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Ann Thorac Surg 2004;77:2056-2059
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Usefulness of preoperative intraaortic balloon pump therapy during off-pump coronary artery bypass grafting in high-risk patients

^a Department of Cardiovascular Surgery, Kochi Municipal Hospital, Kochi, Japan

Accepted for publication December 10, 2003.

^* Address reprint requests to Dr Suzuki, Department of Cardiovascular Surgery, Kochi Municipal Hospital, 1-7-45 Marunouti, Kochi 780-0850, Japan
e-mail: suzukit{at}bronze.ocn.ne.jp

	Abstract

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

 
BACKGROUND: In off-pump coronary artery bypass grafting (OPCABG) surgery, the most critical complication is hemodynamic deterioration, which can occur during displacement of the heart to expose the target vessels. Preoperative intraaortic balloon pump (IABP) therapy improves cardiac performance and facilitates access to the target coronary artery while maintaining hemodynamic stability, especially in high-risk patients.

METHODS: One hundred thirty-three consecutive patients who underwent OPCABG through sternotomy between April 2000 and July 2003 were studied. We compared the clinical results of 32 patients who underwent preoperative IABP placement (group 1) with those of 101 patients who did not have IABP placement (group 2). Of the 32 patients satisfying the insertion criteria, 15 had critical left main artery disease, 20 had unstable angina, 5 had acute myocardial infarction, and 5 had left ventricular dysfunction.

RESULTS: There were no significant differences in the average number of distal anastomoses performed between group 1 and group 2 (3.1 ± 0.8 versus 3.3 ± 0.9, p = not significant). The complete revascularization rate was 95% in both group. There was no conversion to on-pump surgery in either group. There was no operative death in group 1 and only 1 death in group 2. In group 1, the number of patients who required prolonged ventilatory support (longer than 48 hours) was higher (3 versus 1, p = 0.036), and there was a higher incidence of low cardiac output syndrome (1 versus 0, p = 0.074). There were no IABP-related complications in group 1.

CONCLUSIONS: Preoperative IABP therapy for high-risk coronary patients is very effective in preventing hemodynamic instability and providing surgical results comparable with those in moderate- to lower-risk patients.

	Introduction

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

 
Off-pump coronary artery bypass grafting (OPCABG) surgery has been gaining acceptance among cardiovascular surgeons because it eliminates the problems associated with cardiopulmonary bypass (CPB) [1–4]. However, displacement of the heart to expose the target vessels during OPCABG often causes hemodynamic deterioration [5–7]. Hemodynamic compromise more often occurs in high-risk patients.

Preoperative intraaortic balloon pump (IABP) therapy is an effective modality in protecting high-risk patients undergoing coronary artery bypass grafting (CABG) surgery [8–12]. In the setting of OPCABG, preoperative IABP therapy improves cardiac performance and facilitates access to the target vessels while maintaining hemodynamic stability, even in high-risk patients [13, 14]. In our institution, preoperative IABP is used selectively as a modality to support OPCABG surgery in high-risk patients. The purpose of this study was to assess the effectiveness of OPCABG under preoperative IABP support in high-risk patients by comparing the results with those of OPCABG in lower-risk patients.

	Patients and methods

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

 
One hundred thirty-three consecutive patients who underwent OPCABG through sternotomy between April 2000 and July 2003 were studied. We compared the clinical results of 32 patients who underwent preoperative IABP placement (group 1) with those of patients who did not have IABP placement (group 2). The mean age of the patients was 65 ± 10.8 years (range, 42 to 92) in group 1 and 67.9 ± 9.5 years (range, 45 to 81) in group 2. Urgent or emergent operations, unstable angina, acute myocardial infarction, and left main artery stenosis were common factors in group 1 (Table 1). Cardiac catheterization and coronary angiography were performed in all patients. The preoperative left ventricular ejection fraction (LVEF) was measured from biplane ventricular angiography by the area-length method.

	Preoperative management and IABP insertion

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

The thoracic and abdominal aortic status and peripheral arterial status were evaluated by angiography or enhanced computed tomography to confirm the safety of insertion and performing of IABP. In all patients ungergoing IABP placement, a 9.5F Percor balloon (Stat-DL cattheter, Datascope system; Datascope, Fairfield, NJ) was inserted percutaneously in the common femoral artery using a 10F sheath. After IABP insertion, all patients were given 1 mg/kg heparin, which was supplemented to maintain an activated clotting time of more than 150 seconds during placement of IABP.

	Surgical procedure

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

 
Standard intraoperative monitoring techniques were used. Pulmonary artery flotation catheters were used routinely and provided continuous evaluation of cardiac output. Transesophageal echocardiography was used in selected patients. A CPB circuit was on stand-by for all cases. All procedures were performed through a median sternotomy. After the conduits (one or both internal thoracic arteries, the radial artery, right gastroepiploic artery, and saphenous vein) were harvested and skeletonized, the patients were administered heparin to maintain an activated clotting time more than 250 seconds. Ischemic preconditioning was performed only if hemodynamic deterioration occurred during test occlusion of the coronary artery. We use a suction-type mechanical stabilizer (Octopus3; Medtronic, Mineapolis, MN) to immobilize the target coronary artery, but do not use heart positioner. Intracoronary shunt tubes were used routinely in all target vessels. The distal anastomosis was constructed using 8-0 polypropylene and standard techniques.

	Statistical analysis

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

 
Data are presented as the mean ± standard deviation. Comparison of continuous variables was accomplished using the t test, whereas categoric variables were compared with the ² test. Calculated p values less than 0.05 were considered significant.

	Results

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

 
Thirty-two patients (24.0%) received a preoperative IABP (group 1) and 101 patients (75.9%) did not receive a preoperative IABP (group 2). Of the 32 patients satisfying the insertion criteria, 15 (46.9%) had critical left main artery disease with 75% or greater stenosis, 20 (62.5%) had unstable angina that was refractory to medical therapy, 5 (15.6%) had acute myocardial infarction, and 5 (15.6%) had left ventricular dysfunction with an LVEF less than 35%. In 7 patients of group 2, we did not use the IABP in spite of fulfilling our insertion criteria because of unsuitable vascular status including peripheral vascular disease, atheroscrelosis of aorta, and serpentine descending aorta.

The average number of distal anastomoses in group 1 and group 2 were 3.1 ± 0.8 and 3.3 ± 0.9, respectively, with no significant difference between the two groups. There was no operative mortality in group 1 and 1 death due to gastrointestinal ischemia in group 2. Patients in group 1 had longer ventilator support time (> 48 hours) and a higher incidence of low output syndrome (1 versus 0, p = 0.074). There were no significant differences in the incidences of postoperative morbidities such as cerebrovascular accident (0 versus 0), acute renal failure (2 versus 4,p = 0.58), or mediastinitis (0 versus 1,p = 0.57). Complete revascularization was achieved in 94% of patients in group 1 and in 95% of patients in group 2. Postoperative angiography was performed in 28 patients (92 anastomoses) in group 1, and in 96 patients (318 anastomoses) in group 2. The graft patency rate was 100% (92 of 92) in group 1 and 99.7% (317 of 318) in group 2. There were no IABP-related complications in group 1. In 27 patients, the IABP was removed intraoperatively after the completion of revascularization, and in 5 patients it was removed postoperatively in the intensive care unit because of their hemodynamical instability. The mean duration of postoperative IABP support in intensive care unit was 3.2 ± 4.3 hours in group 1 (Table 2).

	Comment

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

In OPCABG surgery, the most severe complication is hemodynamic compromise, which can occur during displacement of the heart to expose the target vessels. Displacement of the heart during OPCABG may impair cardiac function by decreasing stroke volume and cardiac output, lowering systemic blood pressure, and worsening regional myocardial ischemia [7]. Several supportive devices have been developed for use during OPCAB. The suction-type mechanical stabilizer and heart positioner provide a very stable surgical field with minimum hemodynamic change [19]. Intracoronary shunt tube is also effective in supporting OPCABG, by maintaining coronary perfusion, creating a bloodless surgical field, and preventing "back walling" while creating the anastomosis [20, 21]. The effects of IABP support, such as the reduction of ventricular afterload, improvement of diastolic coronary perfusion, and enhancement of subendocardial perfusion, are very beneficial to the displaced heart in maintaining hemodynamic stability during OPCABG.

Hemodynamic compromise occurs more often in high-risk patients [4]. Therefore, we performed preoperative IABP therapy selectively in high-risk patients with definite indications. Our indications for preoperative IABP insertion were significant left main coronary artery disease (> 75% stenosis), unstable angina, left ventricular dysfunction (LVEF < 35%), recent acute myocardial infarction, and congestive heart failure requiring medical treatment. Kim and colleagues [14] used the IABP preoperatively to reduce operative risk and to facilitate posterior vessel OPCABG in high-risk patients. Christenson and associates [22] presented a prospective randomized study to evaluate the efficacy and safety of preoperative and perioperative IABP in high-risk OPCABG surgery. They concluded that preand perioperative IABP offered efficient hemodynamic support during high-risk OPCABG and was safe and shortened both intensive care unit and hospital length of stay [22].

We use IABP intraoperatively only in high-risk patients and remove the balloon promptly after completion of the revascularization if the patient's hemodynamic status is stable. Vascular complications associated with use of IABP are not uncommon. Other major complications associated with the use of IABP include aortic dissection, paraplesia, bacteremia, mesenteric infarction, balloon rupture, and balloon entrapment [8, 9]. Cohen and colleagues [23] reported a prospective study of 1,119 consecutive patients examining the complications associated with IABP and their predictors. They reported that major complications occurred 15% in high-risk patients (women, smaller patients, diabetic patients, and patients with peripheral vascular disease) compared with 3% among patients not at high rish [23]. Several groups have suggested that the percutaneous approach is associated with an increased rate of major vascular complications [8, 24, 25]. Therefore, it is important to make an effort to prevent these complications. To reduce the risk of ischemic complications, Phillips and coworkers [26] recommend sheathless insertion of the percutaneous balloon in patients with small or diseased arteries. Our precautions to reduce IABP-related complication include (1) evaluating the status of the thoracic and abdominal aorta and peripheral arteries by aortography or enhanced computed tomography, (2) maintaining an activated clotting time more than 150 seconds with heparin during IABP, and (3) shortening the IABP placement time by immediate removal after procedure. In our series of patients, we did not observe any IABP-related complications.

In this study, we presented our criteria for the use of selective preoperative IABP therapy and methods to avoid IABP-related complications. Using our strategy, preoperative IABP therapy for high-risk patients undergoing OPCABG surgery was effective and was not associated with significant intraand postoperative complications. Furthermore, use of this technique resulted in good surgical results, comparable with those in lower-risk patients. We believe that using preoperative IABP allows surgeons to complete OPCABG procedures safely while maintaining stable hemodynamics and providing good clinical results.

	References

Top Abstract Introduction Patients and methods Preoperative management and IABP... Surgical procedure Statistical analysis Results Comment References

 

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