Elsevier

The Annals of Thoracic Surgery

Volume 64, Issue 5, November 1997, Pages 1237-1244
The Annals of Thoracic Surgery

Preoperative Intraaortic Balloon Pump Enhances Cardiac Performance and Improves the Outcome of Redo CABG

https://doi.org/10.1016/S0003-4975(97)00898-9Get rights and content

Background

Reoperative coronary artery bypass grafting (redo CABG) is associated with an increased operative risk compared with primary CABG. Because the hospital mortality in redo CABG is known to be influenced by poor left ventricular function (left ventricular ejection fraction ≤0.40), unstable angina, and left main stem stenosis greater than or equal to 70%, a preoperative intraaortic balloon pump (IABP) support could be beneficial to improve the outcome in high-risk redo CABG.

Methods

Between June 1994 and October 1996, 48 high-risk patients underwent redo CABG and were randomized into the following groups: group 1 (24 patients) who received preoperative IABP treatment on average 2 hours before cardiopulmonary bypass, and group 2 (24 patients) who received no preoperative IABP and served as controls. Mean age was 65 years and 90% (43 patients) were men. Forty-one patients had preoperative left ventricular ejection fraction less than or equal to 0.40 (85%), 38% (18 patients) had left main stem stenosis greater than or equal to 70%, and 54% (26 patients) had unstable angina preoperatively. Preoperative patient characteristics did not differ between the groups.

Results

The time on cardiopulmonary bypass was shorter in group 1, 86 versus 110 minutes (p = 0.006). There were no hospital deaths in group 1, but four deaths occurred in the control group (p = 0.049). Cardiac index rose significantly preoperatively after introduction of the IABP in group 1. Cardiac index was significantly higher postoperatively in group 1 compared with group 2 and remained significantly higher during the first 24 hours after cardiopulmonary bypass. Significantly fewer patients in the IABP group had postoperative low cardiac output (4 versus 13 patients). Nine patients in group 2 required IABP support postoperatively for 4.1 ± 1.7 days. Only 2 patients in group 1 needed IABP postoperatively, and their IABPs were successfully removed on the first postoperative day. The preoperative IABP-supported patients had a shorter intensive care unit stay, 2.4 ± 0.8 days compared with group 2, 4.5 ± 2.2 days (p = 0.007), as well as a shorter hospital stay. The preoperative IABP treatment was found to be cost-effective.

Conclusions

Preoperative treatment with IABP in high-risk redo CABG patients is an effective modality to prepare these patients to have their myocardial revascularization in an as nonischemic situation as possible, which resulted in a significantly lower hospital mortality, fewer instances of postoperative low cardiac output, and shorter stays in both the intensive care unit and the hospital.

Section snippets

Patients and Methods

Between June 1, 1994, and October 1, 1996, 48 high-risk patients underwent redo CABG at our institution, having presented with at least two of the following additional criteria: poor left ventricular function (preoperative LVEF ≤ 0.40), unstable angina at the time of surgery (angina severity fluctuating between angina classes [Canadian Cardiovascular Society’s classification of angina] or angina at rest despite nitroglycerine infusion and calcium-channel inhibitors), left main stem stenosis

Operation Data

The average number of distal anastomoses was 3.5 ± 1.3 per patient (range, 1 to 6 distal anastomoses) in group 1 and 3.3 ± 1.3 per patient (range, 1 to 5 distal anastomoses) in group 2 (p = 0.472, not significant). The internal thoracic artery was used in 67% (16/24 patients) in group 1 and 63% (15/24 patients) in group 2 (p = 0.521, not significant). Coronary artery thromboendarterectomy was required in 8 patients in group 1 and 5 patients in group 2. The mean ischemia time did not differ between the

Comment

When compared with primary CABG, reoperative CABG is associated with an increased operative risk in terms of increased postoperative mortality and morbidity 1., 2., 3., 4.. Hospital mortality after redo CABG is independently influenced by infarct-borne left ventricular dysfunction [23], unstable angina at the time of the operation [4], and presence of a significant (≥70%) main stem stenosis of the left coronary artery [1], as well as a short interval between the primary and the redo operations

Discussion

DR CARY W. AKINS (Boston, MA): Maybe you can tell us about your techniques of myocardial preservation. One of the issues might be that if your reoperative patients had patent internal mammary grafts that you did not clamp, then the use of counterpulsation would help in perfusing those areas of the myocardium. Tell us about the incidence of arterial grafts that were patent in your redo patients and what your technique of myocardial preservation is.

DR CHRISTENSON: Regarding myocardial

Acknowledgement

This study was supported by a grant from St. Jude Medical AG, Basel, Switzerland. We are grateful to the perfusionists Jaenine Reuse and Bruno Nowicki.

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    Presented at the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.

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