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Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients
J T Christenson1, F Simonet, P Badel
1Cardiovascular Surgery, Columbia Hôpital de la Tour, Meyrin-Geneva, Switzerland.
Insights
Preoperative intra-aortic balloon pump (IABP) support for high-risk cardiac surgery patients significantly reduces hospital mortality and intensive care unit (ICU) stay. Early IABP use improves cardiac performance, proving cost-beneficial.
Area of Science:
- Cardiology
- Cardiac Surgery
- Mechanical Circulatory Support
Background:
- Intra-aortic balloon pump (IABP) is an adjunct therapy for heart failure post-myocardial infarction, unstable angina, and cardiac surgery.
- The study evaluated the impact of preoperative IABP in high-risk patients undergoing coronary artery bypass grafting (CABG).
Purpose of the Study:
- To assess the efficacy of preoperative intra-aortic balloon pump (IABP) support in high-risk patients undergoing coronary artery bypass grafting (CABG).
Main Methods:
- High-risk patients for CABG were randomized into three groups: IABP 1 day pre-surgery, IABP 1-2 hours pre-cardiopulmonary bypass (CPB), and a control group with no preoperative IABP.
- Patient criteria included left ventricular ejection fraction (LVEF) ≤40%, left main stem stenosis ≥70%, REDO-CABG, or unstable angina.
Main Results:
- Groups receiving preoperative IABP (1 day or 1-2 hours pre-CPB) showed significantly shorter CPB times and reduced hospital mortality (6% vs. 25% in controls).
- Postoperative low cardiac output was less frequent in IABP groups (19% vs. 60%), with higher cardiac index post-CPB.
- Intensive care unit (ICU) stay was shorter for patients receiving preoperative IABP (2.3 days vs. 3.5 days).
Conclusions:
- Preoperative IABP in high-risk cardiac surgery patients improves cardiac performance, lowers hospital mortality, and shortens ICU stays, demonstrating cost-effectiveness.
- While 1-day preoperative IABP showed better cardiac performance improvement than 1-2 hour pre-treatment, neither significantly altered overall mortality or morbidity outcomes.
Objective:
The intra-aortic balloon pump (IABP) is an established additional support to pharmacological treatment of the failing heart after myocardial infarction, unstable angina and cardiac surgery. The effect of preoperative IABP in high risk patients was evaluated.
Methods:
Between June 1994 and March 1996 all high risk patients for CABG (two or more of these criteria: Left ventricular ejection fraction (LVEF) < or = 40%, left main stem stenosis > or = 70%, REDO-CABG, unstable angina) were randomized into either of 3 groups: (1) IABP 1 day prior to surgery, (2) IABP 1-2 h prior to CPB and (3) no preoperative IABP, controls.
Exclusion Criteria:
cardiogenic shock preoperatively. Fifty-two patients have entered the study-group 1 (13 patients), group 2 (19 patients) and group 3 (20 patients). Preoperative patient characteristics and operative data revealed no group differences. There were 56% REDO's, unstable angina 59%, LVEF < or = 40%, 87% (34.0 +/- 11.6%) and left main stem stenosis in 35%.
Results:
The CPB-time was shorter in groups 1 and 2 88.7 +/- 20.3 min than in group 3 105.5 +/- 26.8 min, P < 0.001, while ischemia time did not differ. Hospital mortality was higher in group 3, 25% vs. 6% (groups 1 and 2). Postoperative low cardiac output was seen in 12 patients (60%) in group 3 vs. 6 patients (19%) in groups 1 and 2, P < 0.05. Cardiac index increased significantly prior to CPB in groups 1 and 2. After CPB cardiac index was significantly higher in groups 1 and 2 compared to Group 3 and continued to increase. The IABP was removed after 3.1 +/- 1.0 days in group 3 vs. 1.3 +/- 0.6 days in groups 1 and 2, P < 0.001. In group 3, 11 patients required IABP postoperatively compared to only 4 patients in groups 1 and 2. ICU stay was shorter in groups 1 and 2--2.3 +/- 0.9 days vs. 3.5 +/- 1.1 days for group 3, P = 0.004. All patients received dopamin postoperatively, however in a lower dose in groups 1 and 2, 4.5 vs. 13.5 microg/kg/min. Dobutamine was added in 23% of the patients (group 1), 32% (group 2) and 95% (group 3). Adrenalin/amrinonum was required in 40% of the patients in group 3, 5% in group 2 and none in group 1. Group 1 patients had a better improvement of cardiac performance than group 2, while other parameters did not differ. Three months follow up of hospital survivors showed no group differences.
Conclusions:
The use of preoperative IABP in high risk patients lowers hospital mortality and shortens the stay in ICU, due to improved cardiac performance, compared to a controls. The procedure was cost-beneficial. One day preoperative IABP treatment improves cardiac performance more than 1-2 h preoperative IABP treatment, but does not significantly affect the outcome in terms of hospital mortality or postoperative morbidity.