Preoperative intra-aortic balloon support in surgery for left main coronary stenosis

Hanging by a thread-urgent coronary artery bypass grafting for ST elevation myocardial infarction in a patient with isolated left main coronary artery disease

A 78-year-old man presented with a left main stenosis as the culprit lesion in an acute myocardial infarction. He had no significant narrowing in any other coronary territory. This case describes findings in an isolated left main myocardial infarction and discusses appropriate treatment strategies.

Development of "plug and play" TransApical to aorta VAD

Our TransApical to Aorta pump, a simple and minimally invasive left ventricular (LV) assist device, has a flexible, thin-wall conduit connected by six struts to a motor with ball bearings and a turbine extending into the blood path. Pulsatile flow is inherent in the design as the native heart contraction preloads the turbine. In six healthy sheep, the LV apex was exposed by a fifth intercostal left thoracotomy. The pump was inserted from the cardiac apex through the LV cavity into the ascending aorta. Aortic and LV pressure waveforms, pump flow, motor current, and pressure were directly measured. All six cannula pumps were smoothly advanced on the first attempt. Pump implantation was <15 minutes (13.6 +/- 1.8 minutes). Blood flow was 2.8 l/min to 4.4 l/min against 86 +/- 8.9 mm Hg mean arterial blood pressure at maximum flow. LV systemic pressure decreased significantly from 102.5 +/- 5.55 mm Hg to 58.8 +/- 15.5 mm Hg at the fourth hour of pumping (p = 0.042), and diastolic LV pressure decreased from 8.4 +/- 3.7 to 6.1 +/- 2.3 mm Hg (p > 0.05). The pump operated with a current of 0.4 to 0.7 amps and rotation speed of 28,000 to 33,000 rpm. Plasma free hemoglobin was 4 +/- 1.41 mg/dl (range, 2 to 5 mg/dl) at termination. No thrombosis was observed at necropsy.A left ventricular assist device using the transapical to aorta approach is quick, reliable, minimally invasive, and achieves significant LV unloading with minimal blood trauma.

Intraaortic balloon pump in open heart operations: 10-year follow-up with risk analysis

BACKGROUND

The intraaortic balloon pump (IABP) is the primary mechanical device used for perioperative cardiac failure.

METHODS

We analyzed the prognostic predictors and long-term survival of 344 patients undergoing cardiac operations who required the perioperative use of an IABP at our institution from January 1980 to December 1989. Hospital survivors (163 patients) were followed up for a mean of 7.45 years (range, 1 month to 15.3 years); cumulative follow-up included 1,167 patient-years.

RESULTS

The early mortality rate was 52.6% (181 patients). From parameters available at the time of IABP insertion, logistic regression analysis identified preoperative serum creatinine level, left ventricular ejection fraction, perioperative myocardial infarction, timing of IABP insertion, and indication for operation as independent predictors of early (30-day) death (p < 0.05). Cox regression analysis of hospital survivors identified timing of IABP insertion, perfusion time, and preoperative serum creatinine level as independent prognostic factors for late death (p < 0.05), whereas patient age was only marginally significant (p < 0.06). There was no association between IABP-related complications and death. Survival analysis demonstrated a 10-year actual survival rate of 22.04% +/- 0.023%, with 57 patients still at risk and significantly improved survival among those who received an IABP before operation (p < 0.02).

CONCLUSIONS

The early mortality rate in patients who received an IABP was high. Hospital survivors had a relatively good long-term prognosis. The significantly better short- and long-term survival of patients who received an IABP before operation may justify more liberal preoperative use of the IABP in high-risk patients.

Fatal haemorrhage following intra-aortic balloon counterpulsation: a case report and a brief review of its clinico-pathological and medico-legal aspects

Intra-aortic balloon counterpulsation may result in serious and possibly fatal vascular complications, such as arterial dissection, in as many as 20 per cent of cases. A significant proportion of these complications may go unrecognized clinically. The following is an account of such a case from Singapore in which an elderly patient with a history of severe ischaemic heart disease died within 25 hours of coronary bypass surgery (resulting from massive intraperitoneal haemorrhage), as a consequence of post-operative intra-aortic balloon counterpulsation. The clinico-pathological and medico-legal aspects of the case are also discussed, together with a brief mention of the role of post-mortem coronary angiography in assessing venous graft patency and integrity.

Percutaneous intraaortic balloon pumping: four years from Tiblisi

Intraaortic balloon pumping (IABP) has now evolved as the mechanical supportive treatment of choice for the management of refractory left ventricular power failure. A new single-chambered percutaneous intraaortic balloon (Datascope Corp., Paramus, NJ, U.S.A.) has been constructed around a central guidewire. The balloon can be wrapped around the guidewire, enabling its insertion into the femoral artery through a 12-F sheath, inserted by a modified Seldinger technique. A dual-lumen automatic wrapping version has recently been employed. Percutaneous IABP insertion has been performed in 149 patients (mean age 58 years). In our medical group of 75 patients, 59 underwent urgent open heart surgery and 53 (90%) survived. In patients who could not be separated from cardiopulmonary bypass, 23 of 61 (38%) survived. Vascular complications occurred in 10% of the patients. Percutaneous balloon insertion permits the rapid institution of IABP support and broadens the medical and surgical applications of IABP.

A practical and effective protocol for the post angiographic management of patients with critical stenosis of the left main coronary artery

The management of newly diagnosed left main obstruction varies throughout institutions. At some Centers, very aggressive measures including intra-aortic balloon counterpulsation and emergent revascularization are routine protocol. Twenty consecutive patients with greater than 50% luminal narrowing of the left main coronary artery were treated over a 1 year period. Routine post catheterization protocol for 19 patients included intensive care observation, continuation of nonparenteral anti-anginal agents, and coronary revascularization within 24 hours of diagnosis. One patient experienced severe hemodynamic embarrassment at the time of catheterization and underwent emergency coronary bypass. All patients were discharged uneventfully following successful surgery. Based on this experience, it is felt that with surgical support, patients with significant left main stenosis can be treated with standard anti-anginal therapy, and undergo elective revascularization without complications.

Clinical experience with intra-aortic balloon counterpulsation in 112 consecutive patients

Intra-aortic balloon pumping (IABP) was attempted in 112 consecutive patients, resulting in successful placement in 49 of 50 (98%) patients when the percutaneous technique was used and in 60 of 62 (97.3%) patients when the surgical technique was used. Complications following acute myocardial infarction and perioperative problems were the two most frequent (47% and 52%, respectively) indications for IABP. A favorable survival was observed in patients with acute myocardial infarction with ventricular septal defect undergoing surgery after IABP (80%) and in patients in whom IABP was used in the perioperative setting (57.6%); survival remained poor in patients with postinfarction shock or severe heart failure (20% and 23%, respectively). Complications related to IABP occurred in 23 (20.5% patients but tended to occur more frequently in patients undergoing placement by the percutaneous route than by the surgical route (31% vs 9.6%; p less than 0.03) and in patients over age 70. Thus IABP can be successfully inserted in the majority of patients, but the high complication rate, especially with the percutaneous route, suggests caution in its indiscriminate use, particularly in patients whose mortality remains high despite its use.

Surgical treatment of 200 consecutive patients with left main coronary artery disease

Two hundred consecutive patients underwent myocardial revascularization for left main coronary artery disease between January, 1975, and December, 1981. The mean age of this group was 64 +/- 8 years, and 78.5% of the patients were men. The anginal pattern was chronic stable in 6% of the patients and progressive or unstable in the remainder. Resting electrocardiograms showed prior myocardial infarction in 45.5%. Left ventricular end-diastolic pressure was elevated in 145 patients, and ejection fraction was less than 50% in 40 patients. The mean number of bypass grafts per patient was 3.2 +/- 1.4 (standard deviation). Seventeen patients underwent major concomitant cardiovascular procedures. The operative mortality was 3.5%, and the incidence of perioperative infarction was 3%. Factors associated with reduced operative survival were increased age; unstable angina, or acute myocardial infarction, or both; female sex; circumflex-dominant circulation; and major concomitant procedures. Late mortality at a mean follow-up of 33.5 months was 6%, and 91% of the surviving patients assessed their quality of life as "excellent" or "good."

Mechanical techniques of circulation support: a percutaneous intra-aortic balloon device

As medical indications for intra-aortic balloon (IAB) pumping expand, many physicians without surgical expertise are faced with the decision to institute circulatory support. Accordingly, to facilitate rapid establishment of cardiac assist and to obviate the need for operative insertion and removal, a 40-cc single-chambered device was designed for percutaneous insertion by the Seldinger technique. Hemodynamic augmentation produced by the percutaneous balloon is similar to that obtained with conventional IAB. It appears that complications related to IAB insertion may be decreased by the percutaneous method.

Percutaneous intraaortic balloon counterpulsation. Clinical effectiveness and hazards

Because of its greater ease and rapidity of insertion, the percutaneous intraaortic balloon in many institutions has become the primary method for implementing counterpulsation. We report the results and complications of 113 attempted procedures in a variety of clinical settings. We had a high (93.8 percent) insertion success rate. However, our 18.6 complication rate was similar to the experience reported for the surgical method of insertion. Thus, the original anticipation of reduced complications with this method has not been realized in this and other recent reports.

Severe left main coronary arterial stenosis with right coronary arterial occlusion: results of bypass graft surgery

A detailed study was made of preoperative, operative and postoperative data from 69 patients with severe (70 percent or greater) luminal narrowing of the left main coronary artery and occlusion of the right coronary artery who underwent bypass surgery from December 1970 through December 1978. Preoperatively, 40.6 percent of patients were in functional class III and 55.1 percent in class IV. Ninety-six percent of those tested had a positive electrocardiographic treadmill test. Coronary bypass grafting was accomplished using standard techniques in all patients. An average of 2.7 grafts/patient were placed. The hospital mortality rate was 4.3 percent, and an additional 4.3 percent died before the end of 1 year. A history of congestive heart failure was a significant predictor (p less than 0.05) of postoperative mortality. An intraaortic balloon pump was not inserted in 64 patients, and our experience suggests that it was a necessary preoperative adjunct. A postoperative treadmill test was negative in 92 percent of those patients tested. Of those surviving 1 year postoperatively, 89 percent were in functional class I and 8 percent in class II. This study demonstrates a surgical mortality rate comparable with that of patients with left main coronary stenosis alone and a significantly better survival rate than that of similar patients treated medically.

Risks of coronary arteriography and bypass surgery in patients with left main coronary artery stenosis

The risk of coronary arteriography is considerably increased in patients who have left main coronary artery stenosis (LMCAS). Among 1,060 patients undergoing coronary arteriography over a three-year period, 83 were found to have LMCAS and three of these patients died (3.6 percent) during or shortly after the arteriographic procedure. Bypass surgery, however, can now be carried out at a very low risk irrespective of the degree of coronary disease present--there was no hospital mortality in 74 patients with LMCAS undergoing bypass surgery at our institution during this period. In addition to careful attention to detail, techniques that can minimize the risk of both of these procedures in patients with LMCAS include invasive hemodynamic monitoring and various pharmacologic manipulations to prevent myocardial ischemia. In a small percentage of patients, rest angina may prove refractory to inhospital medical treatment, and intraaortic balloon pumping may be necessary to stabilize the conditions of these patients before proceeding with arteriography and myocardial revascularization.

Total occlusion of the left main coronary artery: clinical and catheterization findings

In this report clinical and angiographic data on three patients with total occlusion of the left main coronary artery is presented. Two of our cases demonstrated rich collateralization with good preservation of left ventricular (LV) function. The third case, with initial subtotal occlusion and no collaterals, sustained a severe anterolateral myocardial infarction (MI) responding to the use of the intra-aortic balloon pump (IABP). This report is consistent with the findings of others who suggest the possible beneficial effect of collaterals in preserving myocardial contractility in this unusual situation. We suggest that the IABP may be of benefit in patients with total occlusion of the left main coronary artery and sparse collaterals who remain unstable and cannot be operated on immediately.

Intra-aortic balloon counterpulsation. Clinical experience

From March 1975 until September 1978, seventy patients were referred for intra-aortic balloon counterpulsation for cardiogenic shock complicating acute myocardial infarction or for the treatment of low cardiac output states following cardiopulmonary bypass. Sixty of these received adequate intra-aortic balloon pump assistance; fifty-two ped successfully off the balloon pump. Twenty-three patients survived to leave hospital.

Further evaluation of the surgical treatment of obstructive disease of the left main coronary artery

A protocol for the operative management of two patient groups with left main coronary artery disease has been evaluated. The period prior to and during induction of anesthesia is managed without using aortic balloon counterpulsation. Of the 86 patients undergoing coronary artery bypass for left main coronary artery disease from 1970 to 1973, there was a surgical mortality of 8.1%. Follow-up of the survivors from 48 to 87 months revealed three coronary and five non-coronary related deaths with survival to seven years of 75.6 +/- 5%. If the operative mortality is excluded, there is an observed survival to seven years of 82.4 +/- 4.8%, almost the same as a "normal" population of similar age and sex. Utilizing the same protocol, 90 similar patients undergoing coronary artery bypass in 1976 had an operative mortality of 4.4%. The deaths were not related to induction of anesthesia. The perioperative infarction rate (2%) and postoperative cardiac enzyme determinations were no greater in a random group having the same operation for less severe forms of coronary artery disease during the same time period. This method of management for patients with significant left main coronary artery disease is judged superior to other more complex techniques.

Preoperative intra-aortic balloon assist in high risk revascularization patients

Sixty-five high risk myocardial revascularization patients had preoperative IABP with two operative deaths. Only six patients needed rapid institution of cardiopulmonary bypass after anesthesia induction despite marked blood pressure drop in half the patients. There were only two instances of postpump power failure. Preoperative IABP is a valid method of limiting morbidity associated with coronary surgery in high risk patients.