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Ann Thorac Surg 1999;68:1438
© 1999 The Society of Thoracic Surgeons

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Correspondence

Preoperative intraaortic balloon therapy

^a Department of Cardiovascular Surgery, Hôpital de la Tour, Meyrin-Geneva, Switzerland

e-mail: jtchristenson{at}latour.ch

To the Editor

I read with great interest the article by Ghali and associates [1]. The great practice variation in Massachusetts that the authors have described in their paper is probably true not only for the rest of the U.S., but also for the rest of the world. In their comments, the authors stated, "A randomized controlled trial is needed to definitively assess the efficacy of preoperative IABP use for selected patients undergoing CABG operation." However, such studies are already available in the literature. In a prospective randomized study Christenson and associates evaluated the effect of preoperative intraaortic balloon pump (IABP) therapy in high-risk redo coronary artery bypass graft patients. A high-risk patient was defined as having two or more of the following criteria: preoperative left ventricular ejection fraction 0.40, unstable angina at the time of surgery despite optimal medical treatment, and/or left main stem stenosis greater than 70%. Myocardial function pre- and postoperatively was studied by repeated measurements of cardiac index. It was demonstrated that preoperative IABP therapy significantly improved cardiac performance postoperatively, resulting in fewer patients with postoperative low cardiac output, a significantly reduced hospital mortality, and significantly shortening of both intensive care unit stay and length of total hospital stay [2]. In another prospective randomized study, by the same authors, similar results were achieved in a mixed group of high-risk patients undergoing myocardial revascularization, and it was suggested that the preoperative IABP therapy in this high-risk patient population was not only effective but also cost-beneficial [3].

The most beneficial timing of preoperative IABP therapy has not yet been fully explored. However, we have just recently finished a prospective randomized study addressing this issue. Results of this study are soon to appear in the Annals.

Ghali and associates furthermore stated in their article that IABP itself could lead to complications. That is very true; IABP complication rates have been reported in the literature to occur in 4% to 12% [4–6]. However, it is my conviction that to a large extent major vascular complications can be avoided by implementing a more rigorous surveillance of patients with IABP and perhaps the usage of smaller-diameter catheters. Another important factor is that high-risk patients who received preoperative IABP therapy either did not require any IABP support or a very short IABP support time postoperatively.

With a rapidly changing pattern of patients submitted to surgical myocardial revascularization (older patients, with severely impaired left ventricular function and a more extensive (diffuse) coronary artery disease and also more patients with ischemic cardiomyopathy), certain precautions are necessary to be undertaken in order to still achieve acceptable outcomes at reasonable cost. Preoperative IABP therapy is definitely an important additional therapy that has already established itself as a valuable modality in this high-risk group of patients.

References

1. Ghali W.A., Ash A.S., Hall R.E., Moskowitz M.A. Variation in hospital rates of intraaortic balloon pump use in coronary artery bypass operations. Ann Thorac Surg 1999;67:441-445.[Abstract/Free Full Text]
2. Christenson J.T., Badel P., Simonet F., Schmuziger M. Preoperative intraaortic balloon pump enhances cardiac performance and improves the outcome of redo CABG. Ann Thorac Surg 1997;64:1237-1244.[Abstract/Free Full Text]
3. Christenson J.T., Simonet F., Badel P., Schmuziger M. Evaluation of preoperative intra-aortic balloon pump support in high-risk coronary patients. Eur J Cardiothoracic Surg 1997;11:1097-1103.[Abstract]
4. Dietl C.A., Berkheimer M.D., Woods E.L., Gilbert C.I., Pharr W.F., Benoit C.H. Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fractions of 0.25 or less. Ann Thorac Surg 1996;62:401-409.[Abstract/Free Full Text]
5. Christenson J.T., Buswell L., Velebit V., Maurice J., Simonet F., Schmuziger M. The intra-aortic balloon pump for postcardiotomy heart failure. Experience with 169 intraaortic balloon pumps. Thorac Cardiovasc Surgeon 1995;43:129-133.[Medline]
6. Naunheim K.S., Swartz M.T., Pennington D.G., et al. Intraaortic balloon pumping in patients requiring cardiac operations. Risk analysis and long-term follow-up. J Thorac Cardiovasc Surg 1992;104:1654-1660.[Abstract]

This Article 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jan T. Christenson Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Christenson, J. T. Search for Related Content PubMed Articles by Christenson, J. T.