Ann Thorac Surg 2007;84:502-503
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Jan T. Christenson, MD, PhD
Department of Cardiovascular Surgery, University Hospital of Geneva, 24 rue Micheli-du-Crest, Geneva, CH-1211 Switzerland
(Email: jan.christenson{at}hcuge.ch).
The authors of this study have addressed a very important issue in the surgical treatment of myocardial ischemia [1]. With the frequent use of balloon dilation and stenting to overcome myocardial ischemia, surgeons have been faced with a dramatic increase in high-risk coronary patients.
It has been well documented that high-risk coronary artery bypass grafting is associated with an important postoperative mortality and morbidity. Introduction of preoperative intra-aortic balloon counterpulsation (IABC) therapy has significantly reduced mortality and morbidity in this cohort of patients [2].
The use of cardiopulmonary bypass often has deleterious effects due to activation of neutrophils, free oxygen radicals, and cytotoxins leading to myocardial edema and diminished myocardial contractility, directly contributing to cardiac dysfunction, but also participating in a systemic inflammatory response. To avoid aortic cross clamping and cardiopulmonary bypass, the off-pump coronary artery bypass (OPCAB), or beating heart procedure, has been more frequently used for myocardial revascularization. Unfortunately the OPCAB has often resulted in a minimal myocardial revascularization in contrast with a more complete revascularization demonstrated to result in better long-term outcome [3]. This is particularly so in the high-risk coronary patient because of the greater risk for hemodynamic instability during manipulation of the heart. Therefore many surgeons have been reluctant to use the OPCAB procedure in this cohort of patients, which is sad because those are the patients who would most likely benefit. It has been demonstrated that preoperative and postoperative IABC therapy offers efficient hemodynamic support during displacement and manipulation of the heart during OPCAB surgery in high-risk patients [4–5].
In an elegant study, the authors have demonstrated that the use of preoperative IABC in high-risk coronary patients can allow the surgeon to safely extend the benefits of not only an OPCAB procedure but also to perform a complete myocardial revascularization, which should result in better long-term outcome. Even in the highest risk cohort of patients requiring emergency surgery, their results were excellent with a 62% reduction in mortality compared to the EuroSCORE predicted cumulative mortality, and with very low incidence of conversion to cardiopulmonary bypass. The combined use of IABC and OPCAB can now be recommended when myocardial revascularization in high-risk coronary patients is required.
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- Etienne PY, Papadatos S, Glineur D, et al. Reduced mortality in high-risk coronary patients operated off pump with preoperative intraaortic balloon counterpulsation Ann Thorac Surg 2007;84:498-503.[Abstract/Free Full Text]
- Christenson JT, Simonet F, Schmuziger M. The effect of preoperative intra-aortic balloon pump support in high risk patients requiring myocardial revascularization J Cardiovasc Surg 1997;38:397-402.[Medline]
- Kleisli T, Cheng W, Jacobs MJ, et al. In the current era, complete revascularization improves survival after coronary artery bypass surgery J Thor Cardiovasc Surg 2005;129:1283-1291.[Abstract/Free Full Text]
- Christenson JT, Licker M, Kalangos. The role of intra-aortic counterpulsation in high-risk OPCAB surgery: a prospective randomized study J Card Surg 2003;18:286-294.[Medline]
- Kim KB, Lim Ch, Ahn H, et al. Intra-aortic balloon pump therapy facilitates posterior vessel off-pump coronary artery bypass grafting in high-risk patients Ann Thorac Surg 2001;71:1964-1968.[Abstract/Free Full Text]
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