The need for intra aortic balloon pump support following open heart surgery: risk analysis and outcome

Research progress of intra-aortic balloon counterpulsation in the treatment of acute myocardial infarction with cardiogenic shock: A review

The mortality rate of patients with acute myocardial infarction complicated with cardiogenic shock is very high, and in recent years, intra-aortic balloon counterpulsation has been used more and more. It plays a very important role in improving left ventricular ejection, increasing coronary artery perfusion pressure and reducing myocardial oxygen consumption. This article reviews the development of intra-aortic balloon counterpulsation in the treatment of acute myocardial infarction with cardiogenic shock in recent years.

The influence of intra-aortic balloon counter pulsation on central venous blood oxygen saturation

OBJECTIVES

We aim at identifying the changes in venous blood saturation values that associates intra-aortic balloon pump (IABP) in cardiac surgery patients with reduced left ventricular function (LVF).

METHODS

A retrospective observational study was conducted in a cardiothoracic intensive care unit (CTICU) in a tertiary cardiac center over 5 years in Qatar. A total of 114 patients with at least moderate impairment of LVF with ejection fraction (EF) less than 40% were enrolled. According to the association of IABP, patients were segregated into two groups with and without IABP (groups 1, 40 patients and group 2, 74 patients). Sequential arterial and venous blood gases were analyzed. The primary outcome was to analyze the changes in the central venous saturation (ScvO₂) in both groups and the secondary outcome was to analyze whether these changes affect the overall outcome in terms of intensive care unit (ICU) length of stay.

RESULTS

There was no significant difference between both groups with regard to age, preoperative EF, hemoglobin, and arterial oxygen saturation (SaO₂) in blood gases. Patients with IABP have a higher cScvO₂ when compared to the other group (71.5 ± 12.5 vs 63.5 ± 9.3, 68.3 ± 12.6 vs 60.1 ± 9.5, 62.7 ± 10.8 vs 55.63 ± 8.1, and 60.6 ± 7.6 vs 54.9 ± 8.1; p = 0.04, 0.05, 0.03, and 0.5, respectively). However, generalized estimating equations (GEE) analysis showed that compared with the participants showing that there is a decreasing trend in mean levels within the groups during follow-ups, overall difference between both groups' mean levels was not statistically significant.

CONCLUSIONS

In this study, we observed that after cardiac surgeries, patients with IABP had non-significant higher ScvO₂ when compared with a corresponding group with moderate impairment of LVF. Further prospective studies are required to validate these findings.

The early and long-term outcomes of coronary artery bypass grafting added to aortic valve replacement compared to isolated aortic valve replacement in elderly patients: a systematic review and meta-analysis

In aged population, the early and long-term outcomes of coronary revascularization (CABG) added to surgical aortic valve replacement (SAVR) compared to isolated SAVR (i-SAVR) are conflicting. To address this limitation, a meta-analysis comparing the early and late outcomes of SAVR plus CABG with i-SAVR was performed. Electronic databases from January 2000 to November 2021 were screened. Studies reporting early-term and long-term comparison between the two treatments in patients over 75 years were analyzed. The primary endpoints were in-hospital/30-day mortality and overall long-term survival. The pooled odd ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated for in-early outcome and long-term survival, respectively. Random-effect model was used in all analyses. Forty-four retrospective observational studies reporting on 74,560 patients (i-SAVR = 36,062; SAVR + CABG = 38,498) were included for comparison. The pooled analysis revealed that i-SAVR was significantly associated with lower rate of early mortality compared to SAVR plus CABG (OR = 0.70, 95% CI 0.66–0.75; p < 0.0001) and with lower incidence of postoperative acute renal failure (OR = 0.65; 95% CI 0.50–0.91; p = 0.02), need for dialysis (OR = 0.65; 95% CI 0.50–0.86; p = 0.002) and prolonged mechanical ventilation (OR = 0.57; 95% CI 0.42–0.77; p < 0.0001). Twenty-two studies reported data of long-term follow-up. No differences were reported between the two groups in long-term survival (HR = 0.95; 95% CI  0.87–1.03; p = 0.23). CABG added to SAVR is associated with worse early outcomes in terms of early mortality, postoperative acute renal failure, and prolonged mechanical ventilation. Long-term survival was comparable between the two treatments.

Pre-operative, Intraoperative, and Post-operative Determinants Associated with 30-day Mortality Post-Coronary Artery Bypass Graft: A Retrospective Cohort Study

Abstract Background: Various determinants of 30-day mortality risk in CABG patients have been formulated into certain scoring models such as the EuroSCORE and ACEF model. However, these models only consider preoperative parameters while excluding intraoperative, postoperative, and perioperative parameters. Currently, the prior research has increasingly emphasized the role of these excluded parameters as determinants of post-CABG mortality. Furthermore, there are differences in mortality rate of CABG procedures in Indonesia when compared with other countries. Hence, this study aimed to identify preoperative, intraoperative, and postoperative determinants of 30-day mortality after CABG surgery in Indonesian population. Methods: In this retrospective cohort study, secondary data were obtained from the medical records of 263 patients aged ≥ 18 years who underwent CABG at a single center in Indonesia during the year 2012–2015. Selected preoperative, intraoperative, postoperative, and perioperative determinants were analyzed in both bivariate and multivariate Cox regression models to identify determinants associated with 30-day mortality. Results: The 30-day mortality rate after CABG was 11.8%. Multivariate analysis identified neurological dysfunction (HR 6.16; 95% CI 2.42-15.66), renal impairment (HR 3.9; 95% CI 1.46-10.38), left ventricle dysfunction (HR 3.53;95% CI 1.55-8.03), aortic clamp duration (HR 3.7;95% CI 1.53-8.96), surgery duration (HR 3.85;95% CI 1.39-10.70), postoperative thrombocytopenia (HR 3.99;95% CI 1.72-9.23), and postoperative intra-aortic balloon pump (HR 10.98; 95% CI 4.77-25.28) as significant determinants associated with 30-day mortality after CABG Conclusions: Neurological dysfunction, renal impairment, left ventricle dysfunction, aortic clamp duration, surgery duration, postoperative thrombocytopenia, and postoperative intra-aortic balloon pump were independent determinants for 30-day mortality after CABG.

Perioperative incidence of ECMO and IABP on 5901 mitral valve surgery procedures

Background

Report the incidence and results of peri-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) of patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) and conventional full sternotomy (FS) for a period of 6 years from eleven tertiary Cardiac Surgery Institutes of GVM Care & Research Italia.

Methods

From January 2016 to November 2021, a total of 5901 consecutive patients underwent MVS through RT and FS. The primary outcome of the study was the mortality and incidence of low cardiac output syndrome (LCOS) treated with intra-aortic balloon pump (IABP) with or without inotropic support and the incidence of Postcardiotomy Cardiogenic Shock (PCS) treated with Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) on patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) versus conventional full sternotomy (FS).

Results

The mean age was 66 ± 15 years, 3389 patients underwent in RT approach 2512 in FS, 3081 (52%) patients were male and 2.3% had previous cardiac operations. Cardiopulmonary bypass time was 93 min for RT and 81 min for FS and cross clamp time 75 min for RT and 63 min for FS for mitral valve repair. Incidence of perioperative IABP for the treatment of low cardiac output was reported on 99 patients (1.6%), 51 for RT (1.5%), 35% used inotropic support (adrenaline and milrinone) and 48 in FS (1.9), 28% use inotropic support, 21 patients died after IABP (3 RT and 18 FS). Incidence of perioperative VA-ECMO for the PCS treatment was 13 and 4 with IABP, 9 RT (0.2%) and 4 FS approach (0.15%), 12 patients died after VA-ECMO.

Conclusion

Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity. ECMO and IABP incidence for the treatment of PCS was 0.2% and for Low cardiac output syndrome (LCOS) was 1.6% in elective mitral valve surgery is very low. The patients that use the perioperative IABP in minimally invasive mitral valve surgery (MIMVS) trough RT reported a reduced mortality compared to FS in relation to the operative risk and surgical technique. Low incidence of VA-ECMO was found in RT and FS approach, only one patient survived after VA-ECMO after minimally invasive mitral valve surgery.

Perioperative incidence of ECMO and IABP on 5901 mitral valve surgery procedures

BACKGROUND

Report the incidence and results of peri-operative extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) of patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) and conventional full sternotomy (FS) for a period of 6 years from eleven tertiary Cardiac Surgery Institutes of GVM Care & Research Italia.

METHODS

From January 2016 to November 2021, a total of 5901 consecutive patients underwent MVS through RT and FS. The primary outcome of the study was the mortality and incidence of low cardiac output syndrome (LCOS) treated with intra-aortic balloon pump (IABP) with or without inotropic support and the incidence of Postcardiotomy Cardiogenic Shock (PCS) treated with Veno-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) on patients undergoing mitral valve surgery (MVS) through right mini-thoracotomy (RT) versus conventional full sternotomy (FS).

RESULTS

The mean age was 66 ± 15 years, 3389 patients underwent in RT approach 2512 in FS, 3081 (52%) patients were male and 2.3% had previous cardiac operations. Cardiopulmonary bypass time was 93 min for RT and 81 min for FS and cross clamp time 75 min for RT and 63 min for FS for mitral valve repair. Incidence of perioperative IABP for the treatment of low cardiac output was reported on 99 patients (1.6%), 51 for RT (1.5%), 35% used inotropic support (adrenaline and milrinone) and 48 in FS (1.9), 28% use inotropic support, 21 patients died after IABP (3 RT and 18 FS). Incidence of perioperative VA-ECMO for the PCS treatment was 13 and 4 with IABP, 9 RT (0.2%) and 4 FS approach (0.15%), 12 patients died after VA-ECMO.

CONCLUSION

Minimally invasive mitral valve surgery is a safe and reproducible approach associated with low mortality and morbidity. ECMO and IABP incidence for the treatment of PCS was 0.2% and for Low cardiac output syndrome (LCOS) was 1.6% in elective mitral valve surgery is very low. The patients that use the perioperative IABP in minimally invasive mitral valve surgery (MIMVS) trough RT reported a reduced mortality compared to FS in relation to the operative risk and surgical technique. Low incidence of VA-ECMO was found in RT and FS approach, only one patient survived after VA-ECMO after minimally invasive mitral valve surgery.

Myocardial protection: a forgotten modality

The goals of a cardiac surgical procedure are both technical excellence and complete protection of cardiac function. Cardioplegia is used almost universally to protect the heart and provide a quiet bloodless field for surgical accuracy. Yet, despite the importance of myocardial protection in cardiac surgery, manuscripts or dedicated sessions at major meetings on this subject have become relatively rare, as though contemporary techniques now make them unnecessary. Nevertheless, septal dysfunction and haemodynamic support (inotropes, intra-aortic balloon pump, assist devices) are common in postoperative patients, indicating that myocardial damage following cardiac surgery is still prevalent with current cardioplegic techniques and solutions. This article first describes why cardiac enzymes and septal function are the ideal markers for determining the adequacy of myocardial protection. It also describes the underappreciated consequences of postoperative cardiac enzyme release or septal dysfunction (which currently occurs in 40-80% of patients) from inadequate protection, and how they directly correlate with early and especially late mortality. Finally, it reviews the various myocardial protection techniques available to provide a detailed understanding of the cardioplegic methods that can be utilized to protect the heart. This will allow surgeons to critically assess their current method of protection and, if needed, make necessary changes to provide their patients with optimal protection.

Midterm outcome of off-pump CABG for severe LV dysfunction-Does LV size and function predict their midterm outcome?

BACKGROUND

The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce.

MATERIALS AND METHODS

A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed.

RESULTS

The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts-3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR, 88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868) and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676).

CONCLUSION

OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes, albeit with high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.

Frequency of intra-aortic balloon pump insertion and associated factors in coronary artery bypass Grafting in a tertiary care hospital

Objective

To find the incidence of intra-aortic balloon pump (IABP) induction and factors associated with its insertion in coronary artery bypass grafting (CABG).

Methods

This retrospective observational non interventional study was conducted at Cardiac Surgery Department, North West General Hospital and Research Center, Peshawar from December 2018 to March 2020. The total sample size was 360 patients who underwent coronary artery bypass grafting (CABG). The research was piloted in the cardiac operation theatre then cardiac intensive care unit (CICU) of Northwest General Hospital and Research center Hayatabad Peshawar. Data was collected from 360 patients scheduled for CABG. Total numbers of patients in whom IABP was inserted and factors associated with IABP insertions were noted. All the information was collected on a specifically prepared Form. Data was entered and evaluated in statistical package for social sciences form 25.

Results

In this study, a total of 360 patients were observed who underwent coronary artery bypass grafting (CABG). We determined the frequency of IABP induction and the factors related to it. Gender distribution among patients who were assisted with IABP was 43% female and 57% male. IABP induction was done for most of moderately to severely reduced ejection fraction patients. Other factors related to patients who required IABP support were previous myocardial infarction 100%, hypertension 86%, diabetes mellitus 64%, coronary end-arterectomy 21% and smoking 7%. The results were analyzed. We have used the (SPSS) version 25 and Chi-square test for analysis in which the P-value less than 0.00001 is statistically significant.

Conclusion

Incidence of insertion of IABP among CABG population was 3.9% in our hospital. It is an essential support to post CABG patient with left ventricular dysfunction after cardiopulmonary bypass with moderate to severely reduced ejection fraction, Myocardial infarction, hypertension, diabetes mellitus. Smoking and endarterectomy were not significantly related to IABP induction in our study. Multicenter study is still required to find out the other factors governing the IABP insertion.

Characteristics, morbidity and mortality factors associated with Intra-Aortic Balloon Pump in Coronary Artery Bypass Graft Surgery patients

Objective:

The aim of our study is to analyze the characteristics, morbidity and mortality of patients requiring an Intra-Aortic Balloon Pump (IABP) in Coronary Artery Bypass Grafting (CABG).

Methods:

An analysis was done on the prospectively collected data of 1216 patients who had CABG in our center between July, 2017 and May, 2019 at our hospital. We categorized patients in to an IABP and non-IABP group on the basis of IABP use. We then compared the pre-operative, per-operative and post-operative characteristics of the two groups. We further stratified the patients according to pre-op ejection fraction (EF).

Results:

Out of 1216 patients, 135(11.10%) patients required an IABP. 70(51.9%) patients of IABP group and 699(64.7%) patients of non-IABP group had hypertension (p-value 0.0036). 23.0% had previous myocardial infarction (MI) in the IABP group and 13.8% had prior myocardial infarction (MI) in non-IABP group (p-value 0.0463). Among the patients requiring an IABP, 21(15.5%) of patients had normal EF (>50%) (P-value<0.0001), 72 (53.3%) had EF 35-50%, and 41(30.3%) patients had EF<35% (p-value <0.0001). Mortality of IABP group (19.3%) was greater than non-IABP group (2.4%) (P-value 0.00001).

Conclusions:

Use of IABP increased as the EF decreased. Rate of post-operative stroke, prolonged ICU stay, prolonged ventilation, re-opening due to bleeding and mortality was seen to be significantly higher in the IABP group.

Ultrasound-guided insertion of intra-aortic balloon counterpulsation in intensive care: description of the technique

Intra-aortic balloon counterpulsation (IAoBC) is a mechanical circulatory support device that has been used for more than 50 years, mainly for cardiogenic shock. Although its effect on mortality is controversial, IAoBC is still used in a wide variety of pre- and postoperative clinical settings in cardiac surgery centers. IAoBC has a complication rate of approximately 30%, mostly associated with problems during insertion and malpositioning. Thus, an insertion technique based on the use of ultrasound at the patient's bedside in the intensive care unit (ICU) is proposed.

Outcome analysis for prediction of intraaortic balloon pump support failure and long-term survival in high-risk patients undergoing mitral valve surgery

The outcome predictors of intra-aortic balloon pump (IABP) in patients who undergo mitral valve surgery remain unknown. This study aimed to retrospectively review valvular surgery in patients who received an IABP to identify the predictors of failure of IABP support and anticipate the necessary therapy. This retrospective observational study recruited a total of 157 consecutive patients who underwent open-heart mitral valve surgery with IABP implantation intraoperatively or postoperatively. Univariate and multivariate logistic regression analyses were performed to identify the risk factors attributed to 30-day mortality. Follow-up data of survivors were collected to investigate the effect of IABP support to evaluate long-term outcomes. The overall 30-day mortality was 35.7% (56 patients). The following factors that contributed to 30-day mortality included sepsis (P < .001, OR: 5.627, 95%CI: 2.422-11.683); IABP implantation postoperatively rather than intraoperatively (P = .001, OR: 6.395, 95%CI: 2.085-19.511); right heart failure (P = .042, OR: 3.419, 95%CI: 1.225-12.257); and lack of subvalvular apparatus preservation (P = .033, OR: 3.710, 95%CI: 1.094-13.167). Furthermore, follow-up data of these patients showed an estimation of 5-year and 10-year survival rates of 58.9% and 35.7%, respectively. Patients with intraoperative IABP demonstrated better long-term survival outcomes when compared to those with postoperative IABP (χ²  = 4.291, P = .038). In summary, this study distinguished the preoperative predictors of 30-day mortality of IABP-support in mitral valve surgery patients. These results indicated that early intervention with IABP should be taken into consideration in case of hemodynamic instability in critically ill patients undergoing mitral valve surgery.

Outcomes after intra-aortic balloon pump insertion in cardiac surgery patients

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.

The use of prophylactic intra-aortic balloon pump in high-risk patients undergoing coronary artery bypass grafting

Objective

Intra-aortic balloon pump (IABP) is one of the most commonly used mechanical circulatory assist devices for high-risk patients undergoing cardiac surgery. In an effort to validate previously reported clinical outcomes, we describe the preoperative characteristics and outcomes of patients who underwent prophylactic IABP in high-risk patients undergoing coronary artery bypass grafting (CABG).

Design

A prospective observational study

Methods

From 2005 to 2017, 471 patients underwent either isolated or combined CABG at our institution. Of those, 393 patients underwent isolated CABG and were included for the analysis. Eighty-five patients (22%) were considered high-risk and underwent prophylactic IABP, with subsequent review of surgical morbidity and mortality rates.

Results

The 30-day postoperative mortality (prophylactic IABP group vs non prophylactic IABP group: 0% vs 1.6%, p = 0.589) and major adverse cardiac or cerebrovascular events (5.9% vs 3.3%, p = 0.333) were not significantly different between the two groups. Prolonged mechanical ventilation (>72 hours) (12.5% vs 4.2%, p = 0.014) occurred more frequently in the prophylactic IABP group.

Conclusions

No IABP-related complications were noted, emphasizing that the use of prophylactic IABP in high-risk patients undergoing CABG is an acceptable option.

Intra-aortic balloon pump experience: a single center study comparing with and without sheath insertion

Introduction: The mechanical circulation support used in treatment of low cardiac output at most is the intra-aortic balloon pump (IABP). Its usage fields are the complications occurring due to ischemic heart disease, disrupted left ventricle function, and the low cardiac output syndrome occurring during coronary artery by-pass surgery.

Methods: During 28 years from 1985 to 2013, IABP support has been implemented to 3135 patients in our cardiac surgery operating theater and intensive care unit. The mean age of the patients was 61.4 ± 13.2 years (16-82). 2506 patients (80%) were the ones whom the cardiac surgery has been implemented. IABP support has been provided for 629 (20%) patients for medical treatment. We utilized IABP most frequently in coronary artery patients (70%). The first choice for placing the balloon catheter is the femoral artery in 3093 cases (98.7%).

Results: The most frequently observed balloon complication was the lower extremity ischemia in 383 cases (12.2%).The leg ischemia was statistically significantly more frequent in patients with sheath (P=0.004). The extremity ischemia has developed in 4 of 12 patients with balloon placed from upper extremity. The local bleeding and balloon rupture were more frequent in patients whom the balloon has been placed without sheath. The mortality due to IABP has occurred in only 5 patients.

Conclusion: Despite increase in IABP usage frequency rapidly, the complications due to catheter are still seen. We believe that the leg ischemia that is the most frequently seen complication can be prevented via IABP use without sheath.

Risk of conventional cardiac surgery among patients with severe left ventricular dysfunction in the era of mechanical circulatory support

BACKGROUND

Despite suggestions that severe left ventricle dysfunction may warrant selection of durable mechanical circulatory support over conventional surgery, comparative studies are lacking due to incomplete characterization of patients at highest risk after conventional surgery. We sought to define subsets of patients with severe left ventricle dysfunction who are at greatest mortality risk following conventional cardiac surgery.

METHODS

We studied 892 patients aged ≥ 18 years who underwent conventional coronary or valve surgery from 1993 to 2014, with preoperative ejection fraction ≤ 25%. Exclusions were transcatheter interventions, major concomitant procedures, active endocarditis, and prior/concurrent durable mechanical circulatory support use. Logistic and Cox regression identified determinants of early and late mortality.

RESULTS

Median age was 70 years (interquartile range, 62-76 years), 46% (n = 411) had New York Heart Association (NYHA) functional class IV symptoms, and 16% (n = 142) had undergone prior surgery. Operative mortality was 7.5%. NYHA functional class IV (odds ratio [OR], 1.88; P = .033), prior cardiac surgery (OR, 2.13; P = .017), peripheral vascular disease (OR, 2.55; P = .001), emergency status (OR, 2.68; P = .024), and intra-aortic balloon pump use (OR, 4.95; P < .001) independently predicted operative death. Risk imparted by presence of both NYHA functional class IV symptoms and prior surgery was additive, with a 4-fold increase in early mortality risk (OR, 3.95; P = .003). Prior surgery increased the hazard of late death by 60% (P < .001). In patients without prior surgery, late mortality was greatest in those aged ≥ 70 years (hazard ratio, 1.86; P < .001), especially if NYHA functional class IV symptoms were concurrently present (hazard ratio, 2.25; P < .001). Surgery type (coronary artery bypass graft surgery, aortic valve surgery, or mitral valve surgery) did not predict long-term outcome.

CONCLUSIONS

In patients referred for conventional surgery with an ejection fraction ≤ 25%, prior cardiac surgery, and/or NYHA functional class IV symptoms-particularly in those aged ≥ 70 years-confer significant and sustained survival disadvantages. Such high-risk subsets may benefit from durable mechanical circulatory support consideration.

Outcomes of Coronary Artery Bypass Graft Surgery Versus Percutaneous Coronary Intervention in Patients Aged 18-45 Years with Diabetes Mellitus

BACKGROUND

Debate on treatment for young patients with coronary artery disease still exists. This study aimed to investigate the intermediate- and long-term outcomes between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients aged 18-45 years with diabetes mellitus (DM).

METHODS

Between January 2006 and March 2016, a total of 2018 DM patients aged 18-45 years including 517 cases of CABG and 1501 cases of PCI were enrolled in the study. Using propensity score matching (PSM), 406 patients were matched from each group. The intermediate- and long-term data were collected. The primary end point of this study was long-term death. The secondary end points included long-term major adverse cardiovascular and cerebrovascular events (MACCEs), stroke, angina, myocardial infarction (MI), and repeat revascularization.

RESULTS

Before PSM, the in-hospital mortality was 1.2% in the CABG group and 0.1% in the PCI group, with statistically significant difference (P < 0.0001). The 10-year follow-up outcomes including long-term survival rate and freedom from MACCEs were better in the CABG group than those in the PCI group (97.3% vs. 94.5%, P = 0.0072; 93.2% vs. 86.3%, P < 0.0001), but CABG group was associated with lower freedom from stoke compared to PCI group (94.2% vs. 97.5%, P = 0.0059). After propensity score-matched analysis, these findings at 10-year follow-up were also confirmed. Freedom from MACCEs was higher in CABG group compared to PCI group, but no significant difference was observed (93.1% vs. 89.2%, P = 0.0720). The freedom from recurrent MI was significantly higher in CABG patients compared with PCI patients (95.6% vs. 92.5%, P = 0.0260). Furthermore, CABG was associated with a higher rate of long-term survival rate than PCI (97.5% vs. 94.6%, P = 0.0403). There was no significant difference in the freedom from stroke between CABG and PCI groups (95.3% vs. 97.3%, P = 0.9385). The hospital cost was greater for CABG (13,936 ± 4480 US dollars vs. 10,926 ± 7376 US dollars, P < 0.0001).

CONCLUSIONS

In DM patients aged 18-45 years, the cumulative survival rate, and freedom from MI and repeat revascularization for CABG were superior to those of PCI. However, a better trend to avoid stroke was observed with PCI.

Levosimendan in patients with left ventricular systolic dysfunction undergoing cardiac surgery on cardiopulmonary bypass: Rationale and study design of the Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial

BACKGROUND

Low cardiac output syndrome is associated with increased mortality and occurs in 3% to 14% of patients undergoing cardiac surgery on cardiopulmonary bypass (CPB). Levosimendan, a novel calcium sensitizer and K_ATP channel activator with inotropic, vasodilatory, and cardioprotective properties, has shown significant promise in reducing the incidence of low cardiac output syndrome and related adverse outcomes in patients undergoing cardiac surgery on CPB.

METHODS

LEVO-CTS is a phase 3 randomized, controlled, multicenter study evaluating the efficacy, safety, and cost-effectiveness of levosimendan in reducing morbidity and mortality in high-risk patients with reduced left ventricular ejection fraction (≤35%) undergoing cardiac surgery on CPB. Patients will be randomly assigned to receive either intravenous levosimendan (0.2 μg kg^-1 min^-1 for the first hour followed by 0.1 μg/kg for 23hours) or matching placebo initiated within 8hours of surgery. The co-primary end points are (1) the composite of death or renal replacement therapy through day 30 or perioperative myocardial infarction, or mechanical assist device use through day 5 (quad end point tested at α<.01), and (2) the composite of death through postoperative day 30 or mechanical assist device use through day 5 (dual end point tested at α<.04). Safety end points include new atrial fibrillation and death through 90days. In addition, an economic analysis will address the cost-effectiveness of levosimendan compared with placebo in high-risk patients undergoing cardiac surgery on CPB. Approximately 880 patients will be enrolled at approximately 60 sites in the United States and Canada between July 2014 and September 2016, with results anticipated in January 2017.

CONCLUSION

LEVO-CTS, a large randomized multicenter clinical trial, will evaluate the efficacy, safety, and cost-effectiveness of levosimendan in reducing adverse outcomes in high-risk patients undergoing cardiac surgery on CPB.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT02025621).

IABP: history-evolution-pathophysiology-indications: what we need to know

Treatment with the intraaortic balloon pump (IABP) is the most common form of mechanical support for the failing heart. Augmentation of diastolic pressure during balloon inflation contributes to the coronary circulation and the presystolic deflation of the balloon reduces the resistance to systolic output. Consequently, the myocardial work is reduced. The overall effect of the IABP therapy is an increase in the myocardial oxygen supply/demand ratio and thus in endocardial viability.

This is an overall synopsis of what we need to know regarding IABP. Furthermore, this review article attempts to systematically delineate the pathophysiology linked with the hemodynamic consequences of IABP therapy. The authors also look at the future of the use of the balloon pump and conclude that the positive multi-systemic hemodynamic regulation during IABP treatment should further justify its use.

Is Intra-Aortic Balloon Pump Counterpulsation Sufficient to Treat Patients in Cardiogenic Shock, Undergoing Primary Percutaneous Coronary Intervention

Background

A high number of patients do not survive primary percutaneous coronary intervention (PCI) complicated by cardiogenic shock (CS), even when assisted with intra-aortic balloon pump (IABP) counterpulsation. There is no accepted consensus on who may most benefit from IABP counterpulsation, although previous retrospective studies have reported predictors of survival for patients undergoing PCI and cardiac surgery. To date, a risk model for emergency primary PCI patients has not been ascertained. The objective of this study was to identify independent predictors for in-hospital survival, to create a standardized risk model to predict patients who may require IABP insertion during primary PCI.

Method

Retrospective data were from 165 patients who had undergone primary PCI with IABP due to CS complicating acute myocardial infarction (AMI), from September 2007 to 2010, and underwent logistic regression analysis, to evaluate the incremental risk factors associated with survival.

Results

The overall in-hospital mortality was 32.1% (53 patients). The incremental independent predictors for in-hospital survival were: patient age of less than 60 years (OR: 0.303, 95% CI: 0.11 - 0.83, P < 0.02) and the use of IABP support alone, as opposed to in adjunction with inotropic support (OR: 3.177, 95% CI: 1.159 - 8.708, P < 0.025).

Conclusion

This study illustrated an age of less than 60 years, and the use of IABP alone, to be independent predictors of in-hospital survival in patients with CS complicating AMI who undergo primary PCI assisted by IABP. No specific risk model could be determined.

Evaluation of Persistent Organ Dysfunction Plus Death As a Novel Composite Outcome in Cardiac Surgical Patients

OBJECTIVES

Validated composite outcomes after complicated cardiac surgery are poorly established. Therefore, the authors evaluated a novel composite endpoint, persistent organ dysfunction (POD)+death, which is defined as any need for life-sustaining therapies or death at any time within 28 days from surgery.

DESIGN

Secondary analysis extracted from a large-scale prospective randomized trial of critically ill cardiac surgery patients.

SETTING

Multi-institutional, university hospitals.

PARTICIPANTS

Ninety-five cardiac surgery patients with complicated postoperative courses.

INTERVENTIONS

Cardiac surgery with cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

At 28 days following surgery, the prevalence of POD was 15%, and 23% of patients had died (POD+death = 38%). Patients alive with POD at day 28 exhibited a significantly higher extent of organ injury and longer ICU (33 v 7 days; p<0.001) and hospital lengths of stay (49 v 21 days; p<0.001) compared to patients without POD at day 28. At 3 and 6 months, quality-of-life scores (by Short Form 36 questionnaire) showed a significantly reduced rating for most components in patients with POD at day 28 compared to those without POD. The 6-month mortality rate was 21% among patients alive with POD at day 28 compared to 5% among patients alive without POD (p = 0.05). The calculated number of patients needed per arm to detect a 25% relative risk reduction for mortality alone was 762 compared to 386 per arm for POD+ death.

CONCLUSIONS

POD+death at day 28 following cardiac surgery may be a valid composite endpoint and offers statistical efficiencies in terms of sample size calculations for cardiac surgical trials.

Counterpulsation: a concept with a remarkable past, an established present and a challenging future

The intra-aortic balloon pump (IABP), which is the main representative of the counterpulsation technique, has been an invaluable tool in cardiologists' and cardiac surgeons' armamentarium for approximately half a century. The IABP confers a wide variety of vaguely understood effects on cardiac physiology and mechano-energetics. Although, the recommendations for its use are multiple, most are not substantially evidence-based. Indicatively, the results of recently performed prospective studies have put IABP's utility in the setting of post-infarction cardiogenic shock into question. However, the particular issue remains open to further research. IABP support in high-risk patients undergoing PCI is associated with favorable long-term clinical outcome. In cardiac surgery, the use of IABP in cases of peri-operative low-output syndrome, refractory angina or ischemia-related mechanical complications is a usual, but poorly justified strategy. Anecdotal cases of treatment of incessant ventricular arrhythmias, reversal of right ventricular dysfunction and partial myocardial recovery have also been reported with its use. Converging data demonstrate the potential of safe long-term IABP support as a bridge to decision making or a bridge to transplantation modality in patients with heart failure. The feasibility of IABP insertion via other than the femoral artery sites enhances this potential. Despite the fact that several other counterpulsation devices have been developed and tested overtime none has managed to substitute the IABP, which continues to be most frequently used mechanical assist device.

Predictors of intra-aortic balloon pump insertion in coronary surgery and mid-term results

Background

We aimed to investigate the preoperative, operative, and postoperative factors affecting intra-aortic balloon pump (IABP) insertion in patients undergoing isolated on-pump coronary artery bypass grafting (CABG). We also investigated factors affecting morbidity, mortality, and survival in patients with IABP support.

Methods

Between January 2002 and December 2009, 1,657 patients underwent isolated CABG in İzmir Katip Celebi University Atatürk Training and Research Hospital. The number of patients requiring support with IABP was 134 (8.1%).

Results

In a multivariate logistic regression analysis, prolonged cardiopulmonary bypass time and prolonged operation time were independent predictive factors of IABP insertion. The postoperative mortality rate was 35.8% and 1% in patients with and without IABP support, respectively (p=0.000). Postoperative renal insufficiency, prolonged ventilatory support, and postoperative atrial fibrillation were independent predictive factors of postoperative mortality in patients with IABP support. The mean follow-up time was 38.55±22.70 months and 48.78±25.20 months in patients with and without IABP support, respectively. The follow-up mortality rate was 3% (n=4) and 5.3% (n=78) in patients with and without IABP support, respectively.

Conclusion

The patients with IABP support had a higher postoperative mortality rate and a longer length of intensive care unit and hospital stay. The mid-term survival was good for patients surviving the early postoperative period.

Heparin-free management of intra-aortic balloon pump after cardiac surgery

BACKGROUND

Anticoagulation with heparin is recommended in patients with an intra-aortic balloon pump (IABP) to prevent thrombosis and embolization. However, anticoagulation increases the risk of bleeding, particularly in the early postoperative period after cardiac surgery. We investigated the safety of heparin-free management after IABP insertion in patients who underwent cardiac surgery.

METHODS

We studied 203 consecutive patients who received perioperative IABP support between August 2004 and December 2011. All patients were managed without heparin and were followed for thrombotic and/or hemorrhagic complications.

RESULTS

Patients were divided into two groups, according to time of IABP treatment following surgery. Group I, 81 patients (39.9%) were treated less than 24 hours following surgery and Group II, 122 patients (60.1%) were treated more than 24 hours following surgery. Vascular complications developed in seven patients (3.4%), two in Group I and five in Group II. Three patients had major and four had minor limb ischemia. There were no major bleeding complications, but minor bleeding complications were observed in eight patients (4.2%).

CONCLUSION

In patients undergoing cardiac surgery with IABP support, the rate of thromboembolic complications was relatively low compared to historical controls. Heparin-free management may reduce the risk of hemorrhagic complications, with a low risk of thrombotic complications. Heparin should not be routinely used in patients requiring IABP after cardiac surgery.

Management of intra-aortic balloon pump entrapment: a case report and review of the literature

An intra-aortic balloon pump is one of the most valuable tools in the cardiac surgeon's armament to assist in the management of the failing heart. Despite its widespread use, there are associated risks and complications, one of which is balloon rupture with associated entrapment. Numerous approaches for dealing with this complication have been described; here we review the previous experience with intra-aortic balloon pump entrapment and discuss potential management, with particular reference to a recent case of our own.

Intra-aortic balloon pump in coronary artery bypass graft - factors affecting outcome

BACKGROUND

The management of coronary artery bypass graft (CABG) patients, especially in high risk patients ,can be challenging as the postoperative periods may be characterized by a low cardiac output state. Inotropes used in the perioperative periods to increase cardiac output may be detrimental thus making the use of mechanical devices like intra-aortic Balloon pump (IABP) for circulatory assistance desirable.

AIMS & OBJECTIVES

To study the use of intra-aortic balloon pump in coronary artery bypass patients in preoperative and post operative settings and factors that affect morbidity and mortality.

SETTING

Madras Medical Mission, Chennai, India.

METHOD

A retrospective study of 3974 consecutive patients who had CABG done between March 2007 and February 2011 with or without additional procedures. One hundred and seven (2.7%) patients had IABP instituted either pre-operatively or postoperatively when it was obvious the patient will need cardiac assistance. The demographic data, clinical features, the indications for insertion, management offered and outcome , the creatinine levels, the duration of intraarortic balloon pump, the intensive care unit(ICU) and Hospital stay were analyzed for means and standard deviations and Pearsons Chi-square test using SPSS 10.0 window soft ware version with significant value of p-value<0.005.

RESULT

The mean age of all the patients was 59.7 + SD 10.7, 85(79.4%) patients were males,22(20.6%) were females .Out of the 107 patient who had IABP insertion, 59(55.1%) patients had IABP inserted preoperatively and 48(44.9%) postoperatively. The creatinine levels after the insertion of IABP in 68 patients was<1.5mg/dl and in 39 patients was>1.5mg/dl with mortality of 15.0% for the preoperative insertion group versus 29.0% for the postoperative group respectively (p=0.005). The preoperative and postoperative insertion ICU stay were 8.3+4.7 days and 5.7+1.6days respectively (p=0.005) and mortality were16.8% and 27.1 %( p=0.005) respectively.

CONCLUSION

Early institution of intra-aortic balloon pump gives a better outcome even in high risk coronary artery bypass graft patients as it reduces ICU stay and mortality, and elevated post-insertion creatinine levels has been shown to be an indicator of impending mortality and so an early warning for putting in place mitigating protocols.

Imaging of mechanical cardiac assist devices

Diagnostic imaging plays an important role in the assessment of patients with mechanical cardiac assist devices. Therefore, it is important for radiologists to be familiar with the basic components, function, and radiographic appearances of these devices in order to appropriately diagnose complications. The purpose of this pictorial essay is to review indications, components, normal imaging appearances, and complications of surgically and percutaneously implanted ventricular assist devices, intra-aortic balloon pumps, and cardiac meshes.