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Ann Thorac Surg 1997;64:1237-1244
© 1997 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, Columbia Hôpital de la Tour, Meyrin-Geneva, Switzerland
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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0.40), unstable angina, and left main stem stenosis greater than or equal to 70%, a preoperative intraaortic balloon pump (IABP) support could be beneficial to improve the outcome in high-risk redo CABG. Methods. Between June 1994 and October 1996, 48 high-risk patients underwent redo CABG and were randomized into the following groups: group 1 (24 patients) who received preoperative IABP treatment on average 2 hours before cardiopulmonary bypass, and group 2 (24 patients) who received no preoperative IABP and served as controls. Mean age was 65 years and 90% (43 patients) were men. Forty-one patients had preoperative left ventricular ejection fraction less than or equal to 0.40 (85%), 38% (18 patients) had left main stem stenosis greater than or equal to 70%, and 54% (26 patients) had unstable angina preoperatively. Preoperative patient characteristics did not differ between the groups.
Results. The time on cardiopulmonary bypass was shorter in group 1, 86 versus 110 minutes (p = 0.006). There were no hospital deaths in group 1, but four deaths occurred in the control group (p = 0.049). Cardiac index rose significantly preoperatively after introduction of the IABP in group 1. Cardiac index was significantly higher postoperatively in group 1 compared with group 2 and remained significantly higher during the first 24 hours after cardiopulmonary bypass. Significantly fewer patients in the IABP group had postoperative low cardiac output (4 versus 13 patients). Nine patients in group 2 required IABP support postoperatively for 4.1 ± 1.7 days. Only 2 patients in group 1 needed IABP postoperatively, and their IABPs were successfully removed on the first postoperative day. The preoperative IABP-supported patients had a shorter intensive care unit stay, 2.4 ± 0.8 days compared with group 2, 4.5 ± 2.2 days (p = 0.007), as well as a shorter hospital stay. The preoperative IABP treatment was found to be cost-effective.
Conclusions. Preoperative treatment with IABP in high-risk redo CABG patients is an effective modality to prepare these patients to have their myocardial revascularization in an as nonischemic situation as possible, which resulted in a significantly lower hospital mortality, fewer instances of postoperative low cardiac output, and shorter stays in both the intensive care unit and the hospital.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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The development of invasive and noninvasive cardiology has extensively influenced the indications for primary and reoperative (redo) myocardial revascularization. In the past, patients undergoing reoperative coronary artery bypass grafting (redo CABG) were generally younger than those accepted for primary CABG [1–3], but because of the acceptance of a larger number of elderly patients for a primary operation [4, 5], the average age of patients requiring redo CABG is gradually increasing. This is an added risk to the other well-recognized challenges of redo CABG. As a consequence, both hospital mortality and morbidity rates are reported to be higher after redo CABG compared with those of primary CABG [2, 3, 5, 6]. Poor preoperative left ventricular function (left ventricular ejection fraction; LVEF < 0.40) has been shown to be a more important risk factor for hospital mortality in redo CABG than after primary CABG [6]. Unstable angina, necessitating urgent surgical intervention, and presence of severe left main stem stenosis (
70%), as well as a short interval between the first operation and the reoperation (<1 year) have earlier been reported to be independent risk factors for mortality in redo CABG [2, 6, 7].
The intraaortic balloon pump (IABP) is an established additional support to pharmacologic treatment of the failing heart after myocardial infarction, unstable angina, and cardiac surgery [1, 8, 9]. The IABP treatment results in a more favorable myocardial supply and demand balance [10], reduces afterload, and augments the diastolic pressure [11, 12], which in turn leads to an increased cardiac output. An augmented diastolic pressure results in a redistribution of coronary blood flow toward ischemic areas of the myocardium [13, 14]. Christakis and associates [15] reconfirmed suggestions earlier voiced by Gunstensen and colleagues [16] and others [17] that use of an IABP preoperatively could lead to a preoperative reduction of myocardial ischemia, and thereby possibly improve the outcome of myocardial revascularization in patients with poor preoperative left ventricular function. However, using an IABP preoperatively means increased cost, as well as the possibility of increased morbidity related to the IABP itself [18].
So far only a few studies have been published, all retrospective in nature, that specifically evaluate the benefits of preoperative IABP support in high-risk patients, including those with LVEF less than 0.25 (0.18 to 0.20). These studies have demonstrated that hospital mortality rate could be lowered significantly in patients who receive preoperative IABP support, compared with those who receive IABP perioperatively, only when desperately needed [19, 20]. Moreover, Dietl and associates [20] recently demonstrated that this treatment is cost-efficient. The optimal time for the start of preoperative IABP support has not been defined yet, but Christenson and coworkers [21], in a prospective, randomized study, recently showed that IABP treatment initiated 24 hours preoperatively in high-risk patients did not improve postoperative mortality or morbidity, in comparison with a 1- to 2-hour IABP treatment before aortic cross-clamping.
This study is designed to evaluate the efficacy and cost-benefit analysis of preoperative IABP treatment on perioperative and postoperative cardiac performance (cardiac index), mortality, and morbidity in a controlled, prospective randomized study in a group of high-risk patients undergoing redo CABG.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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0.40), unstable angina at the time of surgery (angina severity fluctuating between angina classes [Canadian Cardiovascular Society's classification of angina] or angina at rest despite nitroglycerine infusion and calcium-channel inhibitors), left main stem stenosis greater than or equal to 70%, or a combination thereof. Patients undergoing redo CABG not fulfilling these high-risk criteria were not included in the study. Only 1 patient (2.1%) had his first CABG at our institution, and all the others were referrals from other hospitals. On admission to the hospital, the patients were randomized by lottery principle, drawing preprepared sealed envelopes containing the group assignment. There were two groups of 24 patients in each as follows: in group 1 (IABP) patients were to receive a preoperative IABP treatment before induction of anesthesia, and in group 2 (controls) the patients did not receive preoperative treatment with IABP. All other interventions and procedures were standardized and remained the same for all patients in the two groups. All patients received a Swan-Ganz catheter preoperatively and cardiac performance was evaluated by cardiac index (L • min-1 • m-2), calculated from cardiac output data measured repeatedly, preoperatively and after weaning from CPB until 72 hours postoperatively. The amount of pharmacologic inotropic support required, preoperatively as well as postoperatively, to maintain a cardiac index greater than or equal to 2.0 L • min-1 • m-2 was also monitored in the two groups. Moreover, postoperative mortality and morbidity, including all balloon-related complications, as well as required stay in the intensive care unit (ICU) and the total hospital stay, were registered.
All preoperative clinical and catheterization data, as well as operative data, were entered into a computer data base at the time of hospitalization. Definitions were made before the start of the study and were not changed during the study period. The LVEF was calculated from the preoperative ventriculography and from echocardiography during the follow-up period.
Patient Profile
The mean age of the patients was 65 ± 8 years (range, 48 to 82 years) in group 1 and 62 ± 9 years (range, 46 to 81 years) in group 2 (p = 0.387, not significant). There were 3 women in group 1 and 2 in group 2. Preoperative risk factor and combinations thereof (inclusion criteria) in the two groups can be found in Table 1
. The classic risk factors for coronary artery disease were similar in both groups and did not differ from previous reports. All patients in group 1 and all but one in group 2 had triple-vessel coronary artery disease. The average time from the primary CABG to the redo CABG was 8.7 ± 4.5 years in group 1 and 8.3 ± 4.9 years in group 2 (p = 0.487, not significant). There were 2 patients in each group with an interval shorter than 1 year, and there were 2 patients in group 1 and 1 patient in group 2 undergoing a second redo CABG.
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All operations were performed through a median sternotomy, and no injuries to heart or bypasses occurred. A cell-saving device was routinely used. The internal mammary artery was harvested as a pediculated graft whenever it was used as a conduit. No other arterial conduits were used in this series. The sequential bypass grafting technique was employed routinely, as earlier described in detail [22], and specific technical aspects employed by us in reoperative CABG surgical procedures have been discussed in detail previously [1].
Intraaortic Balloon Pump
The intraaortic balloon (IAB) used was a 9F, 40-mL balloon Rediguard IAB Catheter (St. Jude Medical, Europe Inc, Zaventem, Belgium, from 1996 CR BARD GmbH, Karlsruhe, Germany) connected to a pump (Datascope, Oakland, NJ). In group 1 (preoperative IABP), 23 of 24 (96%) IAB catheters were inserted by a percutaneous route (femoral artery). Only 1 patient in this group required a surgical cut-down for placement of the IAB catheter. Twenty-one of the 24 IAB catheters in group 1 (88%) were inserted in the operating room just before induction of anesthesia using local analgesia. In 4 patients the IAB catheter was inserted in the ICU before transfer to the operating room. The average preoperative IABP treatment was 2.1 ± 0.6 hours (range, 1 to 5 hours before cardiac arrest). In group 2 the IAB catheter was inserted in the operating room in all instances (9 patients) when a cardiac index more than 2.0 L • min-1 • m-2 could not be maintained postoperatively despite pharmacologic support (dopamine at 15 µg • kg-1 • min-1, dobutamine at 5 to 10 µg • kg-1 • min-1, amrinone at 0.5 mg/kg bolus dose, or a combination of drugs). In group 2, percutaneous insertion of the IAB catheter was performed in 6 patients, whereas 3 required surgical placement. When the IAB catheter was indicated there was no failure in placing the catheter in either of the groups, using the guidewire. All patients received prophylactic antibiotics. We did not give thyroid hormones to any of the patients before beginning postoperative IABP. Patients undergoing preoperative insertion were therapeutically anticoagulated with heparin after IAB catheter placement. Patients returning from the operating room with an IAB catheter in place were anticoagulated with heparin after the mediastinal drainage subsided (usually within 24 hours). The IABP support was terminated after hemodynamic stability was restored (maintaining a cardiac index greater than or equal to 2.0 L • min-1 • m-2 with only minimal pharmacologic inotropic support). Preoperative unstable angina in group 1 patients stabilized after IABP support and was stable at the time of the operation, whereas group 2 patients with unstable angina remained unstable at the time of the operation.
Cost-effectiveness was derived from a comparison of the mean total hospital costs for each group.
Follow-up
All hospital survivors were evaluated clinically (New York Heart Association, Canadian Cardiovascular Society, and ergometry) and with estimation of their LVEF by echocardiography 3 months postoperatively.
Statistics
Student's t test (one-sample paired test), Mann Whitney, and Fisher's exact test were employed to assess differences between groups for statistical significance, where appropriate. A probability level of p less than 0.05 was regarded significant. All data were presented as mean ± standard deviation.
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Results |
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Cardiac Performance
Cardiac index data are presented in Figure 1 and Table 2. All measurements of cardiac output were performed without IABP support, except the before CPB data in group 1 and postoperatively in subgroup of patients in group 2, in whom measurements were obtained with ongoing IABP treatment. There was a significant increase in cardiac index after preoperative IABP support in group 1. Cardiac index was significantly higher in both groups 5 minutes after CPB compared to values before CPB, reaching significantly higher values in group 1. Cardiac index in group 1, without IABP support, was significantly higher during the first 48 hours postoperatively compared with group 2.
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No IABP-related mortality was encountered. The IABP-related morbidity in this series involved 2 patients (4.2%). In group 1, 1 patient who required postoperative IABP support had leg ischemia that was not relieved by removal of the IAB catheter, and an arterial thrombectomy was required to restore the peripheral circulation. The second IAB catheter complication occurred in group 2, in which 1 patient, on the second day of treatment, had leg ischemia. Fortunately the IABP support was no longer required in this patient, and after removal of the catheter normal peripheral circulation was reestablished.
On ending the IABP treatment a slight drop in cardiac index was generally observed. However, no dramatic deterioration of cardiac performance occurred that required resumption of IABP support or need for massive doses of pharmacologic inotropic support.
Preoperatively the amount of inotropic pharmacologic support was the same in the two groups. During the first 24 hours postoperatively all patients undergoing myocardial revascularization receive a small dose of dopamine (3 µg • kg-1 • min-1) at our institution. However, the required dopamine dose was significantly higher in group 2 during the first 24 hours. Moreover, the number of patients requiring additional support with dobutamine and amrinone during the first 24-hour period was significantly greater in group 2 compared with group 1 (Table 3).
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Three months' follow-up of hospital survivors showed satisfactory results with a significant improvement in the patients' functional status (LVEF by echocardiography, New York Heart Association and Canadian Cardiovascular Society class, as well as ergometry results) without group differences (Table 5).
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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70%) main stem stenosis of the left coronary artery [1], as well as a short interval between the primary and the redo operations [7]. Difficulties in weaning a patient from CPB because of severely disturbed cardiac performance (low cardiac output) is known to be associated with a very high postoperative mortality, despite massive pharmacologic support, even after the introduction of IABP support [8, 20, 24]. This was confirmed in the present study. Group 2 patients with low cardiac output had a hospital mortality rate of 30.8% (4/13 patients). Indications for preoperative IABP treatment before myocardial revascularization include acute coronary artery insufficiency with unstable angina, left main coronary artery stenosis greater than or equal to 70% and severe left ventricular dysfunction [14, 20, 21]. An additional risk group would be patients undergoing redo CABG who have one or more of the above-mentioned criteria present [1, 20]. In the present study we have used all the above high-risk patient inclusion criteria.
Previous studies have been retrospective in nature and focused on end results, such as influence on hospital mortality, rather than studying measurable effects, such as the effects of preoperative IABP treatment on cardiac index, which was the case in the present study [12, 13, 20, 24]. Preoperative IABP treatment resulted in a significant improvement of cardiac index, thus presenting a less ischemic or in many cases even a nonischemic myocardium at the time of aortic cross-clamping. This may well be the main explanation for the beneficial results obtained in patients who received preoperative IABP support. Parallel to the improved cardiac performance obtained in group 1 patients, the need for pharmacologic inotropic support during the first 24 hours after CPB was less in the preoperative IABP patients compared with controls.
As a consequence of fewer patients with low cardiac output postoperatively after myocardial revascularization and CPB in group 1, the ICU stay was significantly shorter in this group compared with controls (group 2). This corresponds to findings described by Dietl and colleagues [20].
The optimal timing for the insertion of an IABP preoperatively has been addressed in a recent report [21], in which a 24-hour period of IABP treatment preoperatively was found to result in a better postoperative cardiac index than a shorter treatment period (1 to 2 hours preoperative IABP support), but to have no impact on hospital mortality or postoperative morbidity and required stay in the ICU [21].
The incidence of perioperative myocardial infarction as well as neurologic complications was low in both groups in our series, in contrast to previous reports [20, 24]. The incidence of gastrointestinal complications has been reported to be higher after redo CABG than after primary CABG procedures. A possible link between postoperative low cardiac output, splanchnic hypoperfusion, and development of gastrointestinal complications has been suggested [25, 26]. In the present study fewer postoperative gastrointestinal complications occurred in group 1 compared with group 2, 1 of 24 patients (4.2%) versus 3 of 24 (12.5%). However, this difference was not statistically significant, most likely as a result of the small number of observations.
Even though we have clearly demonstrated the efficacy and cost-benefit effect of preoperative insertion and treatment with IABP in high-risk patients undergoing redo CABG, it must be emphasized that IABP treatment is associated with a nonnegligible morbidity. The most common morbidities are early vascular complications, caused by either flow impairment as a result of partial or complete obstruction by the IAB catheter itself or distal embolization, resulting in leg ischemia [18, 20]. A review of other, less common, complications of IABP has recently been discussed in the paper by Dietl and associates [20] and need not be repeated here. A careful surveillance of any patient treated with IABP is strongly advocated. In the present series we encountered relatively few IABP complications, 1 of the 24 patients (4.2%) in group 1 (preoperative IABP) and 1 of the 9 patients (11.1%) receiving an IABP postoperatively (group 2). It is possible that the shorter time required for the IAB catheter to be in place in group 1 contributed to the lower complication rate, but because of the small number of patients, this suggestion cannot be proved. Further studies will be needed after redo CABG to address this question specifically.
In summary, preoperative treatment with IABP in high-risk patients undergoing redo CABG with unstable angina at the time of operation, moderate to severe left ventricular dysfunction (LVEF < 0.40), and left main coronary artery stenosis greater than or equal to 70% or combinations thereof is an effective modality to eliminate or lessen myocardial ischemia before myocardial revascularization. Preoperative IABP treatment, when compared with a similar high-risk group of control patients who did not receive preoperative IABP support, resulted in a significantly lower hospital mortality and significantly fewer patients with cardiac index less than 2.0 L • min-1 • m-2 (thus avoiding massive pharmacologic inotropic support and urgent additional IABP support). Moreover, preoperative IABP support resulted in shorter ICU stay. In this group of high-risk redo CABG patients, preoperative IABP insertion and treatment (1 to 2 hours before cross-clamping) was also found to be highly cost-effective. However, because of a not negligible IABP morbidity of predominently vascular complications, a close surveillance of the peripheral circulation is advocated with special emphasis on looking out for early signs of acute ischemia or acute compartmental syndrome development.
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Acknowledgments |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Christenson, Department of Cardiovascular Surgery, Columbia Hôpital de la Tour, 1 av J.-D. Maillard, CH-1217 Meyrin-Geneva, Switzerland.
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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