Ann Thorac Surg 2003;76:1992
© 2003 The Society of Thoracic Surgeons
Invited commentary
Jan T. Christenson, MA, MD
Clinic for Cardiovascular Surgery, University Hospital of Geneva, 24, rue Micheli-du-Crest, CH-1211 Geneva 14, Switzerland
e-mail: jan.christenson{at}hcuge.ch
Intraaortic balloon counterpulsation (IABC), introduced in the 60's, still remains the mainstay therapy for patients with postcardiotomy heart failure and acute coronary syndromes. Cardiogenic shock and recurrent intractable arrhythmia have long been regarded as clear indications for IABC use. Signs of hemodynamic instability, poor LV function, or persistent asymptomatic or symptomatic ischemia in patients with large areas of myocardium at risk have been added to the list of indications. During recent years, an enlightened, proactive approach has emerged as an additional indication and has been added to the guidelines adopted by the American College of Cardiology/American Heart Association [1]. In cardiac surgery, both retrospective studies and prospective randomized trials have reported improved outcomes with preoperative insertion of IABC in high-risk CABG patients as compared to controls on to intra- or postoperative insertion [2–5]. Large variations in IABC use have been reported from single centre trials [6].
Baskett and associates in the present paper made a multicenter comparison of IABC use in CABG surgery involving 10 centers (U.S. and Canada) on a large number of patients over a recent 6-year time period. They have elegantly and convincingly demonstrated a marked increase in IABC utilization over time, particularly in preoperative use. This corresponds to findings reported recently from analysis of data from the Benchmark Registry and the STS database [7]. Moreover, a substantial variation in IABC use between the different study centers was demonstrated in the paper by Baskett et al. They suggested that these variations reflect a lack of consensus among cardiac surgeons on the appropriate use of IABC in CABG patients. Part of the existing controversy could be the lack of well-defined high-risk criteria to serve as a guide for selection of CABG patients who will truly benefit from preoperative IABC therapy. The more liberal and aggressive attitude toward proactive IABC use by several cardiologists is certainly a contributing factor to the increasing number of patients receiving preoperative IABC.
In conclusion, I believe we have now reached a point where the establishment of a multidisciplinary consensus regarding high-risk criteria and indications for preoperative IABC therapy in coronary surgery is needed. Formation of a working group, eg, under the auspices of the STS, in collaboration with the American College of Cardiologists/American Heart Association is highly recommended.
References
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- Dietl C.A., Berkheimer M.D., Woods E.L., Gilbert C.L., 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]
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