy for low cardiac output, 42.9% (12/28) of whom died. Median postoperative hospital stay was 9.9 days and 12.0 days, and mean hospital charges were $50,627 and $54,818 for survivors in groups A and B, respectively (p = not significant).
Conclusions. Our experience suggests that patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting may benefit from preoperative intraaortic balloon pump insertion, especially patients in functional class III or IV. This approach improved survival significantly, reduced hospital stay, and was more cost-effective.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Severe left ventricular (LV) dysfunction is an incremental risk factor for patients undergoing coronary artery bypass grafting (CABG), especially if the LV ejection fraction (LVEF) is 0.25 or less [1–5]. Despite the major advances in monitoring devices, anesthesia, techniques of myocardial preservation, and perioperative pharmacologic support, the operative mortality rate remains elevated, ranging from 4.8% to 14.3% according to several reports published during this decade [1–5].
Christakis and colleagues [3] suggested that to improve these results, strategies should be focused on patient selection, improvement of myocardial protection, and more aggressive use of the intraaortic balloon pump (IABP) before operation to reduce myocardial ischemia. Diastolic counterpulsation is the only means currently available to increase aortic diastolic pressure while reducing myocardial oxygen demand in patients with critical coronary artery stenosis [6].
Gunstensen and associates [6] recommended insertion of an IABP under local anesthesia prior to induction of general anesthesia in patients with acute coronary insufficiency, critical left main coronary artery stenosis, or severe LV dysfunction. These authors believed that prophylactic use of balloon counterpulsation in such patients is cost-effective because in their experience, the postoperative stay in the intensive care unit was shorter, and the prevalence of respiratory and renal complications was also reduced.
The purpose of the present study is to determine whether patients with severe LV dysfunction benefit from prophylactic insertion of an IABP and to evaluate its cost-effectiveness. A multivariate analysis of associated risk factors was done to predict which subgroups of patients are more likely to benefit from prophylactic use of balloon counterpulsation.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Cardiac catheterization and coronary angiography were performed in all patients. The preoperative LVEF was measured by the area-length method from biplane ventricular angiography. Left main coronary artery stenosis was defined as a lesion obstructing 50% or more of the lumen.
Preoperative functional class of congestive heart failure was rated according to the criteria of the New York Heart Association (NYHA) [7], and angina pectoris was graded using the classification of the Canadian Cardiovascular Society [8].
An IABP was placed percutaneously before operation in 37 patients (group A) either in the catheterization laboratory (n = 10) or in the operating room (n = 27) before induction of general anesthesia. The remaining 126 patients underwent CABG without preoperative insertion of an IABP (group B). Mean age was 61.7 years (range, 39 to 83 years) and 62.7 years (range, 36 to 79 years) for groups A and B, respectively (p = not significant).
Mean LVEF was 0.22 (range, 0.14 to 0.25) and 0.23 (range, 0.10 to 0.25) (p = not significant), and mean LV end-diastolic pressure (LVEDP) was 24.2 mm Hg (range, 12 to 40 mm Hg) and 22.5 mm Hg (range, 10 to 42 mm Hg) (p = not significant) for groups A and B, respectively. Group A had a significantly higher prevalence of associated risk factors, including previous CABG, emergency operation, NYHA class IV, recent myocardial infarction (0 to 7 days before operation), and left main stenosis (Table 1
).
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Surgical Technique
Ten patients in group A required counterpulsation in the catheterization laboratory either before or after the study because of refractory unstable angina and were taken directly to the operating room for emergency CABG. The other 27 patients in group A underwent IABP insertion in the operating room using local anesthesia before induction of general anesthesia. In all these patients, a 9.5F Percor balloon (Stat-DL dual-lumen intraaortic balloon catheter with 40-mL balloon, Datascope System; Datascope Corp, Fairfield, NJ) was inserted percutaneously using the provided 12F sheath through the common femoral artery. The correct position of the balloon in the descending thoracic aorta was verified by fluoroscopy in the catheterization laboratory, or by transesophageal echocardiography when the IABP was placed in the operating room.
All patients received prophylactic antibiotics. After IABP insertion, all patients were given 5,000 units of heparin and a continuous infusion of heparin (1,000 U/h) until they were fully heparinized and cannulated. Mild systemic hypothermia (30° to 32°C) was used during cardiopulmonary bypass. To maintain a pulsatile flow, counterpulsation was continued during cardiopulmonary bypass in several patients using the internal trigger of the console to activate the balloon, which was partially inflated with 20 mL of helium.
Antegrade cold blood cardioplegia was used for myocardial protection in most patients in both groups. A combination of antegrade and retrograde cold blood cardioplegia was used in several patients, especially those having reoperations. Complete revascularization was accomplished in most instances. The average number of grafts per patient was 3.52 (range, 1 to 6) and 3.43 (range, 1 to 7) for groups A and B, respectively (p = not significant). A left internal mammary artery graft was used in 32 patients (86.5%) in group A and 116 (92.1%) in group B (p = not significant).
A postcardiotomy IABP was used in 28 patients (22.2%) in group B, including 23 who required the device for weaning from cardiopulmonary bypass and 5 who required postoperative device insertion for low cardiac output. The percutaneous common femoral artery approach was used in 22 patients and a surgical cutdown was used in 6 to expose the common femoral artery. However, the IABP was inserted through the aortic arch in 2 of these patients because attempted insertion through the femoral vessels failed.
Statistical Analysis
Mean age and mean LVEF for the two groups were tested using unpaired Student's t test. Comparison of the prevalence of risk factors and of the characteristics of patients in group B who required postcardiotomy IABP use was carried out using the 
2 test. Comparison of the 30-day mortality for groups A and B was analyzed using a multiple logistic regression analysis. The postoperative hospital stay was analyzed by means of the Mann-Whitney test, and an analysis of covariance was used to compare the data for hospital charges in those instances when significant differences were found in the mean postoperative hospital stay. Calculated p values lower than 0.05 were considered significant.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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In group B, 98 patients (77.8%) were weaned from cardiopulmonary bypass without IABP support and did not require such support postoperatively (subgroup B1). The other 28 patients (22.2%) (subgroup B2) required postcardiotomy IABP placement for low cardiac output. For these patients, postoperative IABP support ranged from 1 hour to 96 hours (mean duration, 42.3 hours).
Incremental risk factors for postcardiotomy IABP insertion included previous CABG, NYHA functional class III or IV, nonelective operation, recent myocardial infarction (0 to 7 days before operation), unstable angina, and left main stenosis (p < 0.05). Advanced age, female sex, diabetes, LVEDP higher than 20 mm Hg, and coexisting mitral regurgitation did not increase the need of postcardiotomy IABP support in these patients (Table 2).
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Vascular complications occurred in 14.3% (4/28) of the patients in group B who required postcardiotomy counterpulsation (subgroup B2). One patient underwent thrombectomy and embolectomy of the involved extremity, and 2 patients required thrombectomy of the femoral artery and fasciotomy. In the other patient, the extremity improved after IABP removal; no operation was necessary. There were no amputations, no aortic dissections, no cases of gangrenous bowel or paraplegia, and no deaths related to use of the IABP in either group A or B.
The prevalence of other postoperative complications was significantly higher in group B. For example, 2.7% (1/37) and 10.3% (13/126) (p < 0.005) of the patients in groups A and B, respectively, sustained a perioperative myocardial infarction, and 3.2% (4/126) of the patients in group B had a cerebrovascular accident compared with none in group A. In group B, 2 patients required hemodialysis, and 1 had a wound infection at the IABP insertion site.
Median postoperative hospital stay was 9.9 days (range, 5 to 40 days) and 12.0 days (range, 5 to 78 days) for groups A and B, respectively. However, an analysis of variance showed no significant difference in the mean length of postoperative stay between the two groups because of the wide variability. The mean duration of the postoperative hospital stay was 10.9 days (range, 5 to 78 days) for patients in subgroup B1 compared with 18.9 days (range, 6 to 56 days) for patients in subgroup B2 (postcardiotomy IABP use) who survived to be discharged from the hospital (p < 0.05). The following patient characteristics significantly increased the mean duration of postoperative hospital stay in subgroup B2: diabetes mellitus, NYHA class III or IV, and LVEDP higher than 20 mm Hg (Table 5).
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Mean hospital charges were $48,583 (range, $21,551 to $239,072) and $79,238 (range, $35,822 to $149,720) for patients in subgroups B1 and B2, respectively (p < 0.001). Compared with subgroup B1, hospital charges were significantly higher (p < 0.05) for subgroup B2 patients with the following characteristics: age lower than 70 years, male sex, diabetes mellitus, previous CABG, NYHA class III or IV, nonelective operation, recent myocardial infarction (0 to 7 days prior to CABG), unstable angina, left main stenosis, and coexisting mitral regurgitation (Table 6).
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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In our experience, the 30-day mortality rate was also significantly reduced (p < 0.005) in a group of 37 patients in whom an IABP was inserted prophylactically before operation compared with a group of 126 patients who underwent CABG without preoperative device insertion (2.7% versus 11.9%). Using multiple logistic regression analysis, we identified the following characteristics to be indicative of increased risk for early death after myocardial revascularization in patients with severely depressed ventricular function (LVEF 
0.25): previous CABG, NYHA class III or IV, left main stenosis, nonelective operation, and LVEDP greater than 20 mm Hg (see Table 4
). Prophylactic placement of an IABP before anesthetic induction may be beneficial in such patients.
Counterpulsation with an IABP was first used in 1967 by Kantrowitz and associates [11] for circulatory support of patients in cardiogenic shock. The IABP augments the aortic diastolic pressure and consequently increases coronary blood flow; the IABP concurrently reduces afterload and myocardial oxygen demand. For these reasons, counterpulsation is particularly useful for providing temporary support of the ischemic myocardium before revascularization procedures.
Isom and co-workers [12] observed that maximum release of the myocardial-specific isoenzyme of creatine kinase occurred in 92% of patients during the prebypass period after induction of general anesthesia. For this reason, Gunstensen and associates [6] recommended insertion of the IABP under local anesthesia prior to induction of general anesthesia in patients with acute coronary insufficiency, critical left main coronary artery stenosis, or severe LV dysfunction. In their series, prophylactic preoperative counterpulsation in patients undergoing CABG was associated with a 7.5% mortality rate compared with a 23.1% mortality rate when the IABP was used after cardiotomy.
Recent studies [13–16] show that the early postoperative mortality rate in patients requiring postcardiotomy IABP assistance after CABG ranges from 37.5% to 48.4%. In our present series, use of an IABP after cardiotomy (subgroup B2) was associated with a 42.9% mortality rate. Golding and associates [15] showed that delayed use of the IABP was associated with an elevated mortality, whereas the prevalence of perioperative myocardial infarction and in-hospital mortality were significantly less in patients in whom IABP support was initiated preoperatively. Creswell [13], Bolooki [17], and their colleagues also demonstrated that earlier use of the IABP is associated with improved survival.
Indications for prophylactic IABP assistance before revascularization procedures include acute coronary insufficiency with refractory unstable angina, severe left main coronary occlusion or its equivalent, and severe LV dysfunction [6, 17]. In this study, our criteria for elective preoperative IABP insertion included the combination of severe LV dysfunction and severe myocardial ischemia, especially in patients with left main stenosis or a recent myocardial infarction or in patients undergoing reoperation.
According to Akins [18], the IABP is the most predictable method of controlling myocardial ischemia, and preoperative counterpulsation allows virtually all patients to have revascularization in a nonischemic state. Intraaortic balloon counterpulsation allows stabilization of the patient's hemodynamic status and permits safer cardiac catheterization and induction of general anesthesia [6]. Another potential advantage of preoperative counterpulsation is that an IABP already in place can be used to provide pulsatile flow during cardiopulmonary bypass, which may result in better organ function than the nonpulsatile flow of conventional bypass [19].
However, great caution must be exercised when using the IABP because vascular complications associated with use of this device are not uncommon. We observed vascular complications in 3 (8.1%) of the 37 patients in group A (preoperative IABP placement) and in 4 (14.3%) of the 28 patients in group B having postcardiotomy IABP insertion. However, no patient in our series required amputation.
With the femoral approach, the prevalence of IABP–related vascular complications ranges from 6.8% to 32.6% [20–25]. Kantrowitz and associates [23], however, suggested that most IABP complications are minor and resolve after balloon removal, are usually related to the vascular status of the patient, and, with the exception of bacteremia, are independent of the duration of counterpulsation. Deaths directly attributable to the IABP are very uncommon [13, 17, 20, 21, 25].
Several groups [21–26] have suggested that the percutaneous approach is associated with an increased rate of major vascular complications, especially in patients with peripheral vascular disease, in women, and in diabetic patients. To reduce the risk of ischemic complications, Phillips and associates [27] recommend a sheathless insertion of the percutaneous balloon in patients with small or diseased arteries. Alternatively, several authors [21, 24] suggest insertion of the IABP through the ascending aorta whenever the wire-guided balloon cannot be easily advanced from the femoral approach.
Other major complications associated with the IABP include aortic dissection [21, 23, 25], paraplegia [21, 24], bacteremia [21–26], mesenteric infarction [22, 24, 28], balloon rupture [21, 22], and balloon entrapment [29]. We did not observe any of these complications in our series.
Finally, with emphasis on cost containment in health care today, a very important aspect to consider is whether a procedure is cost-effective or not. Bolooki and colleagues [17] observed that the average hospital stay was 12 days for patients who had elective IABP insertion before operation compared with 18 days for patients requiring IABP support after CABG. They also noted an increased rate of renal and pulmonary complications in the latter group. Gunstensen and associates [6] had a similar experience and concluded that prophylactic IABP use is cost-effective in patients with severely depressed ventricular function, left main stenosis, or refractory unstable angina.
We compared the average duration of postoperative hospitalization and the mean hospital charges for all surviving patients. We observed that the average hospital stay was 2.1 days shorter for patients with elective preoperative IABP placement (group A) compared with those without preoperative counterpulsation (group B) (mean, 9.9 days versus 12.0 days). Also, the mean hospital charges for patients with an IABP preoperatively were lower than those for patients without preoperative IABP insertion ($50,627 versus $54,818). Because of the wide variability, these differences between groups A and B were not significant.
Nevertheless, we observed that prophylactic use of the IABP did not prolong hospital stay and did not increase costs. Table 5, for example, shows that the mean postoperative hospital stay was slightly shorter (but not significantly so) for patients in group A compared with patients in subgroup B1 (no counterpulsation). However, mean hospital charges were higher (but not significantly higher) for patients in group A compared with patients in subgroup B1 (see Table 6). A possible explanation is that the hospital charges included heart catheterization and CABG (diagnostic-related group 106) done on an urgent or emergency basis during the same hospital admission in 81.1% (30/37) of the patients in group A compared with only 60.2% (59/98) of the patients in subgroup B1.
Our study also demonstrated that the mean postoperative hospital stay and the mean hospital charges were significantly higher for patients in subgroup B2 (p < 0.05) compared with patients in group A and subgroup B1 (see Tables 5, 6). Thus, it is also important to identify the patients with severely impaired ventricular function who may require counterpulsation after CABG (see Table 2).
Statistical analysis showed that the following patients were more likely to need an IABP after CABG (in group B): patients in NYHA class III or IV (odds were 5.8 times higher), patients undergoing reoperation (odds were 4.5 times higher), patients with a recent myocardial infarction (0 to 7 days before operation), and patients undergoing a nonelective operation with unstable angina, intravenous nitroglycerin, or left main stenosis (odds were between 2 and 3 times higher) (see Table 2).
Table 7 shows the trend toward more frequent use of the IABP preoperatively during 1994 and 1995, which was associated with a lower overall mortality, a shorter hospital stay, and reduced hospital charges (especially during 1995).
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Although our results do not show any particular advantage for use of the IABP preoperatively in patients with an LVEF of 0.25 or less who are undergoing elective CABG and are in class I or II of the NYHA and Canadian Cardiovascular Society classifications, our experience suggests that most patients with severe LV dysfunction undergoing coronary bypass operations may benefit from prophylactic IABP insertion, especially patients undergoing reoperations, patients in NYHA class III or IV, patients with a recent myocardial infarction, or patients with left main stenosis. Elective preoperative IABP insertion significantly improved survival, reduced hospital stay, and was the more cost-effective approach for these patients.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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References |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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A. V. Mulay, S. Zacharias, S. D. Hansbro, R. W. Catchpole, and R. U. Nair Should intraaortic balloon counterpulsation be continued during cardiopulmonary bypass? J. Thorac. Cardiovasc. Surg., December 1, 1997; 114(6): 1128 - 1129. [Full Text]
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J. T. Christenson, P. Badel, F. Simonet, and M. Schmuziger Preoperative Intraaortic Balloon Pump Enhances Cardiac Performance and Improves the Outcome of Redo CABG Ann. Thorac. Surg., November 1, 1997; 64(5): 1237 - 1244. [Abstract] [Full Text]
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L. P. Perrault, P. Menasche, J. Peynet, B. Faris, A. Bel, T. de Chaumaray, C. Gatecel, B. Touchot, G. Bloch, and J.-M. Moalic On-Pump, Beating-Heart Coronary Artery Operations in High-Risk Patients: An Acceptable Trade-off? Ann. Thorac. Surg., November 1, 1997; 64(5): 1368 - 1373. [Abstract] [Full Text]
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R. L. Quigley and F. L. Reitknecht A Coronary Artery Bypass "Fast-Track" Protocol Is Practical and Realistic in a Rural Environment Ann. Thorac. Surg., September 1, 1997; 64(3): 706 - 709. [Abstract] [Full Text]
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G. E. Cimochowski, M. D. Harostock, and P. J. Foldes MINIMAL OPERATIVE MORTALITY IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS WITH SIGNIFICANT LEFT VENTRICULAR DYSFUNCTION BY MAXIMIZATION OF METABOLIC AND MECHANICAL SUPPORT J. Thorac. Cardiovasc. Surg., April 1, 1997; 113(4): 655 - 666. [Abstract] [Full Text]
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R. A. Ott, D. E. Gutfinger, M. P. Miller, H. Alimadadian, and T. M. Tanner Rapid Recovery After Coronary Artery Bypass Grafting: Is the Elderly Patient Eligible? Ann. Thorac. Surg., March 1, 1997; 63(3): 634 - 639. [Abstract] [Full Text]
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