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Ann Thorac Surg 1999;67:610-613
© 1999 The Society of Thoracic Surgeons

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Original Articles

Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting

^a Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange, California, USA

Accepted for publication July 16, 1998.

Address reprint requests to Dr Ott, Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Bldg 53, Rte 81, 101 City Drive South, Orange, CA 92668

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. The use of the intraaortic balloon pump (IABP) in patients undergoing coronary artery bypass grafting has been traditionally associated with a high complication rate and adverse outcomes. However, recent reports show that many of these catastrophic outcomes can be avoided by preoperatively placing the IABP in high-risk patients. To further validate these reports, we defined a set of liberal criteria for preoperative IABP insertion and applied them to a series of elderly patients (70 years or older) undergoing isolated coronary artery bypass grafting.

Methods. Two hundred six consecutive patients who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass were retrospectively reviewed. A rapid recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthetic protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. Patients who required an urgent operation because of failed percutaneous transluminal coronary angioplasty, a critical left main stenosis (70% or greater), pronounced left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy or who required an emergency reoperation received preoperative IABP support.

Results. The 30-day mortality rate for the entire group was 4.4%. There were 97 patients (47%) who received a preoperative IABP (group II) in comparison with 109 patients (53%) who did not fulfill the preoperative insertion criteria (group I). Patients in group II had a lower left ventricular ejection fraction (mean, 46% versus 59%, p < 0.001) and a higher incidence of congestive heart failure (35% versus 17%, p < 0.01) and acute myocardial infarction (37% versus 17%, p < 0.01) than patients in group I. The average postoperative hospital length of stay for patients in group II was slightly longer than for those in group I (9.0 ± 10.5 versus 6.0 ± 3.7 days, p < 0.01). However, there were no statistically significant differences in complication or mortality rates between the two groups. Only 2 patients (2.2%) had complications related to IABP insertion. Lower extremity ischemia occurred in both patients, and both were treated successfully with thromboembolectomy.

Conclusions. Liberal preoperative insertion of the IABP can be performed safely in high-risk elderly patients undergoing coronary artery bypass grafting, with results comparable to those in lower risk patients.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Historically, use of the intraaortic balloon pump (IABP) in patients undergoing coronary artery bypass grafting (CABG) has been associated with a high complication rate and poor outcomes [1–7]. Many of the catastrophic outcomes have been reported for patients in whom the IABP was placed emergently during either intraoperative or postoperative hemodynamic decompensation. Several recent reports, however, have shown that many of these complications and catastrophic outcomes can be minimized by preoperative placement of the IABP [6–9].

Commonly accepted guidelines for preoperative insertion of the IABP include cardiogenic shock after percutaneous transluminal coronary angioplasty (PTCA) and unstable angina refractory to medical therapy [1, 6]. Other less commonly accepted guidelines for preoperative insertion of the IABP that have recently been reported [7–9] include emergency cardiac reoperation, critical left main stenosis (70% or greater), and significant left ventricular dysfunction (left ventricular ejection fraction 40% or less). These less commonly accepted guidelines evolved from the clinical experience with intraoperative and postoperative IABP insertion, which demonstrated that many patients who ultimately required insertion of an IABP were those undergoing repeat CABG or those with critical left main stenosis or poor left ventricular function.

In an effort to minimize the complications and catastrophic outcomes associated with either intraoperative or postoperative IABP insertion, we defined a set of liberal criteria for preoperative placement of the IABP and applied them to a series of elderly patients (70 years or older) undergoing isolated CABG. Our intent was to improve operative outcomes by avoiding delays in IABP institution while minimizing the complications associated with IABP use. The results of this experience are described here.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
From January 1993 through September 1996, 423 patients underwent isolated CABG with cardiopulmonary bypass (CPB) by a single surgeon (R.A.O.). Of these patients there were 206 consecutive elderly patients (70 years or older) who were retrospectively reviewed. All operations were performed within 24 hours of cardiac catheterization, unless additional time was needed to optimize the clinical condition. After coronary catheterization, when the arterial sheath was still in place, a decision was made as to whether preoperative placement of the IABP was necessary. Patients who required an urgent operation because of failed percutaneous transluminal coronary angioplasty (PTCA), critical left main stenosis (70% or greater), significant left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy or who required an emergency cardiac reoperation received a preoperative IABP. The intent was to identify a group of patients who were at risk for perioperative cardiac decompensation and to provide additional hemodynamic stability, such that episodes of low-output syndrome and subsequent end-organ dysfunction were minimized. In all instances the IABP was inserted preoperatively using a percutaneous technique. No cutdown or transthoracic insertion methods were used.

Emergency cardiac reoperation refers to patients with a previous CABG requiring emergent operation secondary to (1) failed PTCA; (2) significant lesions (70% stenosis or greater) of the left main coronary artery or a dominant coronary system that is unprotected with patent bypass grafts; or (3) graft dependency to a dominant coronary vascular system with a significant stenosis (70% or greater); and (4) unstable anginal pattern. A cutoff of 70% stenosis of the left main coronary artery was chosen because more significant flow obstruction occurs with angiographic stenosis of 70% or greater. A left ventricular ejection fraction of 40% was chosen because it is the accepted cutoff between moderate and severe left ventricular dysfunction.

A previously described rapid recovery protocol [10, 11] that emphasizes short CPB time, early extubation, perioperative steroid and thyroid administration, and aggressive diuresis was applied to all patients. Attention was directed toward reducing CPB time so that the deleterious effects of CPB on recovery would be minimized. A combination of antegrade and retrograde cardioplegia was used, as previously described [10, 11]. Triiodothyronine was administered intraoperatively, whereas dexamethasone, thyroxine and early extubation techniques were used postoperatively [10, 11]. Every effort was made to wean the patient from the IABP and to remove it within 12 to 24 hours postoperatively. In the absence of bleeding, and after successful early extubation and removal of the IABP, patients were transferred to a monitored floor and subsequently rehabilitated in the normal manner.

A database and risk assessment profile [12] were completed retrospectively for each patient. Results are expressed as mean value ± standard deviation. Comparison of continuous variables was accomplished using the t test, whereas categoric variables were compared with the ² test. Statistical significance was tested for p < 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Two hundred six consecutive elderly patients undergoing isolated CABG with CPB were retrospectively reviewed. The 30-day operative mortality rate for the entire series was 4.4% (9 patients). Ninety-seven patients (47%) received a preoperative IABP (group II) versus 109 patients (53%) who did not fulfill the preoperative insertion criteria (group I). Table 1 shows a comparison of the preoperative comorbidity for groups I and II. Patients in group II had a lower left ventricular ejection fraction (mean, 46% versus 59%, p < 0.001) and a higher incidence of congestive heart failure (35% versus 17%, p < 0.01) and acute myocardial infarction (37% versus 17%, p < 0.01) than patients in group I. Patients in group II naturally represented a group of patients with a higher risk for perioperative cardiac decompensation. This is also reflected by the higher Parsonnet risk assessment score for group II compared with group I (p < 0.001) [12].

Table 2 shows a comparison of the intraoperative variables. For the entire series the average number of bypass grafts was 2.9 ± 1.1, the aortic cross-clamp time was 33 ± 12 minutes, and the CPB time was 64 ± 27 minutes. There were no statistically significant differences in intraoperative variables between the two groups.

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

In the present study we focused on elderly patients (70 years or older) and defined a set of liberal criteria for preoperative IABP use, so that the number of patients requiring intraoperative or postoperative IABP insertion would be minimized (in our study no such patients required intraoperative or postoperative IABP insertion). The insertion criteria included patients who required an urgent operation because of a failed PTCA or an emergency repeat CABG and patients with a critical left main stenosis (70% or greater), significant left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy. These insertion criteria are not unique to the present study but have recently been used by others [8, 9]. Of 206 consecutive elderly patients undergoing isolated CABG with CPB, 97 patients (47%) satisfied the insertion criteria, with 30 (31%) of these 97 satisfying more than one criterion simultaneously.

Patients who received a preoperative IABP (group II) represented higher risk patients, with a greater proportion having congestive heart failure and acute myocardial infarction than those not receiving a preoperative IABP (group I). These patients also had a higher predicted operative risk according to the Parsonnet scale (21.4 ± 7.3 versus 15.0 ± 6.4, p < 0.001) [12]. Despite this higher predicted operative risk, there were no statistically significant differences (p > 0.05) in the operative mortality (6.2% versus 2.8%) and postoperative complication rates, between patients who received a preoperative IABP and those who did not. However, patients who received a preoperative IABP had a longer postoperative hospital LOS than those who did not require an IABP (9.0 ± 10.5 versus 6.0 ± 3.7 days, p < 0.01). This difference probably does not reflect any consequence of IABP use; rather, it reflects the increased preoperative morbidity associated with patients in group II.

Although many of the patients may have done well without an IABP, four recent studies [6–9] demonstrate that patients who fulfill the insertion criteria do significantly worse when the IABP is not used preoperatively. Such studies show that intraoperative or postoperative IABP insertion generally results in catastrophic outcomes and is not sufficient to reverse the clinical outcome. By avoiding delays in IABP use through preoperative insertion, improved outcomes comparable to those attained in lower risk patients can be achieved successfully.

Another important issue regarding preoperative IABP is the low observed rate of device-related complications compared with previous reports [4–6]. In our series there were only 2 patients (2.2%) who had device-related complications, both of which were lower extremity ischemia that was treated successfully with thromboembolectomy. This result may further justify preoperative use of the IABP in a large proportion of patients. Additionally the studies by Dietl and colleagues [8] and Christenson and associates [9] demonstrate that the extra cost incurred by preoperative IABP insertion is reclaimed through avoidance of the complications and the prolonged postoperative hospital LOS in patients who receive the IABP intraoperatively or postoperatively.

Liberal use of the IABP preoperatively for support of high-risk CABG remains controversial but, as demonstrated by the present study, can be safely accomplished. Our selection criteria were specifically designed to aggressively use the IABP preoperatively in an effort to avoid the complications and mortality associated with intraoperative or postoperative insertion (delayed insertion). It is clear from these results and others [6–9] that serious device-related complications can be avoided in the preoperative period when pulsatile pressure, along with the absence of vasoconstrictive agents, aids in uneventful IABP insertion. Similarly, the improved mortality in the present series compared with after intraoperative and postoperative IABP placement [1, 2, 6, 7] most likely reflects the avoidance of progressive cardiac dysfunction before insertion. Through early preoperative IABP insertion, episodes of low-flow state with subsequent end-organ dysfunction are minimized [9]. Therefore, because older and sicker patients constitute a greater percentage of candidates for CABG, indications for use and the timing of application of the IABP should be reexamined.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Pamela Dumas for her assistance.

In memory of our colleague Michele A. Codini, MD

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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