Pre-operative intra-aortic balloon counterpulsation in stable patients with left main coronary disease
P Fasseas1, M Cohen, C Kopistansky
1Division of Cardiology, Department of Medicine, MCP Hahnemann University School of Medicine, Philadelphia, PA, USA.
Insights
Prophylactic intra-aortic balloon counterpulsation (IABC) may lower mortality in stable left main coronary artery disease patients. However, confounding factors like peripheral vascular disease necessitate a large randomized trial to confirm IABC
Area of Science:
- Cardiology
- Cardiovascular Surgery
Background:
- Severe left main coronary artery disease (LMCD) poses significant risks for patients undergoing coronary artery bypass graft surgery (CABG).
- The role of prophylactic intra-aortic balloon counterpulsation (IABC) in stable LMCD patients remains unclear.
Purpose of the Study:
- To evaluate the clinical impact of pre-operative, prophylactic intra-aortic balloon counterpulsation (IABC) in stable patients with severe left main coronary artery disease undergoing CABG.
Main Methods:
- A post-hoc analysis of 457 prospectively tracked patients with 50% LMCD and multivessel disease, excluding those with hemodynamic compromise or ongoing angina.
- Patients were divided into two groups: 287 without pre-operative IABC (Group 1) and 170 with prophylactic IABC (Group 2).
- Exclusion criteria included heart failure, shock, ongoing ischemia, or prior CABG.
Main Results:
- Baseline characteristics were similar, but Group 1 had more peripheral vascular disease (PVD), while Group 2 had more diabetes and lower ejection fraction.
- Unadjusted 30-day mortality was significantly higher in Group 1 (5.6%) compared to Group 2 (1.2%) (p=0.02).
- After adjusting for PVD, the difference in mortality between groups was not statistically significant (p=0.10), despite zero deaths in PVD patients receiving IABC.
Conclusions:
- Unadjusted data suggest a potential mortality benefit of prophylactic IABC in stable LMCD patients.
- Confounding variables, particularly PVD, limit definitive conclusions from this observational analysis.
- A larger, randomized clinical trial is required to establish the true role of prophylactic IABC in this patient population.
Objective:
To determine whether prophylactic, pre-operative, intra-aortic balloon counterpulsation (IABC) improves clinical outcome in stable patients with severe left main coronary artery disease.
Methods:
A post-hoc analysis of 457 prospectively tracked, non-randomized patients undergoing coronary artery bypass graft surgery (CABG) for left main stenoses 50% and multivessel coronary disease, but without any hemodynamic compromise or ongoing angina, was conducted. Patients with heart failure, shock, ongoing ischemia or previous CABG were excluded. In 287 patients, pre-operative IABC was not used (Group 1), while IABC was initiated in 170 patients for "prophylaxis" (Group 2).
Results:
Groups 1 and 2 were similar in age (67 +/- 10 years versus 67 +/- 11 years, respectively), sex (72% male versus 71% male, respectively), and body mass index (28 +/- 5.5 versus 27 +/- 5.1, respectively). However, more Group 1 patients had peripheral vascular disease (PVD) (25% versus 11%), but more Group 2 patients had diabetes (37% versus 29%), and a lower left ventricular ejection fraction. The unadjusted 30-day mortality was significantly higher in Group 1 [16 (5.6%) versus 2 (1.2%); p = 0.02]. Cardiopulmonary bypass time and post-operative length of stay did not differ between the two groups. After adjusting for PVD in the multivariate analysis, the p-value for the no IABP versus IABP comparison in the presence of PVD was 0.10, even though 0/18 patients with PVD and IABC died.
Conclusion:
While unadjusted mortality appears lower with prophylactic IABC, confounding variables such as PVD mandate a larger, randomized clinical trial in order to establish the role of IABC in stable patients with left main disease.
Related Concept Videos
01:25Aortic Regurgitation III: Medical Management
01:27Coronary Artery Disease V: Interprofessional Care
01:28Cardiomyopathy VII: Pre and Post Operative Nursing Management