HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Osama E. Arafa Jan L. Svennevig Erik Fosse Odd R. Geiran Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Arafa, O. E. Articles by Geiran, O. R. Search for Related Content PubMed PubMed Citation Articles by Arafa, O. E. Articles by Geiran, O. R.

Ann Thorac Surg 1998;65:741-747
© 1998 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Intraaortic Balloon Pump in Open Heart Operations: 10-Year Follow-up With Risk Analysis

Department of Surgery A, Rikshospitalet, Oslo, Norway

Accepted for publication September 29, 1997.

Dr Arafa, Department of Surgery A, Rikshospitalet, 0027 Oslo, Norway.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The intraaortic balloon pump (IABP) is the primary mechanical device used for perioperative cardiac failure.

Methods. We analyzed the prognostic predictors and long-term survival of 344 patients undergoing cardiac operations who required the perioperative use of an IABP at our institution from January 1980 to December 1989. Hospital survivors (163 patients) were followed up for a mean of 7.45 years (range, 1 month to 15.3 years); cumulative follow-up included 1,167 patient-years.

Results. The early mortality rate was 52.6% (181 patients). From parameters available at the time of IABP insertion, logistic regression analysis identified preoperative serum creatinine level, left ventricular ejection fraction, perioperative myocardial infarction, timing of IABP insertion, and indication for operation as independent predictors of early (30-day) death (p < 0.05). Cox regression analysis of hospital survivors identified timing of IABP insertion, perfusion time, and preoperative serum creatinine level as independent prognostic factors for late death (p < 0.05), whereas patient age was only marginally significant (p < 0.06). There was no association between IABP-related complications and death. Survival analysis demonstrated a 10-year actual survival rate of 22.04% ± 0.023%, with 57 patients still at risk and significantly improved survival among those who received an IABP before operation (p < 0.02).

Conclusions. The early mortality rate in patients who received an IABP was high. Hospital survivors had a relatively good long-term prognosis. The significantly better short- and long-term survival of patients who received an IABP before operation may justify more liberal preoperative use of the IABP in high-risk patients.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The intraaortic balloon pump (IABP) usually is the first mechanical device used for perioperative cardiac failure [1]. Its main effects are reduction of ventricular afterload, improvement of diastolic coronary perfusion, and enhancement of subendocardial perfusion [2].

Augmentation of the arterial diastolic pressure first was recorded as early as 1953, through retardation of the systolic pulse pressure by recovery of the systolic arterial wave from the femoral artery to the aorta through an elastic tube [3]. The first experimental results using an inflatable latex balloon inserted into the descending thoracic aorta through the femoral artery for the purpose of counterpulsation were reported in 1962 by Moulopoulos and associates [4]. The first clinical application was reported in 1968, primarily for use in cardiogenic shock [5]. Since that time, the IABP has gained widespread acceptance, and it is estimated that 70,000 IABPs are inserted annually in the United States [6].

Several previous studies [7][8][9] focused on prognostic factors for death in patients treated with an IABP without agreement on preoperative determinants of survival. As a result of variability in the indications for IABP insertion and differences in the patient populations, there is great variability in the results reported [7][8][9]. The present study, which includes clinical material from one surgical department, was undertaken to analyze the short- and long-term outcome of patients who receive an IABP perioperatively and to determine possible prognostic factors for early and late death. Further, a 10-year survival analysis considering possible significant prognostic factors was performed.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients and Procedures
Over the 10-year period from January 1980 through December 1989, 5,768 patients underwent open heart operations at our institution. All the patients who were treated with an IABP during the perioperative period were identified using our cardiothoracic database. Whenever necessary, additional data were obtained from the patients’ records. A total of 344 patients (5.9% of all patients), 231 males and 113 females with a mean age of 58 ± 11.8 years (range, 7 to 80 years), were treated with an IABP before (n = 53), during (n = 192), or after (n = 99) operation. The outcome analysis considered all deaths irrespective of the cause. The 163 operative survivors (47.4%) were followed up for a mean of 7.45 ± 4.8 years (range, 1 month to 15.3 years). The cumulative follow-up for hospital survivors was 1,167 patient-years. Data concerning patient survival are complete and were verified using the Norwegian civil registry. Follow-up data were acquired from the patients’ records at either our institution or the local hospital.

Clinical Parameters
The following clinical variables were included in the analysis: age, sex, body surface area, hypercholesterolemia (serum cholesterol >6 mmol/L), smoking (5 cigarettes per day), diabetes mellitus, hypertension (systolic pressure >160 mm Hg), preoperative New York Heart Association class, cardiac rhythm, serum creatinine level (in micromoles per liter), number of previous myocardial infarctions (MIs), previous cardiac operations, and emergency operations (operation within 24 hours of diagnosis). Cardiac catheterization data included the number of diseased vessels (obstruction >75%), the left ventricular ejection fraction, and the left ventricular end-diastolic pressure. Relative heart volume was measured from standard chest roentgenograms. Perioperative MI was defined as new Q waves in association with increased enzyme creatine kinase and isoenzyme creatine kinase-myocardial band levels. We considered only perioperative MIs diagnosed before the insertion of an IABP.

Operative Variables
All surgical procedures were performed using moderate hemodilution, systemic moderate hypothermia (28°C), crystalloid cardioplegia, and topical cooling. Cardiopulmonary bypass time and aortic cross-clamp time were recorded. A total of 216 (62.8%) patients were operated on for ischemic heart disease, 67 (19.5%) for valvular heart disease, 43 (12.5%) for combined ischemic and valvular disease, and 18 (5.2%) for other conditions (Table 1). The site and technique of insertion of the IABP were recorded. Major IABP-related complications were defined as aortic perforation, dissection or ischemia requiring a vascular operation, and fasciotomy or amputation. Minor complications included ipsilateral transient limb ischemia, which recovered after removal of the IABP, and local infection or bleeding at the site of insertion. All patients who died in the hospital underwent autopsy. Early death was defined as any death that occurred within 30 days of operation and late death as any death after that time.

Using the BMDP statistical software package, release 7.01 [11], all variables with a p value of 0.15 or less were entered into a stepwise logistic regression model to determine independent risk factors for early death. Cox regression analysis was used to determine independent predictors of late death among factors that were identified in the univariate analysis or were considered clinically important.

Survival Analysis
Cumulative survival curves were computed according to Kaplan and Meier using the life table and survival functions program in the BMDP package [11] and stratifying according to the most significant risk factors. Differences between survival curves were estimated using the Mantel-Cox and Breslow tests. Survival rates were given as cumulative survival ± standard error.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Over the 10-year study period, the frequency of IABP insertion decreased gradually from 9% to 4.2% (p < 0.05). The decrease was accompanied by an increase in the early mortality rate from 41% to 66% (p < 0.05). The relative proportion of IABPs inserted before, during, and after operation remained unchanged over the study period (² = 11.9; p > 0.8). The IABP was used before operation in 53 (15.4%) patients to treat refractory circulatory failure, mostly caused by postischemic ventricular septal rupture and acute mitral regurgitation. During operation, the IABP was used in 192 (55.8%) patients to assist in weaning from cardiopulmonary bypass. After operation, the IABP was used in 99 (28.8%) patients to treat cardiogenic shock or persistent hypotension (n = 97) and refractory arrhythmia (n = 2).

Risk Factors for Early Death
Univariate analysis identified the following factors as associated with early death: previous MI, previous cardiac operation, emergency operation, body surface area, New York Heart Association class, lack of sinus rhythm, preoperative serum creatinine level, left ventricular ejection fraction, end-diastolic pressure, perfusion time, and perioperative MI. Multivariate analysis using forward logistic regression identified preoperative creatinine level, ejection fraction, perioperative MI, type of surgical procedure, and timing of IABP insertion as independent risk factors for early death (p < 0.05).

Risk Factors for Late Death
Univariate analysis of possible preoperative and intraoperative factors revealed that age, perfusion time, cardiac ischemic time, and timing of IABP insertion correlated significantly with late death (Table 2). Cox regression analysis identified the following as independent risk factors: timing of IABP insertion (p < 0.01), preoperative serum creatinine level (p < 0.05), and perfusion time (p < 0.05). Further, age was found to be marginally significant (p < 0.06).

View larger version (13K): [in this window] [in a new window]   Survival curve for 344 patients who received an intraaortic balloon pump, with an early mortality rate of 52.6%. (Op = operative day; Y = year.)

View larger version (16K): [in this window] [in a new window]   Survival curves showing a significant increase in the early mortality rate in patients with a perioperative myocardial infarction (MI) who received an intraaortic balloon pump. (Op = operative day; pts = patients; Y = year.)

View larger version (18K): [in this window] [in a new window]   Survival curves for patients who received an intraaortic balloon pump stratified according to their preoperative serum creatinine level (in micromoles per liter). The preoperative serum creatinine level correlated significantly with early death. (Op = operative day; pts = patients; Se-creat. = serum creatinine level.

View larger version (19K): [in this window] [in a new window]   Survival curves for patients who received an intraaortic balloon pump stratified according to their preoperative ejection fraction (EF). (Op = operative day; pts = patients; Y = year.)

View larger version (19K): [in this window] [in a new window]   Survival curves for patients who received an intraaortic balloon pump, classified according to the timing of IABP insertion. (Op = operative day; pts = patients; Y = year.)

View larger version (21K): [in this window] [in a new window]   Survival curves for patients who received an intraaortic balloon pump, stratified according to age. (Op = operative day; pts = patients; Y = year.)

View larger version (25K): [in this window] [in a new window]   Survival curves for patients who received an intraaortic balloon pump, stratified according to the indication for operation. (CABG = coronary artery bypass grafting; Op = operative day; pts = patients; Y = year.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
During the 10-year study period, use of the IABP in our department became more restricted as a result of the institution of rigid hemodynamic criteria for its application. Most of our patients were treated with an IABP because of low cardiac output that was refractory to maximum pharmacologic treatment and judicious volume loading, in agreement with other reports [9][12][13][14]. This may explain the increased mortality rate in the treated patients. Analysis of patients who underwent coronary artery bypass grafting or valve operations during the same period demonstrated early mortality rates of 3% and 5%, respectively [15][16]. Our annual rate of perioperative IABP insertion during the study period was 5.9% (range, 4% to 9%), which is similar to the rates documented in other reports [1][8][10][13][14][17]. In spite of a general increase in the use of the IABP [1][7][17], our rate of insertion decreased from 9% to 4.2% over the study period. This decrease was accompanied by an increase in the early mortality rate from approximately 40% in the early years of the study to more than 66% in 1989.

In our series, most IABPs were inserted during or after operation for low output syndrome. This is consistent with some other reports [8][18]. Most of the patients who received an IABP before operation had serious post-MI complications. However, despite the absolute decrease in IABP use during the study period, the relative distribution of preoperative, intraoperative, and postoperative insertion remained relatively constant.

The early mortality rate for patients who are treated with an IABP remains high. The average early mortality rate in this study was 53%, which is consistent with the range (36% to 61%) reported in series of patients undergoing cardiac operations, including patients with cardiogenic shock [1][8][9][12][13][14][17][18][19]. Survival rates are better in series in which the IABP was inserted prophylactically before operation in high-risk patients with unstable angina, left main coronary artery stenosis, and left ventricular dysfunction [20][21]. However, the criteria for selecting appropriate candidates for preoperative use of the IABP remain controversial [12][18].

Identification of the group of patients who are at the highest risk of death at the time of IABP insertion will help to determine which patients may benefit from temporary support of the heart beyond that offered by the IABP [7] or from other management strategies. In our analysis of prognostic factors in patients who received an IABP, we depended entirely on variables that were available at the time of IABP insertion for the prediction of early death. Our model identified five factors as independently significant.

Postoperative renal dysfunction previously has been correlated with poor outcome after cardiac operations [22]. In our study, as in others [9][17], there was a significant linear trend between the preoperative serum creatinine level and early death. Furthermore, we found that the preoperative serum creatinine level significantly affected late death. We agree with Bolooki and associates [23] and with Corral and Vaughn [24] that the preoperative left ventricular ejection fraction and end-diastolic pressure are important determinants of patient survival, and that a minimum degree of left ventricular function should be required for patients who receive an IABP.

The effect of the type of operation performed on the survival of patients who receive an IABP has been documented by others [7][9][16][24]. In our series, we found that the poorest prognosis was associated with low cardiac output complicating congenital heart operations and heart transplantation. Patients who underwent operation for ischemia and ischemic complications had better survival than those who underwent operation for valvular heart disease either alone or in combination with ischemia. The IABP may be more beneficial for myocardium with ischemia than for myocardium with chronic mechanical strain caused by valvular heart disease.

Perioperative MI is one of the most significant risk factors cited in the literature [9][22]. In our study, the timing of IABP insertion affected significantly the prognosis of patients with perioperative MI, with preoperative insertion proving most favorable. However, perioperative MI was not a significant risk factor for late death in patients who received an IABP. The patients with perioperative MI who survived 30 days after operation had a survival curve similar to that of the patients without MI. Thus, our results support a policy of earlier and more liberal use of the IABP in high-risk patients, as recommended previously by other investigators [2][7][23][25].

The morbidity rate related to IABP insertion in our study was 16%, which is within the range (8.7% to 29%) reported elsewhere [17][26]. Complications related to the IABP ranged from minor local wound infection or hemorrhage from the access site, which rarely resulted in long-term morbidity, to major vascular complications, which led to long-term morbidity and even death in some patients. The IABP itself was the cause of death in 2 patients (0.5%). However, there was no statistically significant association between IABP-related complications and the short- or long-term mortality rate, in agreement with other studies [1][12]. Thus, complications related to the IABP should not restrict its use in high-risk patients.

A thorough analysis of survival curves showed that the IABP failed to support the circulation in 70 (20%) patients who died during the first 4 hours after operation, in accordance with previous reports [8][9][13]. According to Baldwin and co-workers [8], such patients are most likely to benefit from more effective modalities of ventricular support.

Survival analysis showed that hospital survivors usually had a relatively good probability of late survival. The highest mortality rate after hospital discharge occurred in the first year, especially in the first 3 months after operation. Taking into account the advanced clinical profile of our patients, the 5- and 10-year actual survival rates of approximately 32% and 23% are comparable to other published reports [1][12][14].

In conclusion, although the early mortality rate in patients who received an IABP was high, the long-term prognosis was relatively good for patients who survived the early postoperative period. Preoperative insertion of an IABP was associated with improved early as well as late survival. This finding suggests that more liberal and earlier use of the IABP is advisable in high-risk patients.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Naunheim KS, Swartz MT, Pennington DG, et al. Intraaortic balloon pumping in patients requiring cardiac operations. Risk analysis and long term follow-up. J Thorac Cardiovasc Surg 1992;104:1654-1661.[Abstract]
2. Maccioli GA, Lucas WJ, Norfleet EA The intra-aortic balloon pump: a review. J Cardiothorac Anesth 1988;2:365-373.
3. Kantrowitz A, Kantrowitz A Experimental augmentation of coronary flow by retardation of the arterial pressure pulse. Surgery 1953;34:678-687.[Medline]
4. Moulopoulos SD, Topaz S, Kolff WJ Diastolic balloon pumping (with carbon dioxide) in the aorta: a mechanical assistance to the failing circulation. Am Heart J 1962;63:669-675.[Medline]
5. Kantrowitz A, Tjønneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL, Jr Initial clinical experience with intra-aortic balloon pumping in cardiogenic shock. JAMA 1968;203:135-140.
6. Kantrowitz A Origins of intraaortic balloon pumping. Ann Thorac Surg 1990;50:672-674.[Abstract]
7. Creswell LL, Rosenbloom M, Cox JL, et al. Intraaortic balloon counterpulsation: patterns of usage and outcome in cardiac surgery patients. Ann Thorac Surg 1992;54:11-20.[Abstract]
8. Baldwin RT, Slogoff S, Noon GP, et al. A model to predict survival at time of post cardiotomy intraaortic balloon pump insertion. Ann Thorac Surg 1993;55:908-913.[Abstract]
9. Christenson JT, Buswell L, Velebit V, Maurice J, Simonet F, Schmuzger M The intraaortic balloon pump for postcardiotomy heart failure. Experience with 189 intraaortic balloon pumps. Thorac Cardiovasc Surg 1995;43:129-133.[Medline]
10. Epi Info, Version 6. A word processing, database, and statistics program for epidemiology on microcomputers. Atlanta: Centers for Disease Control and Prevention, 1994.
11. Dixon WJ BMDP statistical software. Los Angeles: University of California Press, 1985.
12. Pennington DG, Swartz M, Codd JE, Merjavy JP, Kaiser GC Intraaortic balloon pumping in cardiac surgical patients: a nine year experience. Ann Thorac Surg 1983;36:125-131.[Medline]
13. Lund O, Johansen G, Allermand H, Berg E, Petersen T, Heil L Intraaortic balloon pumping in the treatment of low cardiac output following open heart surgery, immediate results and long-term prognosis. Thorac Cardiovasc Surg 1988;36:332-337.[Medline]
14. Hedenmark J, Ahn H, Henze A, Nystrom SO, Svedjeholm R, Tyden H Intra-aortic balloon counterpulsation with special reference to determinants of survival. Scand J Thorac Cardiovasc Surg 1989;23:57-62.[Medline]
15. Risum Ø, Abdelnoor M, Svennevig JL, et al. Risk factors for early and late mortality in surgical treatment of coronary artery disease. Cardiovasc Surg 1995;3:537-544.[Medline]
16. Fiane AE, Saatvedt K, Svennevig JL, et al. The CarboMedics valve: midterm follow-up with analysis of risk factors. Ann Thorac Surg 1995;60:1053-1058.[Abstract/Free Full Text]
17. Di Lello F, Mullen DC, Flemma RJ, Anderson AJ, Kleinman LH Results of intraaortic balloon pumping after cardiac surgery: experience with the percor balloon catheter. Ann Thorac Surg 1988;46:442-446.[Abstract]
18. Craver JM, Kaplan JA, Jones EL, Kopchak PA, Hatcher CR What role should the intra-aortic balloon have in cardiac surgery?. Ann Surg 1979;189:769-776.[Medline]
19. McEnany MT, Kay HR, Buckley MJ, et al. Clinical experience with intraaortic balloon pump support in 728 patients. Circulation 1978;58(Suppl 1):124-132.
20. Gunstensunsen J, Goldman BS, Scully HE, Huckell VF, Adelman AG Evolving indications for pre-operative intraaortic balloon pump assistance. Ann Thorac Surg 1976;22:535-543.[Abstract]
21. Cooper GN, Singh AK, Christian FC, Cashman C, Vargas L, Karlson KE Preoperative intra-aortic balloon support in surgery for left main coronary stenosis. Ann Surg 1977;185:242-246.[Medline]
22. Downing TP, Miller DC, Stofer R, Shumway NE Use of the intraaortic balloon pump after valve replacement. J Thorac Cardiovasc Surg 1986;92:210-217.[Abstract]
23. Bolooki H, Williams C, Turner RJ Clinical and hemodynamic criteria for use of intraaortic balloon pump in patients requiring cardiac surgery. J Thorac Cardiovasc Surg 1976;72:756-768.[Abstract]
24. Corral CH, Vaughn CC Intraaortic balloon counterpulsation: an eleven year review and analysis of determinants of survival. Tex Heart Inst J 1986;13:39-44.
25. Downing TP, Miller DC, Stinson EB, et al. Therapeutic efficacy of intraaortic balloon pump counterpulsation. Analysis with concurrent "control" subjects. Circulation 1981;64(Suppl 1):108-113.
26. Mackenzie DJ, Wagner WH, Kulber DA, et al. Vascular complications of intra-aortic balloon pump. Am J Surg 1992;164:517-521.[Medline]

This article has been cited by other articles:

				A. S. Rubino, F. Onorati, G. Santarpino, K. Abdalla, S. Caroleo, E. Santangelo, and A. Renzulli Early intra-aortic balloon pumping following perioperative myocardial injury improves hospital and mid-term prognosis Interactive CardioVascular and Thoracic Surgery, March 1, 2009; 8(3): 310 - 315. [Abstract] [Full Text] [PDF]

				G. Santarpino, F. Onorati, A. S. Rubino, K. Abdalla, S. Caroleo, E. Santangelo, and A. Renzulli Preoperative intraaortic balloon pumping improves outcomes for high-risk patients in routine coronary artery bypass graft surgery. Ann. Thorac. Surg., February 1, 2009; 87(2): 481 - 488. [Abstract] [Full Text] [PDF]

				J. L. Svennevig Invited commentary. Ann. Thorac. Surg., February 1, 2009; 87(2): 488 - 488. [Full Text] [PDF]

				A. Karimi, N. Movahedi, A. Salehiomran, M. Marzban, S. Hesameddin Abbasi, and P. Yazdanifard Mortality in Open Heart Surgery with Intraaortic Balloon Pump Support Asian Cardiovasc Thorac Ann, August 1, 2008; 16(4): 301 - 304. [Abstract] [Full Text] [PDF]

				O. V. Hein, J. Birnbaum, K. Wernecke, M. England, W. Konertz, and C. Spies Prolonged Intensive Care Unit Stay in Cardiac Surgery: Risk Factors and Long-Term-Survival Ann. Thorac. Surg., March 1, 2006; 81(3): 880 - 885. [Abstract] [Full Text] [PDF]

				M. B. Reid and D. Cottrell Nursing Care of Patients Receiving: Intra-aortic Balloon Counterpulsation Crit. Care Nurse, October 1, 2005; 25(5): 40 - 49. [Full Text] [PDF]

				I. R. Ramnarine, A. D. Grayson, W. C. Dihmis, N. K. Mediratta, B. M. Fabri, and J. A.C. Chalmers Timing of intra-aortic balloon pump support and 1-year survival Eur. J. Cardiothorac. Surg., May 1, 2005; 27(5): 887 - 892. [Abstract] [Full Text] [PDF]

				F. Onorati, M. De Feo, P. Mastroroberto, L. Cristodoro, F. Pezzo, A. Renzulli, and M. Cotrufo Determinants and Prognosis of Myocardial Damage After Coronary Artery Bypass Grafting Ann. Thorac. Surg., March 1, 2005; 79(3): 837 - 845. [Abstract] [Full Text] [PDF]

				T. Suzuki, M. Okabe, M. Handa, F. Yasuda, and Y. Miyake Usefulness of preoperative intraaortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients Ann. Thorac. Surg., June 1, 2004; 77(6): 2056 - 2059. [Abstract] [Full Text] [PDF]

				R. J. F. Baskett, G. T. O'Connor, G. M. Hirsch, W. A. Ghali, K. Sabadosa, J. R. Morton, C. S. Ross, F. Hernandez, W. C. Nugent Jr, S. J. Lahey, et al. A multicenter comparison of intraaortic balloon pump utilization in isolated coronary artery bypass graft surgery Ann. Thorac. Surg., December 1, 2003; 76(6): 1988 - 1992. [Abstract] [Full Text] [PDF]

				A. W. Khir, S. Price, M. Y. Henein, K. H. Parker, and J. R. Pepper Intra-aortic balloon pumping: effects on left ventricular diastolic function Eur. J. Cardiothorac. Surg., August 1, 2003; 24(2): 277 - 282. [Abstract] [Full Text] [PDF]

				R. J.F. Baskett, W. A. Ghali, A. Maitland, and G. M. Hirsch The intraaortic balloon pump in cardiac surgery Ann. Thorac. Surg., October 1, 2002; 74(4): 1276 - 1287. [Abstract] [Full Text] [PDF]

				Z. S. Meharwal and N. Trehan Vascular complications of intra-aortic balloon insertion in patients undergoing coronary reavscularization: analysis of 911 cases Eur. J. Cardiothorac. Surg., April 1, 2002; 21(4): 741 - 747. [Abstract] [Full Text] [PDF]

				K.-B. Kim, C. Lim, H. Ahn, and J.-K. Yang Intraaortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients Ann. Thorac. Surg., June 1, 2001; 71(6): 1964 - 1968. [Abstract] [Full Text] [PDF]

				B. Meyns, P. Sergeant, P. Wouters, F. Casselman, P. Herijgers, W. Daenen, K. Bogaerts, and W. Flameng Mechanical support with microaxial blood pumps for postcardiotomy left ventricular failure: Can outcome be predicted? J. Thorac. Cardiovasc. Surg., August 1, 2000; 120(2): 393 - 400. [Abstract] [Full Text] [PDF]

				J. T. Christenson, F. Simonet, P. Badel, and M. Schmuziger Optimal timing of preoperative intraaortic balloon pump support in high-risk coronary patients Ann. Thorac. Surg., September 1, 1999; 68(3): 934 - 939. [Abstract] [Full Text] [PDF]

				D. E. Gutfinger, R. A. Ott, M. Miller, A. Selvan, M. A. Codini, H. Alimadadian, and T. M. Tanner Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting Ann. Thorac. Surg., March 1, 1999; 67(3): 610 - 613. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Osama E. Arafa Jan L. Svennevig Erik Fosse Odd R. Geiran Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Arafa, O. E. Articles by Geiran, O. R. Search for Related Content PubMed PubMed Citation Articles by Arafa, O. E. Articles by Geiran, O. R.