Original article
Cardiovascular
Reduced Mortality in High-Risk Coronary Patients Operated Off Pump With Preoperative Intraaortic Balloon Counterpulsation

https://doi.org/10.1016/j.athoracsur.2007.03.080Get rights and content

Background

Preoperative intraaortic balloon pump (IABP) counterpulsation has better outcomes compared with perioperative or postoperative insertion in critical patients, and off-pump surgical procedures have been advocated to reduce mortality in high-risk patients. However, some surgeons are reluctant to perform beating heart operations in specific patient subgroups, including those with unstable angina or patients with low ejection fraction, because of their possible perioperative hemodynamic instability.

Methods

We evaluated combined beating heart procedures and preoperative IABP in selected high-risk patients and compared our results with the predictive European System for Cardiac Operative Risk Evaluation (EuroSCORE) model. Fifty-five high-risk patients with a mean logistic EuroSCORE of 24 were prospectively enrolled and then divided into emergency (group 1, n = 25) and nonemergency (group 2, n = 30) groups. IABP was inserted immediately before operation in group 1 and the day before the procedure in group 2.

Results

Compared with the EuroSCORE predictive model, a dramatic decrease in mortality occurred in both groups. Group I predicted mortality was 36.8%, and observed was 20%; and group 2 predicted mortality was 15.2% and observed was 0%. No specific complications from the use of IABP were encountered. During mid-term (2 years) follow-up, no patient died from a cardiac cause or required percutaneous coronary intervention or subsequent reoperation due to incomplete revascularization.

Conclusions

The combined use of preoperative intraaortic counterpulsation and beating heart intervention allows complete revascularization in high-risk patients with a important reduction in operative mortality and excellent mid-term results.

Section snippets

Patients and Methods

Since March 2000, off-pump operation has been the technique of choice at our center for all isolated coronary procedures, and it was used in 1300 consecutive patients. Between May 2000 and August 2005, we prospectively studied the insertion of preoperative Datascope system IABP (Datascope, Fairfield, CT) in 55 (4.2%) consecutive high-risk off-pump patients. During the same period, the IABP was inserted during or after the operation in 14 (1.1%) of the 1300 patients. All the procedures were done

Surgical Technique

A total of 213 anastomoses were performed: 3.87 per patient overall; 3.8 per patient in group I, and 3.9 per patient in group 2 (p = NS). Sixty-six percent of the anastomoses were arterial (66% in group I, 67% in group 2; p = NS). Exclusive arterial revascularization was obtained in 34.6% of the overall patient population (16% in group I, 50% in group 2; p < 0.05). The left anterior descending artery was grafted in all 55 cases, the circumflex artery in 48 (87.3%), and the right coronary artery

Comment

Reduction of hospital mortality after coronary revascularization in very high-risk patients remains a challenge for the cardiac team. Decreased mortality has been shown with off-pump procedures, especially in high-risk patients, by avoiding the detrimental effects of extracorporeal circulation and myocardial ischemia [9, 10, 11, 12]. However, most surgeons are reluctant to use beating heart operations in high-risk patients. The major reasons given are the difficulties for optimal coronary

References (18)

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    It is well known that peripheral arterial disease could represent global vasculopathy, which has an adverse effect not only on operative survival but also on late survival [15]. Regarding repeat reintervention, few reports are available on late repeat revascularization after emergency OPCABG in ACS patients preoperatively on IABP support [3, 11, 16]. In the present study, reintervention-free survival (84.2% at 5 years and 79.5% at 10 years) was comparable with the OPCABG analyses in the earlier literature [11, 17]; and preoperative history of PCI emerged as the multivariate risk factor for repeat revascularization after OPCABG during follow-up.

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    Although a consensus exists regarding IABP use in patients with cardiogenic shock and unstable conditions after an acute evolving MI, controversy remains regarding the routine use of IABP for other subgroups of high-risk patients.13 A recently published meta-analysis of 4 randomized controlled trials and 6 cohort studies of 1034 patients supported the preoperative use of IABP in high-risk patients.14 Most studies reporting the results of preoperative IABP support for CABG patients have been small, single-center, retrospective reports without long-term follow-up.

  • "Polarizing" microplegia improves cardiac cycle efficiency after CABG for unstable angina

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    Certainly, we demonstrated a significantly attenuated myocardial injury in UA after Mic. On the other hand, it has been reported that off-pump surgery is able to protect these acutely ischemic hearts during surgery better than cardioplegic techniques, thus determining lower perioperative troponin I leakage [3,4,29]. Although we cannot exclude that off-pump surgery may achieve similar or better results than those here reported after Mic, off-pump surgery is not considered the treatment of choice in unstable angina patients at our institution.

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    The positive effect of preoperative insertion of IABP in high-risk patients is thought to be due to an improved myocardial oxygen supply/demand ratio and reduced ventricular wall stress before the operation in addition to diastolic augmentation and decreased afterload resulting in the redistribution of coronary blood flow toward the ischemic areas of the myocardium, and in the recovered energy depletion of myocardial cells [15]. As a consequence, preoperative prophylactic IABP assistance provides better hemodynamic stability in the crucial times for higher oxygen demand when the anesthesia is induced and the conduits are harvested, as well as when the heart is displaced in off-pump procedures [5, 16–18]. The optimal timing for preoperative insertion of IABP in high-risk patients undergoing CABG remains controversial, although the subject has been treated frequently in the past decade.

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