Surgical management of complicated acute coronary insufficiency

Acute coronary insufficiency (ACI) has a one year mortality rate approximating 40 percent with medical treatment alone. This report reviews our experience over 24 months with preoperative intra-aortic balloon pump assist (IABPA) in 42 patients with ACI. Abnormal left ventricular (LV) hemodynamics were present in the majority of patients; the ejection fraction was less than 40 percent in 14 patients. The endocardial viability ratio (EVR) was less than 0.7 in eight patients. The mean coronary artery score was 13, compared to 9 in an otherwise comparable group of patients with stable angina. Left main coronary stenosis greater than 75 percent was present in seven patients and combined with significant stenosis (less than 72 percent) in the dominant right system in four patients. Four patients had proximal stenoses greater than 90 percent in all three major coronary arteries. IABPA was initiated in 11 patients prior to angiography because of refractory rest pain. One of these six patients died. Twenty-five other patients were supported before and six after induction of general anesthesia. Thirty-three of 36 revascularized patients survived. Of four patients with perioperative myocardial infarctions (12 percent), three had IABPA after induction of general anesthesia. Inotropic support and duration of stay both in intensive care and in the hospital were less than in similar patients treated before the use of IABPA.