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Ann Thorac Surg 2001;71:1964-1968
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Intraaortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients

^a Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea

Accepted for publication March 14, 2001.

Address reprint requests to Dr Kim, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, 28 Yeun-Kun Dong, Chong-Ro Ku, Seoul 110-744, Korea
e-mail: kimkb{at}snu.ac.kr

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Displacement of the heart to expose posterior vessels during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG, or OPCAB) may impair cardiac function. We used the intraaortic balloon pump (IABP) preoperatively to reduce operative risk and to facilitate posterior vessel OPCAB in high-risk patients with left main coronary artery disease (> 75% stenosis), intractable resting angina, postinfarction angina, left ventricular dysfunction (ejection fraction < 35%), or unstable angina.

Methods. One hundred and forty-two consecutive patients who underwent multivessel OPCAB including posterior vessel revascularization were studied prospectively. The patients were divided into group I (n = 57), which received preoperative or intraoperative IABP, and group II (n = 85), which did not receive IABP. In group I, there were 34 patients with left main coronary artery disease, 24 patients with intractable resting angina, 8 patients with left ventricular dysfunction, 5 patients with postinfarction angina, and 40 patients with unstable angina. Seven patients received intraoperative IABP support owing to hemodynamic instability during OPCAB.

Results. There was no operative mortality in group I and 1 death in group II. The average number of distal anastomoses was not different between group I and group II (3.4 ± 0.9 versus 3.5 ± 0.9, p = not significant). There were no significant differences in the number of posterior vessel anastomoses per patient. There were no differences in ventilator support time, length of stay in the intensive care unit, hospital stay, and morbidity between the two groups. There was one IABP-related complication in group I.

Conclusions. IABP therapy facilitates posterior vessel OPCAB in high-risk patients, and surgical results are comparable with those in lower-risk patients.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The surgical results of coronary artery bypass grafting (CABG) without cardiopulmonary bypass (off-pump CABG, or OPCAB) have demonstrated several advantages by avoiding the potentially detrimental effects of cardiopulmonary bypass and eliminating intraoperative global myocardial ischemia [1–4]. However, displacement of the heart to expose the posterior vessels during OPCAB may impair cardiac function by decreasing stroke volume and cardiac output, lowering systemic blood pressure, and further worsening regional myocardial ischemia [5]. These changes are expected to be more serious in patients with high risk factors such as significant left main coronary artery disease ( > 75% stenosis), intractable resting angina, postinfarction angina, left ventricular dysfunction (ejection fraction < 35%), or unstable angina. It has been demonstrated that preoperative intraaortic balloon pump (IABP) therapy significantly improves cardiac performance and effectively controls myocardial ischemia in high-risk patients [6, 7]. Preoperative balloon therapy may permit safer induction of general anesthesia and facilitate posterior vessel OPCAB in high-risk patients.

The aims of this study were to assess the feasibility of posterior vessel OPCAB under IABP support in high-risk patients, and to demonstrate the safety and efficacy of preoperative IABP therapy for posterior vessel OPCAB in high-risk patients by comparing the surgical results with those of OPCAB in lower-risk patients.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
One hundred and forty-two consecutive patients who underwent OPCAB including the posterior vessels between April 1998 and July 2000 were studied in a prospective, but not randomized, manner. Among the total of 228 OPCAB cases performed during the same study period, minimally invasive direct CABG (MIDCAB) cases and OPCAB cases that did not need posterior vessel revascularization were excluded. We compared the clinical results of 57 patients who underwent IABP placement preoperatively or intraoperatively (group I) with those of 85 patients who did not have IABP placement (group II). There were no differences in sex, age, ratio of unstable to stable angina, or left ventricular function between the two groups. Urgent or emergent operations were more common in the group of patients that received IABP therapy (Table 1). There were no differences in preoperative risk factors except smoking between the two groups (Table 2). Our indications for preoperative IABP before OPCAB were significant left main coronary artery disease (> 75% stenosis) in 34 patients, intractable resting angina in spite of continuous intravenous administration of nitroglycerin and heparin sodium in 24 patients, left ventricular dysfunction with ejection fraction (EF) of less than 35% in 8 patients, recent acute myocardial infarction within 4 weeks before operation in 5 patients, and unstable angina in 40 patients. When the number of the high risk factors was compared, the average number of risk factors per patient was 2.2 ± 0.9 in the group that underwent preoperative IABP placement, and 0.9 ± 0.7 in the group that did not receive IABP (p < 0.001). Eighty-four percent of our patients (42 out of 50 patients) presented with two or more high risk factors. We inserted IABP intraoperatively in 7 patients because of hemodynamic instability during OPCAB (Table 3).

Peripheral arterial status was evaluated by Doppler scan, and sometimes by peripheral angiography in elderly patients (70 years or older), patients with symptoms and signs of significant peripheral vascular impairment, and patients with the high risk factors mentioned above. If there was a significant stenosis in the femoroiliac arteries or there was difficulty in IABP insertion, we inserted IABP guided by fluoroscopy. In most of our patients with high risk factors, we inserted IABP in the operating room using local anesthesia just before induction of general anesthesia and then routinely confirmed correct placement of the balloon by roentgenography or by transesophageal echocardiography. In all patients undergoing IABP placement, a 9.5 F Percor balloon (Stat-DL catheter, Datascope System; Datascope, Fairfield, NJ) was inserted percutaneously using a 10 F sheath through the common femoral artery. After IABP insertion, all patients were given 1 mg/kg of heparin. A Swan-Ganz pulmonary artery catheter was introduced in all patients. We inserted IABP intraoperatively when hemodynamic instability occurred such as a significant decrease of systemic systolic pressure to less than 80 mm Hg, elevation of pulmonary diastolic pressure to more than 25 mm Hg, or intractable ventricular arrhythmia, in spite of adequate anesthesia management.

Surgical procedure
All operations were performed through a median sternotomy and a cell-saving device was used routinely. The patients were heparinized with an initial dose of 1 mg/kg of heparin and periodically supplemented to maintain an activated clotting time of more than 300 seconds. Temperature was maintained at normothermia using adequate room temperature, warm circulating water blankets, and warm infusion solutions. After the pericardium was opened, deep pericardial sutures were placed to facilitate pericardial retraction for cardiac elevation and exposure. To reduce the heart rate below 70 to 80 beats per minute and minimize myocardial oxygen consumption, most of the patients were given boluses or continuous infusion of ß-blockers such as esmolol, or adenosine. Ischemic preconditioning was not performed in most of the cases. Anesthesia management, including volume loading and placing the patient in the Trendelenburg position, controlled hemodynamic derangement during displacement or manipulation of the heart. To reduce the amplitude of ventricular wall movement, a compression-type mechanical stabilizer (CTS; CardioThoracic Systems, Inc, Cupertino, CA) or suction-type mechanical stabilizer (Octopus; Medtronic, Minneapolis, MN) was used. After exposure of the coronary artery, vascular control was performed with elastic vessel loops (Retract-O-Tape; Quest Medical Inc, Allen, TX) placed around the proximal artery and distal to the site of the anastomosis. These two sutures were carefully retracted during the anastomosis to occlude the coronary artery. When a bloodless operative field was not adequately maintained owing to profuse collaterals, internal vascular control was achieved with a flow occluder (Florester; Bio-Vascular Inc, St. Paul, MN) or intracoronary shunt (FloCoil Shunt; CTS Inc, Cupertino, CA). A Blower/Mister (Visuflo; Baxter Healthcare Co, Midvale, UT) using carbon dioxide gas (flow rate, 3 L/min) or a microsucker system with a rubber tip was also used to obtain a bloodless surgical field.

The most critical vessel in almost all the patients, the left anterior descending coronary artery, was revascularized first to provide a backup to the less critical area. The distal anastomosis was constructed using a continuous technique with 8-0 polypropylene sutures for arterial grafts or 7-0 polypropylene suture for a saphenous vein graft. All proximal anastomoses on the ascending aorta were constructed after distal anastomoses, using a single partial clamping of the aorta and 6-0 polypropylene continuous sutures. In patients with IABP support, IABP was placed on standby during the proximal anastomosis on the ascending aorta, to avoid possible complication of dissection of the ascending aorta. Protamine has not been given at the end of the procedure since September 1999, unless uncontrollable diffuse bleeding was present. Before September 1999, 0.5 mg of protamine was administered for each 100 U of heparin given at the end of the OPCAB procedure.

Statistical analysis
Statistical analysis was performed with the Statistical Analysis System software package (version 6.12; SAS Institute, Cary, NC). The significance of differences between the group of patients with IABP and without IABP was assessed by unpaired Student’s t test, -square test, or likelihood ratio test. All results are expressed as mean ± standard deviation, and a value of p less than 0.05 is considered statistically significant.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The average number of distal anastomoses in group I and group II were 3.4 ± 0.9 and 3.5 ± 0.9, respectively, with no significant difference between two groups. When the coronary arteries were classified as anterior (left anterior descending artery, diagonal branches, ramus intermedius, and proximal or middle right coronary artery), inferior (posterior descending artery, posterolateral branches, and distal right coronary artery), and posterior (obtuse marginal branches) vessels, the number of posterior vessel anastomoses per patient in both groups was 1.1 ± 0.4, with no difference between the two groups (Table 4). There was no operative mortality in group I and one death in group II. There were no significant differences in ventilator support time, intensive care unit stay, and hospital stay between the two groups. The IABP support was terminated once hemodynamic stability was restored in the intensive care unit. The mean duration of postoperative IABP support was 6.7 ± 9.5 hours in group I (Table 5).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
This study reveals two main findings. First, IABP therapy facilitates posterior vessel OPCAB in high-risk patients, with surgical results comparable with those in lower-risk patients. Second, IABP-related complications can be reduced by close surveillance of the peripheral circulation and keeping the duration of IABP therapy short.

The advantages of OPCAB have been demonstrated by avoiding the potentially detrimental effects of cardiopulmonary bypass and eliminating intraoperative global myocardial ischemia. However, displacement of the heart during OPCAB may impair cardiac function by lowering systemic blood pressure, decreasing stroke volume and cardiac output, reducing the coronary blood flow, and further worsening regional myocardial ischemia; and it may sometimes cause incomplete revascularization [1, 5, 8, 9]. Further displacement of the heart to expose the posterior vessels significantly decreases the coronary flow in the circumflex coronary artery compared with that in the left anterior descending or right coronary artery [10]. In this regard, OPCAB is sometimes contraindicated for hemodynamically unstable patients or patients with left main coronary artery disease, according to some authors [11, 12], although others have suggested that left main coronary artery disease is not a contraindication for OPCAB as long as the anterior and right coronary territories are revascularized first before going to the circumflex area [13]. Significant left main coronary artery disease, left ventricular dysfunction, intractable resting angina in spite of optimal medical treatment, postinfarction angina, and unstable angina are well-established high risk factors after CABG [14–19]. In patients with high risk factors, higher mortality and morbidity rates have been demonstrated in spite of massive pharmacologic support combined with postoperative IABP support [7, 17, 19–21]. IABP therapy results in a more favorable myocardial blood supply, increased stroke volume and cardiac output through augmentation of the diastolic pressure, and afterload reduction [22, 23]. Preoperative IABP therapy could lead to preoperative reduction of myocardial ischemia, avoidance of progressive cardiac dysfunction, and minimization of low-flow episodes with subsequent end organ dysfunction, and may thereby permit safer induction of general anesthesia and improve surgical outcome in high-risk coronary patients [6, 7, 17]. We inserted IABP before OPCAB in patients with significant left main coronary artery disease (> 75% stenosis), intractable resting angina in spite of continuous intravenous administration of nitroglycerin and heparin sodium, left ventricular dysfunction with EF of less than 35%, recent acute myocardial infarction within 4 weeks before operation, and unstable angina, particularly patients who needed posterior vessel revascularization.

This study was not performed in a randomized manner, because randomized controlled trials in this type of study are sometimes unrealistic and impractical. Although it was not randomized, this study was performed prospectively and demonstrated the efficacy and safety of preoperative or intraoperative IABP therapy for posterior vessel OPCAB in high-risk patients. Our data showed that both the number of posterior vessel anastomoses per patient and the incidence of postoperative morbidities in the high-risk group were not different from those in the low-risk group.

During the same study period, there were 11 conversions (11 of 239, 4.6%) to cardiopulmonary bypass due to circulatory collapse during OPCAB. However, with our increased experience performing OPCAB, there was only one conversion to cardiopulmonary bypass during OPCAB in the most recent year. Instead, we inserted IABP intraoperatively if the patient experienced hemodynamic instability during OPCAB. We inserted IABP intraoperatively if there was a significant decrease of systemic systolic pressure to less than 80 mm Hg, elevation of pulmonary diastolic pressure to more than 25 mm Hg, or intractable ventricular arrhythmia, in spite of Trendelenburg positioning of the patient, adequate anesthesia management, use of intracoronary shunt, or temporary pacing.

Intraoperative or postoperative IABP insertion has been reported to be associated with higher operative mortality rate and device-related complication rate [21, 24, 25], compared with preoperative use of IABP [26–28]. In most of our patients with high risk factors, we inserted IABP in the operating room using local anesthesia just before induction of general anesthesia and discontinued the IABP support once hemodynamic stability was restored in the intensive care unit. The mean duration of IABP support was 6.7 ± 9.5 hours postoperatively. There was only one IABP-related complication in a patient in whom IABP was inserted intraoperatively. Our relatively low IABP-related complication rate, without major sequelae, may be due to our experience using IABP, short IABP insertion times, and preoperative evaluation of peripheral arterial status, and close surveillance of the peripheral circulation with special emphasis on noting early signs of acute ischemia.

	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): Ki-Bong Kim Cheong Lim Hyuk Ahn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kim, K.-B. Articles by Yang, J.-K. Search for Related Content PubMed PubMed Citation Articles by Kim, K.-B. Articles by Yang, J.-K. Related Collections Coronary disease Mechanical Circulatory Assistance