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Yang C, Zheng P, Li L, Zhang Q, Luo Z, Shi Z, Zhao S, Li Q. Machine learning-based model development for predicting risk factors of prolonged intra-aortic balloon pump therapy in patients with coronary artery bypass grafting. J Cardiothorac Surg 2024; 19:383. [PMID: 38926828 PMCID: PMC11201335 DOI: 10.1186/s13019-024-02830-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Machine learning algorithms are frequently used to clinical risk prediction. Our study was designed to predict risk factors of prolonged intra-aortic balloon pump (IABP) use in patients with coronary artery bypass grafting (CABG) through developing machine learning-based models. Patients who received perioperative IABP therapy were divided into two groups based on their length of IABP implantation longer than the 75th percentile for the whole cohort: normal (≤ 10 days) and prolonged (> 10 days) groups. Seven machine learning-based models were created and evaluated, and then the Shapley Additive exPlanations (SHAP) method was employed to further illustrate the influence of the features on model. In our study, a total of 143 patients were included, comprising 56 cases (38.16%) in the prolonged group. The logistic regression model was considered the final prediction model according to its most excellent performance. Furthermore, feature important analysis identified left ventricular end-systolic or diastolic diameter, preoperative IABP use, diabetes, and cardiac troponin T as the top five risk variables for prolonged IABP implantation in patients. The SHAP analysis further explained the features attributed to the model. Machine learning models were successfully developed and used to predict risk variables of prolonged IABP implantation in patients with CABG. This may help early identification for prolonged IABP use and initiate clinical interventions.
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Affiliation(s)
- Changqing Yang
- Department of Emergency, The Sixth Affiliated Hospital of Nantong University, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China
- Department of Emergency, Yancheng Third People's Hospital, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China
| | - Peng Zheng
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Luo Li
- Department of Cardiovascular Surgery of the First Affiliated Hospital & Institute for Cardiovascular Science, Suzhou Medical College, Soochow University, Soochow University, 899 Pinghai Road, Suzhou, Jiangsu, 215123, China
| | - Qian Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu, 210029, China
| | - Zhouyu Luo
- Department of Emergency, The Sixth Affiliated Hospital of Nantong University, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China
- Department of Emergency, Yancheng Third People's Hospital, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China
| | - Zhan Shi
- Department of Cardiovascular Surgery, The Sixth Affiliated Hospital of Nantong University, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China.
- Department of Cardiovascular Surgery, Yancheng Third People's Hospital, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China.
| | - Sheng Zhao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China.
| | - Quanye Li
- Department of Emergency, The Sixth Affiliated Hospital of Nantong University, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China.
- Department of Emergency, Yancheng Third People's Hospital, 2 Xinduxi Road, Yancheng, Jiangsu, 224000, China.
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Chandran K, Quimby D, Bezerra HG, Crousillat D. Early use of intrapartum intra-aortic balloon pump support for haemodynamic stabilization of peripartum and anthracycline-induced cardiomyopathy: a case report. Eur Heart J Case Rep 2024; 8:ytae033. [PMID: 38328601 PMCID: PMC10849077 DOI: 10.1093/ehjcr/ytae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Abstract
Background Prior exposure to cardiotoxic cancer therapies has been associated with an increased risk of peripartum cardiomyopathy (PPCM). The management of PPCM in this population remains a clinical challenge. Few studies have explored the use of mechanical circulatory support in PPCM. We present a case of early implementation of intra-aortic balloon pump (IABP) therapy for acute stabilization and intrapartum support of PPCM. Case summary A 36-year-old G4P2103 (4th pregnancy, two full-term, one premature birth, 0 abortions, and three living children) woman at 26 weeks and 5 days gestation with history of combined peripartum and anthracycline-induced cardiomyopathy [previously left ventricular ejection fraction (LVEF) 10-15% and recently 40-45%] presented with acute decompensated heart failure. Her clinical status deteriorated with a drop in LVEF to 15-20% with a significant increase in pulmonary pressures and worsening mitral regurgitation. A multidisciplinary decision with the cardio-obstetrics team was made to place a pulmonary artery catheter for invasive haemodynamic monitoring and IABP insertion prior to delivery. Intra-aortic balloon pump support had a profound immediate decrease in her systemic and pulmonary vascular resistance allowing for a successful repeat caesarean delivery. Her haemodynamics remained stable after IABP removal and pulmonary pressures improved. She was discharged one week following her delivery on guideline-directed medical therapy. Discussion Our case highlights the use of prophylactic intrapartum IABP in combined anthracycline-induced and PPCM and begins to explore its safety and efficacy in this high-risk patient population.
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Affiliation(s)
- Karthic Chandran
- Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Donald Quimby
- Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Hiram G Bezerra
- Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA
- Tampa General Hospital Heart and Vascular Institute, Interventional Cardiology Center of Excellence, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Daniela Crousillat
- Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA
- Tampa General Hospital Heart and Vascular Institute, Women’s Heart and Cardio Obstetrics Program, 2 Tampa General Circle, Tampa, FL 33606, USA
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Alsagaff MY, Revianto O, Sembiring YE, Ilman MI, Intan RE. Intra-aortic balloon pump still has a role in late-onset myocardial infarction complicated by ventricular septal rupture with intractable heart failure: a case report. J Med Case Rep 2024; 18:8. [PMID: 38184640 PMCID: PMC10771645 DOI: 10.1186/s13256-023-04284-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 11/24/2023] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND The current guidelines have discouraged the routine use of intra-aortic balloon pump (IABP) in cardiogenic shock complicating acute coronary syndrome (ACS). Since then, the trend of IABP utilization in ACS has been declining. Nevertheless, the guidelines still preserve the recommendation of IABP use in hemodynamic instability or cardiogenic shock caused by post myocardial infarction (MI) ventricular septal rupture (VSR). CASE PRESENTATION A 46-years-old diabetic Southeast Asian female was referred from a peripheral facility with intractable heart failure despite treatment with vasoactive agents and diuretics for five days. The ECG suggested a recent anteroseptal myocardial infarction with normal high-sensitivity troponin-I value. The echocardiography detected a regional wall motion abnormality and a 10 mm wide ventricular septal defect. Invasive coronary angiography revealed a severe two-vessel coronary artery disease. We planned a delayed surgical strategy with preoperative optimization using IABP as a bridge to surgery. IABP implantation followed by significant hemodynamic improvement and rapid resolution of heart failure without any inotrope support. Afterwards, coronary artery bypass grafting (CABG) and VSR surgical repair were performed. We safely removed IABP on the third postoperative day with proper weaning and minimal vasoactive support. CONCLUSION We report a case where IABP still provided benefits for a patient with intractable heart failure caused by undetermined onset MI complicated by VSR. The use of IABP in such a case is in accordance with the recommendation of the current guidelines. Several studies showed that IABP use during preoperative optimization in the case of post-MI VSR was associated with survival benefits.
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Affiliation(s)
- Mochamad Yusuf Alsagaff
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia.
| | - Oky Revianto
- Department of Cardiovascular Thoracic Surgery, Faculty of Medicine, Airlangga University-RSUD Dr. Soetomo General Hospital Surabaya, Surabaya, East Java, 60286, Indonesia
| | - Yan Efrata Sembiring
- Department of Cardiovascular Thoracic Surgery, Faculty of Medicine, Airlangga University-RSUD Dr. Soetomo General Hospital Surabaya, Surabaya, East Java, 60286, Indonesia
| | - Muhammad Insani Ilman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia
| | - Ryan Enast Intan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga-Dr. Soetomo General Academic Hospital, Surabaya, East Java, 60286, Indonesia
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Sohail AA, Samejo A, Bajwa H, Wahab R, Asif N, Inam H, Shahabuddin S. Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting. Perfusion 2023:2676591231193977. [PMID: 37534589 DOI: 10.1177/02676591231193977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined. METHODOLOGY A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates. RESULTS Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028). CONCLUSION Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.
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Affiliation(s)
| | | | - Hamza Bajwa
- Aga Khan University Hospital, Karachi, Pakistan
| | - Rida Wahab
- Aga Khan University Hospital, Karachi, Pakistan
| | | | - Hina Inam
- Aga Khan University Hospital, Karachi, Pakistan
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Garg P, Hussain MWA, Sareyyupoglu B. Role of acute mechanical circulatory support devices in cardiogenic shock. Indian J Thorac Cardiovasc Surg 2023; 39:25-46. [PMID: 37525710 PMCID: PMC10387030 DOI: 10.1007/s12055-023-01484-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 03/30/2023] Open
Abstract
Cardiogenic shock is a state of low cardiac output that is associated with significant morbidity and mortality. A considerable proportion of patients with cardiogenic shock respond poorly to medical management and require acute mechanical circulatory support (AMCS) devices to improve tissue perfusion as well as to support the heart. In the last two decades, many new AMCS devices have been introduced to support the right, left, and both ventricles. All these devices vary in terms of the support they provide to the body and heart, mechanism of functioning, method of insertion, and adverse events. In this review, we compare and contrast the available percutaneous and surgically placed AMCS devices used in cardiogenic shock and discuss the associated clinical and hemodynamic data to make a conscious decision about choosing a device.
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Affiliation(s)
- Pankaj Garg
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Md Walid Akram Hussain
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
- Cardiothoracic Surgery, Heart and Lung Transplant Program, Mayo Clinic, 4500 San Pablo Road, FL 32224 Jacksonville, USA
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Kralev A, Kalisnik JM, Bauer A, Sirch J, Fittkau M, Fischlein T. Impact of prophylactic intra-aortic balloon pump on early outcomes in patients with severe left ventricular dysfunction undergoing elective coronary artery bypass grafting with cardiopulmonary bypass. Int J Cardiol 2023:S0167-5273(23)00725-8. [PMID: 37209782 DOI: 10.1016/j.ijcard.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/14/2023] [Accepted: 05/17/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Our aim was to analyse whether prophylactic preoperative intraaortic balloon pump (IABP) improves outcomes in hemodynamically stable patients with low left ventricular ejection fraction (LVEF ≤30%) undergoing elective myocardial revascularization (CABG) using cardiopulmonary bypass (CPB). Secondary aim was to identify the predictors for low cardiac output syndrome (LCOS). METHODS Prospectively collected data of 207 consecutive patients with LVEF ≤30% undergoing elective isolated CABG with CPB from 01/2009 to 12/2019, 136 with and 71 patients without IABP, were retrieved retrospectively. Patients with prophylactic IABP were matched 1:1 with patients without IABP by a propensity score matching. Stepwise logistic regression was conducted to identify predictors of postoperative LCOS in the propensity-matched cohort. P value ≤0.05 was considered significant. RESULTS Reduced postoperative LCOS (9.9% vs. 26.8%, P = 0.017) was observed in patients receiving prophylactic IABP. Stepwise logistic regression identified preoperative IABP as preventive factor for postoperative LCOS [Odds Ratio (OR) 0.19,95% Confidence Interval (CI), 0.06-0.55, P = 0.004]. The need of vasoactive and inotropic support was lower in patients with prophylactic IABP at 24, 48 and 72 h after surgery (12.3 [8.2-18.6] vs. 22.2 [14.4-28.8], P < 0.001, 7.7 [3.3-12.3] vs.16.3 [8.9-27.8], P < 0.001 and 2.4 [0-7] vs. 11.5 [3.1-26], P < 0.001, respectively). The patients in both groups did not differ in terms of in-hospital mortality (7.0% vs. 9.9%, P = 0.763). There were no major IABP-related complications. CONCLUSIONS Elective patients with left ventricular ejection fraction ≤30% undergoing CABG with CPB and prophylactic IABP insertion had less low cardiac output syndrome and similar in-hospital mortality.
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Affiliation(s)
- Andrej Kralev
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
| | - Jurij Matija Kalisnik
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany; Surgery, Medical School, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia.
| | - André Bauer
- Department of Computer Science, Julius Maximillian University of Wuerzburg. Am Hubland, 97074 Wuerzburg, Germany
| | - Joachim Sirch
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nuremberg, Paracelsus Medical University, Breslauer Str. 201, 90471 Nurernberg, Germany
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Djordjevic I, Liakopoulos O, Elskamp M, Maier-Trauth J, Gerfer S, Mühlbauer T, Slottosch I, Kuhn E, Sabashnikov A, Rademann P, Maul A, Paunel-Görgülü A, Wahlers T, Deppe AC. Concomitant Intra-Aortic Balloon Pumping Significantly Reduces Left Ventricular Pressure during Central Veno-Arterial Extracorporeal Membrane Oxygenation-Results from a Large Animal Model. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111859. [PMID: 36430994 PMCID: PMC9694613 DOI: 10.3390/life12111859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
(1) Introduction: Simultaneous ECMO and IABP therapy is frequently used. Haemodynamic changes responsible for the success of the concomitant mechanical circulatory support system approach are rarely investigated. In a large-animal model, we analysed haemodynamic parameters before and during ECMO therapy, comparing central and peripheral ECMO circulation with and without simultaneous IABP support. (2) Methods: Thirty-three female pigs were divided into five groups: (1) SHAM, (2) (peripheral)ECMO(-)IABP, (3) (p)ECMO(+)IABP, (4) (central)ECMO(-)IABP, and (5) (c)ECMO(+)IABP. Pigs were cannulated in accordance with the group and supported with ECMO (±IABP) for 10 h. Systemic haemodynamics, cardiac index (CI), and coronary and carotid artery blood flow were determined before, directly after, and at five and ten hours on extracorporeal support. Systemic inflammation (IL-6; IL-10; TNFα; IFNγ), immune response (NETs; cf-DNA), and endothelial injury (ET-1) were also measured. (3) Results: IABP support during antegrade ECMO circulation led to a significant reduction of left ventricular pressure in comparison to retrograde flow in (p)ECMO(-)IABP and (p)ECMO(+)IABP. Blood flow in the left anterior coronary and carotid artery was not affected by extracorporeal circulation. (4) Conclusions: Concomitant central ECMO and IABP therapy leads to significant reduction of intracavitary cardiac pressure, reduces cardiac work, and might therefore contribute to improved recovery in ECMO patients.
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Affiliation(s)
- Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
- Correspondence: ; Tel.: +49-(0)-221-478-30-835
| | - Oliver Liakopoulos
- Department of Cardiac Surgery, Kerckhoff-Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, 61231 Bad Nauheim, Germany
| | - Mara Elskamp
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Johanna Maier-Trauth
- Division of Thoracic and Cardiovascular Surgery, HELIOS Klinikum Siegburg, 53721 Siegburg, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Thomas Mühlbauer
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Ingo Slottosch
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, 39120 Magdeburg, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Pia Rademann
- Experimental Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 51109 Cologne, Germany
| | - Alexandra Maul
- Experimental Medicine, Faculty of Medicine and University Hospital of Cologne, University of Cologne, 51109 Cologne, Germany
| | - Adnana Paunel-Görgülü
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
| | - Antje Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital Cologne, 50937 Cologne, Germany
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Manshadi SD, Eisenberg N, Montbriand J, Luk A, Roche-Nagle G. Vascular Complications with Intra-Aortic Balloon Pump (IABP) – Experience from a large Canadian metropolitan centre. CJC Open 2022; 4:989-993. [DOI: 10.1016/j.cjco.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022] Open
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Heringlake M, Berggreen AE, Paarmann H. Still a place for aortic counterpulsation in cardiac surgery and patients with cardiogenic shock? Crit Care 2021; 25:309. [PMID: 34461956 PMCID: PMC8407061 DOI: 10.1186/s13054-021-03673-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2021. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2021 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany.
| | - Astrid Ellen Berggreen
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Hauke Paarmann
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center, Mecklenburg-Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
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Kimman JR, Van Mieghem NM, Endeman H, Brugts JJ, Constantinescu AA, Manintveld OC, Dubois EA, den Uil CA. Mechanical Support in Early Cardiogenic Shock: What Is the Role of Intra-aortic Balloon Counterpulsation? Curr Heart Fail Rep 2021; 17:247-260. [PMID: 32870448 PMCID: PMC7496039 DOI: 10.1007/s11897-020-00480-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purpose of Review We aim to summarize recent insights and provide an up-to-date overview on the role of intra-aortic balloon pump (IABP) counterpulsation in cardiogenic shock (CS). Recent Findings In the largest randomized controlled trial (RCT) of patients with CS after acute myocardial infarction (AMICS), IABP did not lower mortality. However, recent data suggest a role for IABP in patients who have persistent ischemia after revascularization. Moreover, in the growing population of CS not caused by acute coronary syndrome (ACS), multiple retrospective studies and one small RCT report on significant hemodynamic improvement following (early) initiation of IABP support, which allowed bridging of most patients to recovery or definitive therapies like heart transplant or a left ventricular assist device (LVAD). Summary Routine use of IABP in patients with AMICS is not recommended, but many patients with CS either from ischemic or non-ischemic cause may benefit from IABP at least for hemodynamic improvement in the short term. There is a need for a larger RCT regarding the role of IABP in selected patients with ACS, as well as in patients with non-ACS CS.
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Affiliation(s)
- Jesse R Kimman
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Alina A Constantinescu
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Eric A Dubois
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Corstiaan A den Uil
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.,Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
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Concomitant ECMO And IABP Support in Postcardiotomy Cardiogenic Shock Patients. Heart Lung Circ 2021; 30:1533-1539. [PMID: 33903028 DOI: 10.1016/j.hlc.2021.03.276] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/27/2021] [Accepted: 03/11/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Simultaneous mechanical circulatory support (MCS) with intra-aortic balloon pump (IABP) to extracorporeal membrane oxygenation (ECMO) is common in postcardiotomy cardiogenic shock (PCS). This study aimed to analyse the effect of concomitant ECMO and IABP therapy on the short-term outcomes of patients with PCS. METHODS Between March 2006 and March 2017, 172 consecutive patients with central (c) or peripheral (p) veno-arterial ECMO therapy due to PCS were identified at the current institution and included in this retrospective analysis. Patients were divided into ECMO+IABP and ECMO alone groups. Further, the impact of ECMO flow direction was analysed for the groups. RESULTS A total of 129 patients received ECMO+IABP support and 43 patients were treated with ECMO alone. Median ECMO duration did not differ between the groups (68 [34; 95] hours ECMO+IABP vs 44 [20; 103] hours ECMO; p=0.151). However, a trend toward a higher weaning rate was evident in ECMO+IABP patients (75 [58%] ECMO+IABP vs 18 [42%] ECMO; p=0.078). Concomitant IABP support with either cECMO (73% [n=24] cECMO+IABP vs 50% [n=11] ECMO; p=0.098) or pECMO (57% [n=55] ECMO+IABP vs 33% [n=7] ECMO; p=0.056) was also associated with a trend toward a higher weaning rate off ECMO. In-hospital mortality did not differ between the groups. CONCLUSION This analysis found that, independent of ECMO type, additional IABP support might increase ECMO weaning; however, it did not influence survival in PCS patients. Larger studies are necessary to further analyse the impact of this concomitant MSC therapy on clinical outcomes.
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Escutia-Cuevas HH. Use of intra-aortic balloon pump during coronary artery bypass graft surgery. Current questions and few answers. J Card Surg 2021; 36:1466-1467. [PMID: 33604923 DOI: 10.1111/jocs.15436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Hector H Escutia-Cuevas
- Department of Interventional Cardiology, Regional Hospital ISSSTE Puebla, Puebla City, Mexico
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13
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Samanidis G, Kanakis M, Balanika M, Khoury M. Analysis of risk factors for in-hospital mortality in 177 patients who underwent isolated coronary bypass grafting and received intra aortic balloon pump. J Card Surg 2021; 36:1460-1465. [PMID: 33604940 DOI: 10.1111/jocs.15437] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/23/2020] [Accepted: 01/16/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Intra-aortic balloon pump (IABP) is the most commonly used device for circulatory support of patients with heart disease. The aim of this study evaluated the risk factors for outcomes of patients who underwent isolated coronary bypass grafting and received IABP. METHODS One hundred-seventy-seven patients underwent isolated coronary bypass grafting and received intraoperative IABP. All perioperative data were recorded. The primary end-point was in-hospital mortality, while the secondary end-points were the length of intensive care unit (ICU) stay and hospital length of stay (LOS). RESULTS In-hospital mortality was 5.6% (10 patients). Multivariable logistic regression analysis showed that the risk factors for in-hospital mortality were preoperative plasma creatinine level and cardiopulmonary bypass (CPB) time (for both p < .05). Multivariable linear regression analysis showed that postoperative acute kidney injury (AKI), immediate plasma troponin after operation, numbers of grafts, and CPB time were predicted the hospital LOS, while postoperative AKI, preoperative left ventricular ejection fraction, and immediate plasma troponin after operation were predicted the lengths of ICU stay. CONCLUSION Our analysis showed that increased preoperative plasma creatinine, postoperative renal dysfunction, and CPB time negatively affected the outcomes of patients who received intraoperative IABP insertion.
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Affiliation(s)
- George Samanidis
- Second Department of Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Marina Balanika
- Department of Anesthesiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Mazen Khoury
- Second Department of Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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de Jong MM, Parise O, Matteucci F, Rutten M, Devos M, Romano M, Micali LR, Parise G, Maessen JG, Gelsomino S. Aortic flow below and visceral circulation during aortic counterpulsation: Evaluation of an in vitro model. Perfusion 2020; 37:69-77. [PMID: 33325335 DOI: 10.1177/0267659120978641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This study aimed to test a computer-driven cardiovascular model for the evaluation of the visceral flow during intra-aortic balloon pump (IABP) assistance. METHODS The model includes a systemic and pulmonary circulation as well as a heart contraction model. The straight polyurethane tube aorta had a single visceral while four windkessel components mimicked resistance compliance of the brachiocephalic, renal and sub-mesenteric, pulmonary, and systemic circulation. Twelve flow probes were placed in the circuit to measure pressures and flows with the IABP on and off. RESULTS With the balloon off, the meantime to reach the steady state was 48 ± 16 s; with the balloon on, this figure was 178 ± 20 s. The stability of pressure and flow signals was obtained after 72 ± 11 min. The number of cycles of stability of the system was 93 [86-103]. Measurements were reliable either with samples of 10 or 20 beats. Bland Altman method demonstrated the reliability of measurements. Finally, all measurements were comparable to published in vivo data. CONCLUSION The presented mock circulation was reliable and gave values with high accuracy both at baseline and during mechanical assistance. This system allows evaluation of the mesenteric flow during IABP, under different clinical/hemodynamic conditions. Nonetheless, its translational potential needs to be further evaluated.
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Affiliation(s)
- Monique Mj de Jong
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Orlando Parise
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Francesco Matteucci
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Marcel Rutten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Noord-Brabant, The Netherlands
| | - Maxime Devos
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Noord-Brabant, The Netherlands
| | | | - Linda Renata Micali
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Gianmarco Parise
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Jos G Maessen
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, Maastricht, The Netherlands
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Ali US, Lan NSR, Gilfillan M, Ho K, Pavey W, Dwivedi G, Slimani EK, Edelman J, Merry C, Larbalestier R. Preoperative Intra-Aortic Balloon Pumps in Cardiac Surgery: A Propensity Score Analysis. Heart Lung Circ 2020; 30:758-764. [PMID: 33109455 DOI: 10.1016/j.hlc.2020.09.924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/21/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The role of intra-aortic balloon pumps (IABP) in high-risk patients undergoing coronary artery bypass graft (CABG) surgery remains controversial. We report the 5-year experience from a new Australian centre. METHODS We retrospectively analysed 690 patients undergoing urgent isolated CABG surgery at a Western Australian tertiary centre from February 2015 to May 2020. De-identified data was obtained from the Australia & New Zealand Society of Cardiothoracic Surgeons database. Patients were stratified according to preoperative IABP use. A propensity score was created for the probability of IABP use and a propensity adjusted analysis was performed using logistic regression. The primary outcome was 30-day mortality. Secondary outcomes were postoperative inhospital outcomes. RESULTS Preoperative IABP was used in 78 patients (11.3%). After propensity score adjustment, in a subgroup of patients with reduced ejection fraction or left main disease, 30-day mortality (7.0% vs 2.0%, OR 6.03, 95% CI 1.89-19.28, p=0.002) was significantly higher in the IABP group. Red blood cell transfusions (19.7% vs 12.6%, OR 1.86, 95% CI 1.02-3.35, p=0.039), prolonged inotrope use (78.9% vs 50.9%, OR 6.11, 95% CI 2.77-13.48, p<0.001), prolonged invasive ventilation (28.2% vs 3.4%, OR 20.2, 95% CI 8.24-49.74, p<0.001), mesenteric ischaemia (2.8% vs 0%, OR 4.52, 95% CI 1.15-17.77, p=0.031) and multisystem organ failure (1.3% vs 0.7%, OR 25.68, 95% CI 2.55-258.34, p=0.006) were significantly higher in the IABP group. CONCLUSION In patients undergoing isolated CABG surgery, preoperative IABP use was associated with increased 30-day mortality and adverse outcomes. Large randomised controlled trials are required to confirm our findings.
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Affiliation(s)
- Umar S Ali
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia.
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Molly Gilfillan
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Kwok Ho
- Medical School, University of Western Australia, School of Veterinary & Life Sciences, Murdoch University and Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
| | - Warren Pavey
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Eric K Slimani
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - James Edelman
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Chris Merry
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Robert Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
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Knapik P, Hirnle G, Kowalczuk-Wieteska A, O.Zembala M, Pawlak S, Hrapkowicz T, Przybyłowski P, Nadziakiewicz P, Cieśla D, Perek B, Kapelak B, Cisowski M, Rogowski J, Pietrzyk E, Tobota Z, Zembala M. Off-pump versus on-pump coronary artery surgery in octogenarians (from the KROK Registry). PLoS One 2020; 15:e0238880. [PMID: 32913359 PMCID: PMC7482977 DOI: 10.1371/journal.pone.0238880] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/25/2020] [Indexed: 12/04/2022] Open
Abstract
Background According to the medical literature, both on-pump and off-pump coronary artery surgery is safe and effective in octogenarians. Objectives The aim of our study was to examine the epidemiology, in-hospital outcomes and long-term follow-up results in octogenarians undergoing off-pump and on-pump coronary artery surgery utilizing nationwide registry data. Methods All octogenarians (≥ 80 years) enrolled in the Polish National Registry of Cardiac Surgical Procedures (KROK Registry), who underwent isolated coronary surgery between January 2006 and September 2017 were identified. Preoperative data, perioperative complications, hospital mortality and long-term mortality were analyzed. Unadjusted and propensity-matched comparisons were performed between octogenarians undergoing off-pump and on-pump coronary artery bypass surgery. Results Octogenarians accounted for 4.1% of the total population undergoing coronary artery surgery in Poland during the analyzed period (n = 152,631) and this percentage is increasing. Among 6,006 analyzed patients, 2,744 (45.7%) were operated on-pump and 3,262 (54.3%) were operated off-pump. Propensity-matched analysis revealed that patients operated on-pump were more often reoperated due to postoperative bleeding and their in-hospital mortality was higher (6.6% vs 4.5%, p = 0.006 and 8.7% vs 5.8%, p = 0.001, respectively). Long-term all-cause mortality was lower among patients operated off-pump (p = 0.013). Conclusion On the basis of our findings we suggest that off pump technique should be considered as perfectly acceptable in octogenarians.
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Affiliation(s)
- Piotr Knapik
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
- * E-mail:
| | - Grzegorz Hirnle
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Anetta Kowalczuk-Wieteska
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Michał O.Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Szymon Pawlak
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Tomasz Hrapkowicz
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Diseases, Zabrze, Poland
- First Chair of General Surgery, Jagiellonian University, Medical College, Cracow, Poland
| | - Paweł Nadziakiewicz
- Department of Anaesthesiology, Intensive Therapy and Emergency Medicine, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
| | - Daniel Cieśla
- Department of Science and New Technologies, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Marek Cisowski
- First Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biala, Poland
| | - Jan Rogowski
- Department of Cardiac and Vascular Surgery, Medical University of Gdańsk, Gdańsk, Poland
| | - Edward Pietrzyk
- Department of Cardiac Surgery, Świętokrzyskie Centre of Cardiology, Kielce, Poland
| | - Zdzisław Tobota
- Department of Paediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Marian Zembala
- Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Silesian Centre for Heart Diseases, Medical University of Silesia, Zabrze, Poland
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Liakopoulos OJ, Schlachtenberger G, Wendt D, Choi YH, Slottosch I, Welp H, Schiller W, Martens S, Welz A, Neuhäuser M, Jakob H, Wahlers T, Thielmann M. Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North-Rhine-Westphalia Surgical Myocardial Infarction Registry. J Am Heart Assoc 2020; 8:e012049. [PMID: 31070076 PMCID: PMC6585325 DOI: 10.1161/jaha.119.012049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock (CS) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non–ST‐segment–elevation myocardial infarction (NSTEMI) and ST‐segment–elevation myocardial infarction (STEMI). Methods and Results Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in‐hospital mortality (IHM) and major adverse cardiocerebral events (MACCEs). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI (P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On‐pump surgery with cardioplegia was the preferred surgical technique in CS. IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI (IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score. Conclusions Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.
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Affiliation(s)
- Oliver J Liakopoulos
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - G Schlachtenberger
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Daniel Wendt
- 2 Department of Thoracic and Cardiovascular Surgery West German Heart Center University of Duisburg-Essen Essen Germany
| | - Yeong-Hoon Choi
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Ingo Slottosch
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Henryk Welp
- 4 Department of Cardiac Surgery University Hospital Münster Münster Germany
| | | | - Sven Martens
- 4 Department of Cardiac Surgery University Hospital Münster Münster Germany
| | - Armin Welz
- 5 Department of Cardiac Surgery University of Bonn Germany
| | - Markus Neuhäuser
- 3 Institute of Medical Computer Science, Biometry and Epidemiology University of Duisburg-Essen Essen Germany.,6 Department of Mathematics and Technique Koblenz University of Applied Science Remagen Germany
| | - Heinz Jakob
- 2 Department of Thoracic and Cardiovascular Surgery West German Heart Center University of Duisburg-Essen Essen Germany
| | - Thorsten Wahlers
- 1 Department of Cardiothoracic Surgery Heart Center of the University Hospital of Cologne Germany
| | - Matthias Thielmann
- 2 Department of Thoracic and Cardiovascular Surgery West German Heart Center University of Duisburg-Essen Essen Germany
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Wu Z, Liu C, Fang Y, Wei H, Gu C. Intraoperative intra-aortic balloon pump improves 30-day outcomes of patients undergoing extensive coronary endarterectomy. J Cardiothorac Surg 2020; 15:223. [PMID: 32819396 PMCID: PMC7439531 DOI: 10.1186/s13019-020-01261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The efficacy of intra-aortic balloon pump (IABP) has been proven in high-risk patients undergoing coronary artery bypass grafting (CABG). However, data on the timing and benefits of IABP support in diffuse coronary artery disease after CABG combined with coronary endarterectomy (CE) remain scarce. This retrospective study assessed the effect of intraoperative or postoperative IABP on 30-day outcomes of off-pump CABG+CE. METHODS From January 2012 to December 2018, 546 patients undergone off-pump CABG+CE were divided into control group (n = 437) and IABP group (n = 109). Risk factors for 30-day outcomes were evaluated. Subgroup analysis from IABP group was conducted to identify the effect of timing IABP on 30-day outcomes. RESULTS CE on left anterior descending branch of coronary artery (LAD) (OR = 3.079, 95% CI 1.077-8.805, P = 0.036), CE with≥2 vessels (OR = 9.123, 95% CI 3.179-26.033, P < 0.001) and length of atherosclerotic plaque ≥3 cm (OR = 16.017, 95% CI 5.941-43.183, P < 0.001) were independent risk factors for postoperative acute myocardial infarction (AMI) and 30-day mortality. Comparing with intraoperative IABP support, postoperative IABP support (OR = 3.987, 95% CI1.194-13.317, P = 0.025) was closely associated with postoperative AMI and 30-day mortality. CONCLUSIONS For patients undergone off-pump CABG and extensive CE (CE on LAD, CE ≥2 vessels and length of atherosclerotic plaque ≥3 cm), intraoperative IABP support may improve 30-day outcomes.
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Affiliation(s)
- Zhen Wu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Anzhen Street No.2 Chaoyang District, Beijing, 100029, China
| | - Changcheng Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Anzhen Street No.2 Chaoyang District, Beijing, 100029, China
| | - Ying Fang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Anzhen Street No.2 Chaoyang District, Beijing, 100029, China
| | - Hua Wei
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Anzhen Street No.2 Chaoyang District, Beijing, 100029, China
| | - Chengxiong Gu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Anzhen Street No.2 Chaoyang District, Beijing, 100029, China.
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Balloon Pump Counterpulsation Part II: Perioperative Hemodynamic Support and New Directions. Anesth Analg 2020; 131:792-807. [DOI: 10.1213/ane.0000000000004999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Bhimaraj A, Agrawal T, Duran A, Tamimi O, Amione-Guerra J, Trachtenberg B, Guha A, Hussain I, Kim J, Kassi M, Xu J, Suarez E, Ngo UQ, Torre-Amione G, Estep JD. Percutaneous Left Axillary Artery Placement of Intra-Aortic Balloon Pump in Advanced Heart Failure Patients. JACC-HEART FAILURE 2020; 8:313-323. [PMID: 32241538 DOI: 10.1016/j.jchf.2020.01.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/28/2020] [Accepted: 01/28/2020] [Indexed: 11/15/2022]
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Escutia-Cuevas H, Suárez-Cuenca J, Espinoza-Rueda M, Macedo-Calvillo L, Castro-Gutiérrez A, García-García J, García-Ortegón M, Robledo R, Mondragón-Terán P. Preoperative Use of Intra-Aortic Balloon Pump Support Reduced 30-Day Mortality in a Population with LVEF >35% and High Surgical Risk after Coronary Artery Bypass Graft Surgery. Cardiology 2020; 145:267-274. [DOI: 10.1159/000506393] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 02/08/2020] [Indexed: 11/19/2022]
Abstract
Introduction: The intra-aortic balloon pump (IABP) is used to prevent complications after coronary artery bypass grafting (CABG) surgery, although some results are controversial and basal ventricular function may play a role. This study assessed the benefit of preoperative use of IABP, as stratified by the ventricular function, in a population submitted to high-surgical-risk CABG. Methods: Patients >18 years old, with multiple coronary artery disease and thus candidates for CABG, were included. Cardiogenic shock, acute myocardial infarction (AMI), acute ventricle mechanical dysfunction, severe aortic regurgitation, tachyarrhythmia, massive pulmonary embolism, coagulopathy, or low life expectancy were exclusion criteria. Results: One hundred and twenty-nine patients aged 65 years old with hypertension, dyslipidemia, type 2 diabetes mellitus, and mean left ventricular ejection fraction (LVEF) 46% constituted the study population. No difference was observed at 30-day mortality endpoint (IABP vs. no IABP, 17 vs. 24%, OR 0.63, p = 0.20; AMI 25 vs. 31%, OR 0.75, p = 0.29). After LVEF stratification, the subgroup of 48 (75%) patients under IABP support and LVEF >35% had a reduced 30-day mortality risk (LVEF ≤35% vs. LVEF >35%, 37.5 vs. 10.4%, OR 0.3, p = 0.03), independently from potential confounders and showing an interaction with European System for Cardiac Operative Risk Evaluation-II (EuroSCORE-II). At secondary endpoints, IABP use was associated with a lower prevalence of acute renal failure and renal replacement therapy, but with a longer stay in the intensive care unit and longer hospitalization time. Conclusion: The preoperative use of IABP was associated with an independent reduction of 30-day mortality risk in cases with LVEF >35% in a population submitted to high-surgical-risk CABG. Likewise, the use of IABP was associated with a lower risk of postoperative renal complications.
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Samanidis G, Georgiopoulos G, Bousounis S, Zoumpourlis P, Perreas K. Outcomes after intra-aortic balloon pump insertion in cardiac surgery patients. Rev Bras Ter Intensiva 2020; 32:542-550. [PMID: 33470355 PMCID: PMC7853672 DOI: 10.5935/0103-507x.20200091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 04/04/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To assess whether preoperative versus intraoperative insertion of an intra-aortic balloon pump is associated with lower 30-day mortality or reduced length of hospital stay among patients who had an intra-aortic balloon pump inserted for cardiac surgery. Methods This was an observational study of patients who had an intra-aortic balloon pump inserted in the preoperative or intraoperative period of cardiac surgery in our department between 2000 and 2012. We assessed the association between preoperative versus intraoperative insertion of an intra-aortic balloon pump and 30-day mortality in a multivariable logistic regression analysis, including preoperative New York Heart Association class, postoperative atrial fibrillation, reoperation, postoperative creatinine and isolated coronary bypass grafting as cofactors. We used a multivariate linear model to assess whether a preoperative versus intraoperative intra-aortic balloon pump was associated with length of postoperative hospital stay, adjusting for reoperation, isolated coronary bypass grafting, heart valve surgery, sex, age, cardiopulmonary bypass time, aortic cross-clamp time, preoperative patients’ status (elective, urgency or emergency surgery) and preoperative myocardial infarction. Results Overall, 7,540 consecutive patients underwent open heart surgery in our department, and an intra-aortic balloon pump was inserted pre- or intraoperatively in 322 (4.2%) patients. The mean age was 67 ± 10.2 years old, the 30-day mortality was 12.7%, and the median length of hospital stay was 9 days (7 - 13). Preoperative versus intraoperative intra-aortic balloon pump insertion did not affect the incidence of 30-day mortality (adjusted OR = 0.69; 95% CI, 0.15 - 3.12; p = 0.63) and length of postoperative hospital stay (β = 5.3; 95%CI, -1.6 to 12.8; p = 0.13). Conclusion Preoperative insertion of an intra-aortic balloon pump was not associated with a lower 30-day mortality or reduced length of postoperative hospital stay compared to intraoperative insertion.
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Affiliation(s)
- George Samanidis
- Serviço de Cirurgia Cardíaca em Adultos, Onassis Cardiac Surgery Center - Atenas, Grécia
| | | | - Stefanos Bousounis
- Serviço de Cirurgia Cardíaca em Adultos, Onassis Cardiac Surgery Center - Atenas, Grécia
| | - Panagiotis Zoumpourlis
- Serviço de Cirurgia Cardíaca em Adultos, Onassis Cardiac Surgery Center - Atenas, Grécia
| | - Konstantinos Perreas
- Serviço de Cirurgia Cardíaca em Adultos, Onassis Cardiac Surgery Center - Atenas, Grécia
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Perioperative use of levosimendan in patients undergoing cardiac surgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2019. [DOI: 10.1097/cj9.0000000000000121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Johnson DM, Lozekoot P, de Jong M, Parise O, Makhoul M, Matteucci F, Lucà F, Maessen JG, Gelsomino S. Superior mesenteric and renal flow patterns during intra-aortic counterpulsation. Exp Physiol 2019; 104:643-653. [PMID: 30821049 DOI: 10.1113/ep086810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 02/27/2019] [Indexed: 11/08/2022]
Abstract
NEW FINDINGS What is the central question of this study? Visceral ischaemia is one of the most feared complications during use of an intra-aortic balloon pump. Using an animal model, we measured the flows at the abdominal level directly and examined flow patterns to enable investigation of flow patterns during the use of the intra-aortic balloon pump. What is the main finding and its importance? We show that there is a significant balloon-related reduction in superior mesenteric flow in both early and mid-diastole. ABSTRACT A number of previous studies have shown that blood flow in the visceral arteries is altered during intra-aortic balloon pump (IABP) treatment. We used a porcine model to analyse the pattern of blood flow into the visceral arteries during IABP use. For this purpose, we measured the superior mesenteric, right renal and left renal flows before and during IABP support, using surgically placed flowmeters surrounding these visceral arteries. The superior mesenteric flow significantly decreased in early diastole (P < 0.001) and in mid-diastole (P = 0.003 versus early diastole), whereas in late diastole it increased again (P < 0.001 versus mid-diastole). During systole, the flow was not significantly increased compared with late diastole (P = 0.51), but it was significantly lower than at baseline (both P < 0.001). Flows did not differ between right and left kidneys. Perfusion of either kidney did not change significantly in early diastole (P > 0.05), whereas it decreased significantly in mid-diastole (P < 0.001), rising dramatically in late diastole (P < 0.001) and with an additional slight increase in systole (P = 0.054). This study provides important insights into abdominal flows during intra-aortic pump counterpulsation. Furthermore, it supports the need to rethink the balloon design to avoid visceral ischaemia during circulatory assistance.
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Affiliation(s)
- Daniel M Johnson
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Pieter Lozekoot
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Monique de Jong
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Orlando Parise
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Maged Makhoul
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands.,Cardiothoracic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Francesco Matteucci
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Fabiana Lucà
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
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Rahban Y, Davila CD, Natov PS, Kapur NK. Revascularization in Cardiogenic Shock and Advanced Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:4. [DOI: 10.1007/s11936-019-0708-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gelsomino S, Johnson DM, Lorusso R. Intra-aortic balloon pump: is the tide turning? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:345. [PMID: 30563544 PMCID: PMC6299544 DOI: 10.1186/s13054-018-2266-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/18/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands. .,Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.
| | - Daniel M Johnson
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Universiteitssingel 50, 6229 ER, Maastricht, The Netherlands.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
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Mechanical support for high-risk coronary artery bypass grafting. Indian J Thorac Cardiovasc Surg 2018; 34:287-296. [PMID: 33060951 PMCID: PMC7525900 DOI: 10.1007/s12055-018-0740-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 11/04/2022] Open
Abstract
Mechanical circulatory support devices are being used to an increasing extent. The use of these devices as an adjunct to cardiac surgery to support ventricular function has contributed to improved outcomes for the highest risk patients. In the context of patients undergoing coronary artery bypass grafting, there are several potential indications for mechanical circulatory support: preoperatively in the setting of acute cardiogenic shock, or in patients with intractable angina with or without haemodynamic compromise; at induction of anaesthesia prophylactically in patients with critical coronary anatomy and/or severely impaired left ventricular function; intraoperatively in the setting of failure to wean from cardiopulmonary bypass; or postoperatively in patients who develop an intractable low cardiac output state. The use of the intra-aortic balloon pump, veno-arterial extracorporeal membrane oxygenation, TandemHeart, Impella and central ventricular assist devices will be considered in the setting of high-risk patients undergoing coronary artery bypass grafting.
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Grieshaber P, Schneider T, Oster L, Orhan C, Roth P, Niemann B, Böning A. Prophylactic intra-aortic balloon counterpulsation before surgical myocardial revascularization in patients with acute myocardial infarction. Perfusion 2018; 33:390-400. [DOI: 10.1177/0267659118760384] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Prophylactic intra-aortic balloon counterpulsation (pIABC) is recommended for high-risk patients undergoing coronary artery bypass grafting (CABG) surgery. Criteria for high-risk patients benefiting from pIABC are unclear. This study aimed to specifically describe the effect of pIABC on outcomes of patients with acute myocardial infarction (AMI) undergoing CABG. Methods: In 178 of 484 AMI patients (non-ST-segment elevation myocardial infarction [NSTEMI] or ST-segment elevation myocardial infarction [STEMI] ≤5 days before surgery) without cardiogenic shock who underwent CABG between 2008 and 2013, pIABC was initiated preoperatively. After propensity score matching, the outcomes of 400 patients were analyzed (pIABC: 150; Control: 250). Results: After propensity score matching, baseline and operative characteristics were balanced between the groups except for a higher rate of patients with a left ventricular ejection fraction (LVEF)≤30% in the pIABC group (26% vs. Control: 13%; p=0.032). Seven point two percent (7.2%) of the control patients received an IABP intraoperatively or postoperatively. Postoperative extracorporeal life support (ECLS) was only needed in the control group (1.2% vs. 0%; p=0.01). Postoperative plasma curves of troponin I, creatine kinase (CK) and creatine kinase isoform MB (CK-MB) levels were reduced in the pIABC group compared with the control group. In-hospital mortality was reduced in the pIABC group (3.3% vs. control: 6.4%; p=0.18). After multivariate adjustment for other preoperative risk factors, pIABC was significantly protective concerning in-hospital mortality (HR 0.56; 95%-CI 0.023-0.74; p=0.021). Mortality (pIABC vs. control) was more affected in patients with preoperative LVEF≤30% (2/36 (5.6%) vs. 6/31 (19%); heart rate (HR) 0.25; 95%-CI 0.046-1.3; p=0.13) compared with LVEF>30% (3/114 (2.6%) vs. 10/219 (4.6%); HR 0.56; 95%-CI 0.15-2.1; p=0.55). Long-term survival did not differ between the groups. Conclusions: pIABC in CABG for AMI is associated with reduced perioperative cardiac injury and in-hospital mortality. Long-term survival is not affected.
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Affiliation(s)
- Philippe Grieshaber
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Tobias Schneider
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Lukas Oster
- Department of Anesthesiology, Sana Hospital Berlin-Lichtenberg, Berlin, Germany
| | - Coskun Orhan
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Peter Roth
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
| | - Andreas Böning
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Giessen, Germany
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de Jong MM, Lorusso R, Al Awami F, Matteuci F, Parise O, Lozekoot P, Bonacchi M, Maessen JG, Johnson DM, Gelsomino S. Vascular complications following intra-aortic balloon pump implantation: an updated review. Perfusion 2017; 33:96-104. [PMID: 28816093 PMCID: PMC5844455 DOI: 10.1177/0267659117727825] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: The use of the intra-aortic balloon pump (IABP) as a support device remains controversial due to the fact that a number of studies have shown no benefit in end mortality whilst using this device. One of the reasons for this could be the increase in vascular complications when using the pump. Therefore, the aim of the present review was to assess the current literature available with regards to IABP vascular complications during the clinical situation. Methods: A literature search was performed, searching for IABP complications in adult human studies between 1990 and 2016. Results: A total of 20 reports were identified as fitting the criteria of this study. The majority of vascular complications were limb ischemia, bleeding or mesenteric ischemia. The overall incidence of vascular complications ranged from 0.94% to 31.1%. Diabetes, peripheral vascular disease and hypertension, as well as smoking were all identified as risk factors for complications following IABP. Furthermore, studies supported the use of sheathless balloon insertion to reduce the risk of complications. Conclusion: Major vascular complications, including limb and mesenteric ischemia as well as bleeding and hemorrhage, have been associated with IABP. However, the incidence of these complications was generally low. Further studies are still required to truly understand the risk/benefit associated with the use of IABP.
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Affiliation(s)
- Monique M de Jong
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Roberto Lorusso
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Fatima Al Awami
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Francesco Matteuci
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Orlando Parise
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Pieter Lozekoot
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Massimo Bonacchi
- 2 Section of Cardiac Surgery, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Jos G Maessen
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Daniel M Johnson
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
| | - Sandro Gelsomino
- 1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht-CARIM, Maastricht, The Netherlands
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Lazar HL. The use of vancomycin paste to reduce sternal wound infections after cardiac surgery-why is this still a "sticky" subject. J Thorac Cardiovasc Surg 2017; 154:1324-1325. [PMID: 28709624 DOI: 10.1016/j.jtcvs.2017.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/14/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Harold L Lazar
- Division of Cardiac Surgery, Boston University School of Medicine, Boston, Mass.
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