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Pre-operative balloon counterpulsation and off-pump coronary surgery for high-risk patients
G Babatasi1, M Massetti, P G Bruno
1Cardiovascular and Thoracic Surgery, University Hospital, Avenue Côte de Nacre, CHU Caen 14033 Caen, France. babatasi-g@chu-caen.fr
Insights
Preoperative intra-aortic balloon pump (IABP) use may enable safer off-pump coronary artery bypass grafting (OPCABG) in high-risk patients. This approach showed reduced mortality and morbidity without compromising graft patency.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Procedures
- Mechanical Circulatory Support
Background:
- Coronary artery bypass grafting (CABG) can be performed off-pump (OPCABG) using minimally invasive techniques.
- Multivessel OPCABG presents challenges in high-risk patients with critical left main stenosis or severe ventricular dysfunction.
- Intra-aortic balloon pump (IABP) is a potential tool to stabilize high-risk patients undergoing OPCABG.
Purpose of the Study:
- To evaluate the efficacy of preoperative intra-aortic balloon pump (IABP) use in high-risk patients undergoing multivessel off-pump coronary artery bypass grafting (OPCABG).
- To assess the safety and outcomes of OPCABG with preoperative IABP support compared to on-pump procedures.
Main Methods:
- A comparative study of 23 high-risk OPCABG patients treated with preoperative IABP versus 15 on-pump patients with similar criteria.
- Data collected over a 10-month period.
- Post-operative angiography to assess graft patency.
Main Results:
- Preoperative IABP use was significantly higher in the OPCABG group (70% vs. 46%).
- No conversions to cardiopulmonary bypass (CPB) were needed in the OPCABG group, with 97.5% anastomosis patency.
- The OPCABG group showed a trend towards reduced morbidity (atrial fibrillation, reexploration for bleeding, prolonged ventilation) and significantly lower mortality.
Conclusions:
- Preoperative IABP may facilitate safe OPCABG in high-risk patients, potentially reducing morbidity and mortality.
- Further randomized controlled trials are needed to confirm the efficacy of elective IABP in this patient population.
- The findings suggest preoperative IABP use is warranted for a significant proportion of high-risk OPCABG candidates.
Unlabelled:
Coronary artery bypass surgery (CABG) can be performed less invasively without cardiopulmonary bypass (CPB). Multivessel off-pump CABG (OPCAB) is challenging in patients with critical left main stenosis (> 70%) and/or severe ventricular dysfunction (ejection fraction < 0.35) Our objective was the evaluation of efficiency of intra aortic balloon pump (IABP) preoperatively in this high-risk group in order to perform OPCABG safely.
Material And Method:
In a consecutive 10-month period (out of 88 OPCABG patients) 23 high-risk patients were treated and were compared with 15 on-pump patients (out of 69) with the same criteria.
Results:
Preoperative implantation of IABP was significantly higher in the OPCABG group (70% vs 46%, p < 0.05). No conversion to CPB was required in the OPCABG group. Post-operative angiography was systematically performed and demonstrated 97.5% patency of anastomosis. No device-related complications occurred. No difference was found concerning age, risk factors, emergency surgery, ejection fraction, mean number of grafts per patient (2.64 versus 2.75) and average operating time. In contrast, OPCABG demonstrated a trend toward reduced morbidity in terms of atrial fibrillation, reexploration for bleeding and prolonged ventilator requirement > 12 h. Mortality was less in the OPCABG group (p < 0.05).
Conclusion:
More randomized controlled trials are needed to evaluate the true efficacy of elective IABP in OPCABG high-risk patients. Until such studies are evaluated, and therefore because older and sicker patients now constitute a greater percentage of candidates for OPCABG, the timing of application of the IABP is warranted. These results may further justify preoperative use of the IABP in a large proportion of this group of patients.