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Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass
D E Gutfinger1, R A Ott, M Miller
1Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange 92668, USA.
Insights
Preoperative intraaortic balloon pump (IABP) insertion is safe for high-risk elderly patients undergoing coronary artery bypass grafting. This approach yields comparable outcomes to lower-risk patients, demonstrating improved safety in complex cardiac surgeries.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Devices
Background:
- Intraaortic balloon pump (IABP) use in coronary artery bypass grafting (CABG) traditionally has high complication rates.
- Recent evidence suggests preoperative IABP placement in high-risk patients can mitigate adverse outcomes.
- This study validates these findings by applying liberal criteria for preoperative IABP insertion in elderly patients (≥70 years) undergoing isolated CABG.
Purpose of the Study:
- To evaluate the safety and efficacy of liberal preoperative intraaortic balloon pump (IABP) insertion in high-risk elderly patients undergoing isolated coronary artery bypass grafting (CABG).
- To compare outcomes between elderly patients receiving preoperative IABP support and those who did not.
Main Methods:
- Retrospective review of 206 consecutive patients undergoing isolated CABG with cardiopulmonary bypass.
- Application of a rapid recovery protocol including reduced bypass time, early extubation, perioperative corticosteroids/thyroid hormone, and aggressive diuresis.
- Preoperative IABP support was given to patients with urgent indications: failed angioplasty, critical left main stenosis, severe left ventricular dysfunction, or refractory unstable angina.
Main Results:
- The overall 30-day mortality rate was 4.4%.
- 97 patients (47%) received preoperative IABP (Group II) versus 109 (53%) in Group I.
- Group II patients had lower ejection fraction (46% vs. 59%), higher incidence of heart failure (35% vs. 17%) and myocardial infarction (37% vs. 17%).
- Postoperative hospital stay was longer in Group II (9.0 vs. 6.0 days).
- No significant differences in complication or mortality rates between groups; only 2.2% IABP-related complications (lower extremity ischemia, successfully treated).
Conclusions:
- Liberal preoperative IABP insertion is safe in high-risk elderly patients undergoing CABG.
- Outcomes in this high-risk group receiving preoperative IABP are comparable to lower-risk patients.
- Preoperative IABP can be a valuable tool for managing complex cardiac surgical patients.
Background:
The use of the intraaortic balloon pump (IABP) in patients undergoing coronary artery bypass grafting has been traditionally associated with a high complication rate and adverse outcomes. However, recent reports show that many of these catastrophic outcomes can be avoided by preoperatively placing the IABP in high-risk patients. To further validate these reports, we defined a set of liberal criteria for preoperative IABP insertion and applied them to a series of elderly patients (70 years or older) undergoing isolated coronary artery bypass grafting.
Methods:
Two hundred six consecutive patients who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass were retrospectively reviewed. A rapid recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthetic protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. Patients who required an urgent operation because of failed percutaneous transluminal coronary angioplasty, a critical left main stenosis (70% or greater), pronounced left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy or who required an emergency reoperation received preoperative IABP support.
Results:
The 30-day mortality rate for the entire group was 4.4%. There were 97 patients (47%) who received a preoperative IABP (group II) in comparison with 109 patients (53%) who did not fulfill the preoperative insertion criteria (group I). Patients in group II had a lower left ventricular ejection fraction (mean, 46% versus 59%, p<0.001) and a higher incidence of congestive heart failure (35% versus 17%, p<0.01) and acute myocardial infarction (37% versus 17%, p<0.01) than patients in group I. The average postoperative hospital length of stay for patients in group II was slightly longer than for those in group I (9.0+/-10.5 versus 6.0+/-3.7 days, p<0.01). However, there were no statistically significant differences in complication or mortality rates between the two groups. Only 2 patients (2.2%) had complications related to IABP insertion. Lower extremity ischemia occurred in both patients, and both were treated successfully with thromboembolectomy.
Conclusions:
Liberal preoperative insertion of the IABP can be performed safely in high-risk elderly patients undergoing coronary artery bypass grafting, with results comparable to those in lower risk patients.