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Ann Thorac Surg 2001;71:1220-1223
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Elective intraaortic balloon counterpulsation for high-risk off-pump coronary artery bypass operations

^a Division of Cardiothoracic Surgery, Emory University School of Medicine and Clinic, Atlanta, Georgia, USA

Accepted for publication November 6, 2000.

Address reprint requests to Dr Craver, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365 Clifton Rd, NE, Suite A2218, Atlanta, GA 30322
e-mail: christyjenkins{at}emory.org

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Dislocations of the heart required for exposure and construction of distal anastomoses often produce hemodynamic instability when performing coronary artery revascularization without using cardiopulmonary perfusion (OPCAB). We report our early experience with elective intraaortic balloon counterpulsation (IABP) to enable and facilitate selected high-risk patients to undergo OPCAB.

Methods. Sixteen high-risk patients undergoing multivessel OPCAB using elective IABP are reported. The patients were believed to be at increased risk because of the presence of severe proximal multivessel coronary artery obstruction, ventricular dysfunction, recent acute myocardial infarction, cardiomegaly–cardiomyopathy, and documented cerebral vascular disease. The presence of significant comorbid disease also made the avoidance of cardiopulmonary bypass desirable, if at all possible, in all patients.

Results. The IABP appeared to facilitate the intraoperative management of our series of patients. This was evidenced by improved hemodynamic stability and virtual elimination of the need for inotropic support during the dislocations of the heart needed for exposure and construction of distal anastomoses. There were no complications related to use of IABP. There was one death.

Conclusions. We believe this strategy to use IABP selectively can allow surgeons to safely extend the benefits of OPCAB procedures to high-risk patients and avoid dangerous hemodynamic instability that otherwise, often occurs.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Hemodynamic instability can result during dislocations of the heart needed for exposure and construction of distal anastomoses in performing coronary artery revascularization without using cardiopulmonary perfusion (OPCAB) [1–3]. We hypothesize that the elective use of intraaortic balloon counterpulsation (IABP) will enhance hemodynamic stability that will allow safer OPCAB in high-risk patients and that the benefits of IABP will outweigh the small risk of its complications. These patients, who also often have significant comorbid disease processes, will thereby avoid exposure to cardiopulmonary perfusion (CPB) and the harmful systemic effects it can evoke [4, 5]. We report our early experience with elective IABP to allow and facilitate selected high-risk patients to undergo OPCAB.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Sixteen patients are reported undergoing multivessel OPCAB that was performed by using elective IABP. All of these patients were believed to be at an increased risk of both a likely occurrence of hemodynamic instability and a devastating complication thereof that could be encountered during the displacement of the heart required for an OPCAB procedure. The patients were at increased risk caused by various combinations of the following: the presence of severe proximal multivessel coronary artery obstruction (greater than 80% left main coronary artery stenosis and occlusion of the right coronary artery); ventricular dysfunction (left ventricular end diastolic pressure [LVEDP] greater than 18 torr, ejection fraction less than 35%); congestive heart failure requiring treatment; recent acute myocardial infarction (less than 7 days prior to the operative procedure); chronic renal failure (serum creatinine greater than 2.0 mg/dL); cardiomegaly–cardiomyopathy; and documented cerebral vascular disease, with or without prior stroke. Recent prior clinical experiences, of one author (J.M.C.) of this article, with 3 patients having similar anatomic and functional abnormalities were marked by the need for high levels of inotropic drug infusions to support perfusion pressure during the displacement of their hearts, required to complete OPCAB procedures. There was a need in 1 patient to convert urgently to cardiopulmonary bypass (CPB) support. These experiences propelled both authors to utilize IABP electively on subsequent patients with similar clinical criteria (ie, believed to be at increased hemodynamic risk for OPCAB procedures and comorbidities that made avoidance of CPB desirable, if at all possible). The need for revascularization of the circumflex system was not an isolated factor in the decision to electively insert the IABP, but it was required in all patients in this article.

The surgical method for all patients, was to position and stabilize the heart with an Octopus cardiac stabilizer system (Medtronic, Inc, Grand Rapids, MI). After each distal vein graft was completed for all patients, perfusion was performed through the grafts using a computer-controlled delivery system (Quest/MPS, Quest Medical, Inc, Allen, TX) as described recently by Guyton, and colleagues [6].

Patient LS
The following brief report illustrates a typical patient that was believed to be at a higher risk for hemodynamic instability during an OPCAB procedure, and also at a significantly increased risk for standard coronary artery bypass grafting utilizing CPB and ischemic arrest techniques. He was selected for elective utilization of IABP support to facilitate and permit revascularization by OPCAB techniques.

A 72-year-old male with a history of tobacco abuse (100 cigarette packs/year) was on home oxygen and chronic steroid therapy for severe chronic obstructive lung disease. He presented with a 3-day history of worsening chest pain on nitroglycerin and heparin. Cardiac catheterization showed a 95% left main coronary artery stenosis, a 95% ostial right coronary artery stenosis, and additional distal obstructive disease throughout the coronary vessels. The ejection fraction was 40% with cardiomegaly. He also had a history of intermittent symptomatic bradycardia.

After induction of anesthesia, he had an elective insertion of an IABP catheter and counterpulsation was initiated. Intraoperative transesophageal echocardiography (TEE) had shown the descending thoracic aorta to be only moderately diseased and physical examination had revealed 2 plus femoral pulses bilaterally. The patient developed complete heart block during takedown of the left internal mammary artery, which was treated with epicardial pacing. With IABP, the patient tolerated the required positioning, exposure, and stabilization for construction of all anastomoses without hemodynamic compromise or the need for inotropic drug support. A triple OPCAB was performed (left internal mammary artery to left anterior descending coronary artery, saphenous vein graft [SVG] to first obtuse [OM-1] marginal branch and distal right coronary artery). An aortic side-biting clamp was used to perform the two-vein graft proximal anastomoses. The triple OPCAB was completed uneventfully. The IABP was weaned and removed on postoperative day 1. The ventilator support was weaned and removed on postoperative day 2. He was transferred out of the intensive care unit on postoperative day 3.

Patient TP
A second brief report illustrates another patient that was similarly believed to be at higher risk for OPCAB and also at a significantly increased risk for standard coronary artery bypass grafting utilizing CPB and ischemic arrest techniques. However, elective IABP support was not used because of the presence of Grade 5 atheromatous disease in the descending thoracic aorta evident on intraoperative TEE.

An 83-year-old male with a history of hypertension, peripheral vascular disease, and pulmonary fibrosis with pulmonary hypertension, presented with a 4-year history of worsening resting angina and shortness of breath. Cardiac catheterization revealed severe triple-vessel coronary disease with total occlusion of the right coronary artery and 90% occlusion of both the proximal left anterior descending and circumflex coronary arteries, and an ejection fraction of 40%. Pulmonary function testing revealed a forced expiratory volume in 1 second of 2.3 liters. The patient had a history of tobacco abuse (greater than 60 packs of cigarettes/year). Three years earlier he had undergone an aortobifemoral bypass with a left femoral to popliteal procedure. Physical examination revealed 2 plus femoral pulses bilaterally. After induction of anesthesia, intraoperative TEE revealed multiple mobile atheroma in the mid-descending thoracic aorta, the largest of which measured 6 by 2 cm. Because of this finding, the planned intraaortic balloon pump insertion was aborted and he underwent a triple-vessel OPCAB procedure (saphenous vein graft to left anterior [LAD] descending coronary artery, obtuse marginal [OM] artery, right coronary artery). Hemodynamic deterioration (systolic blood pressure less than 80 torr, mean pulmonary artery pressure greater than 40 torr, heart rate less than 50 beats per minute, decreased left ventricular function by TEE) during exposure and positioning for the construction of the distal anastomoses required a sustained high level of inotropic infusion support and atrial pacing to complete the OPCAB revascularization as planned. The inotropic drug infusions were reduced as the displacement measures required for exposure were relaxed on completion of the OPCAB anastomoses and the patient’s hemodynamic function recovered. Remaining inotropic and mechanical ventilatory support were removed on postoperative day 1 and he was discharged home on postoperative day 5.

Although the OPCAB procedure was successful, 3 other patients with similar clinical pathologies done earlier experienced falls in perfusion pressure and required large doses of inotropic support without improvement. They had to be converted to emergency CPBs, and 1 patient suffered additional intraoperative myocardial injury. These three anecdotal experiences led to our elective utilization of IABP for patients who were technical candidates for OPCAB surgery, but for cardiac and coexisting comorbidities were believed to be at great increased risk not only for OPCAB, but also for the standard coronary artery bypass grafting with CPB perfusion.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Table 1 demonstrates the preoperative characteristics of 14 additional patients in whom elective IABP was used. There was a preponderance of concomitant severe left main and proximal right coronary artery stenoses, ventricular dysfunction, cardiomegaly, heart failure, recent acute myocardial infarction, and chronic renal and pulmonary disease.

In our total study, only 5 out of 350 OPCAB patients required conversion to CPB.

A thorough preoperative physical examination and skilled intraoperative TEE guided us in the selection and placement of elective IABP support for the patients described. Absence of severe aortoiliac disease by physical examination, careful TEEs to detect the presence of dangerous atheroma in the descending thoracic aorta, and early removal of the IABPs minimized any adverse sequelae from using this method. There were no complications related to the use of IABP in this small study.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The IABP method has long been established as a valuable mechanical support for temporary ventricular assistance in the treatment of the failing heart [7–10]. Using IABP provides significant afterload reduction and may result in more favorable myocardial blood supply through augmentation of diastolic pressures. This may also lead to redistribution of coronary blood flow toward ischemic areas of the myocardium [11]. Several studies have shown that use of preoperative IABP can reduce perioperative myocardial ischemia and thus improve outcome in high-risk patients undergoing coronary artery bypass operations with the use of CPB [12–14].

This study sought the protective effect of IABP in reducing the susceptibility of acute perioperative stresses on an injured heart caused by displacement during OPCAB by supporting hemodynamic stability and reducing its myocardial oxygen demand. This benefit is of particular value for hearts that are more vulnerable because of severe proximal multivessel coronary disease, ventricular hypertrophy, and dysfunction.

Progress in the design and function of OPCAB stabilizing devices, intraoperative retraction techniques, anesthesia support, and anticoagulation management have led to an increased application of OPCAB procedures to a wider range of patients. The benefit of OPCAB procedures has been limited to patients believed to be at high risk for intraoperative problems because of the hemodynamic instability that can occur during multivessel OPCAB procedures [1–3, 15]. This instability usually can be corrected in normal risk patients by temporarily supporting perfusion pressures with volume adjustments and inotropic drugs, and thus, avoiding progressive hypotension, myocardial ischemia, and the need for urgent conversion to CPB support [15].

We have electively applied IABP to extend the applicability and advantages of OPCAB techniques to patients believed to be at increased risk of incurring hemodynamic deterioration anticipated during displacement, retraction, arterial occlusion, and local stabilization required for OPCAB procedures. IABP appeared to facilitate the intraoperative management in our 16 patients. This was evidenced by improved hemodynamic stability and virtual elimination of the need for inotropic support during even severe dislocations of the heart needed for exposure and construction of distal anastomoses. This was especially true when grafting the circumflex and its higher branches and those branches that barely emerge from the atrioventricular groove. Exposure of these branches and the left ventricular branch of the right coronary artery can often require extreme displacement of the heart to the right, impairing adequate biventricular function leading to dangerous falls in perfusion pressure. These 16 patients demonstrate the benefits of elective IABP, justifying its use, and outweighing its risk.

In conclusion, we believe this strategy in using IABP selectively can allow surgeons to safely extend the benefits of OPCAB procedures to high-risk patients and avoid dangerous hemodynamic instability that otherwise, often occurs.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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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): Joseph M. Craver Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Craver, J. M. Articles by Murrah, C. P. Search for Related Content PubMed PubMed Citation Articles by Craver, J. M. Articles by Murrah, C. P. Related Collections Coronary disease Mechanical Circulatory Assistance