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

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.

Preventive use of intra-aortic balloon pump in patients undergoing high-risk coronary artery bypass grafting: a retrospective study

Background

Coronary artery bypass grafting (CABG) is an important therapeutic measure for CHD patients. The patients who score more than 12 EuroSCORE points cannot achieve good results because of their low cardiac output and delicate left ventricular function. Therefore, use of an intra-aortic balloon pump (IABP) is essential for coronary surgical patients in the peri-operative period. At present, there is no unified standard about when to insert an IABP. This study aimed to compare the short-term clinical outcomes of the IABP inserted in the preoperative condition with its use in the emergency condition for extremely high-risk patients.

Material/Methods

IABP support time, respirator support time, and ICU stay time were significantly shorter (all p<0.05) in the preoperative IABP group compared to the emergency IABP group, and the rates of low cardiac output syndrome (LCOS), acute myocardial infarction, and acute kidney injury in the preoperative group were also significantly lower in the preoperative IABP group (all p<0.05). There were no significant differences in IABP-related complications and the mortality (p=0.106) between two groups.

Results

Compared to the emergency IABP group, the IABP support time, respirator support time and ICU stay time were significantly lower in the preoperative IABP group (all p<0.05), and the rates of LCOS, acute myocardial infarction, and acute kidney injury in the preoperative group were also significantly lower (all p<0.05). There were no significant differences in IABP-related complications and the mortality (p=0.106) between the 2 groups.

Conclusions

For high-risk patients with CABG, preoperative IABP insertion is a safe and effective measure.

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.

The Use of Intra-aortic Balloon Pump in a Real-World Setting: A Comparison between Survivors and Nonsurvivors from Acute Coronary Syndrome Treated with IABP. The Jakarta Acute Coronary Syndrome Registry

Real-world data on acute coronary syndrome (ACS) patients who received intra-aortic balloon pump (IABP) support are limited. The objective of this study was to evaluate the characteristics of ACS patients who received IABP support from a real-world ACS registry. Patients with ACS (N = 121) who received IABP support were enrolled. Characteristics of survivors and nonsurvivors were compared at 30 days. Mortality rate of patients with ACS who received IABP was 47%. The survivors (N = 64) had less often cardiogenic shock (p < 0.001), more often IABP usage as back-up for a revascularization procedure (p = 0.002), less often resuscitation (p = 0.043), and less mechanical ventilator support (p < 0.001) than nonsurvivors. The nonsurvivors had a significantly higher leukocyte count (p = 0.033), a higher serum creatinine level (p < 0.001), a higher blood sugar on admission (p = 0.001), higher creatine kinase MB levels (p = 0.002), and a higher serum uric acid level (p < 0.001), but significantly lower left and right ventricular function (p = 0.014 and p = 0.003, respectively) than survivors. At 30 days, non-ST elevation (STE)-ACS patients had lower mortality rate than ST segment elevation myocardial infarction patients (log-rank test, p < 0.001), and non-STE-ACS patients who had not suffered from cardiogenic shock showed the lowest mortality rate (log-rank test, p < 0.001). By multivariate analysis, a heart rate ≥ 100 beats per minute before IABP insertion was the strongest predictor of 30-day mortality (hazard ratio = 5.69; 95% confidence interval, 1.49 to 21.78; p = 0.011). In ACS patients presenting with either cardiogenic shock, resuscitated, or patients who needed mechanical ventilation suffered from high mortality, despite the use of IABP. IABP appears to be safe and tended to be favorable in noncardiogenic shock ACS patients, particularly non-STE-ACS. A heart rate of ≥ 100 beats per minute prior to IABP insertion was the strongest predictor of 30-day mortality.

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.

Preoperative Insertion of an Intra-Aortic Balloon Pump Improved the Prognosis of High-Risk Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

This study investigated the efficacy and safety of preoperative insertion of an intra-aortic balloon pump (IABP) in high-risk coronary atherosclerotic disease patients undergoing off-pump coronary artery bypass grafting (OPCAB). A total of 232 patients were recruited to the study, of whom 107 underwent percutaneous insertion of an IABP prior to OPCAB. The remaining 125 patients underwent OPCAB alone. Pre-, peri- and postoperative parameters were compared between the two groups. Preoperative insertion of an IABP was associated with a shorter stay in intensive care, decreased incidence of postoperative dialysis and acute heart failure, and a reduction in postoperative mortality compared with OPCAB alone. There were no between-group differences in terms of haematocrit level, number of distal anastomoses, volume of postoperative drainage or incidence of reoperation for bleeding and postoperative stroke/cerebrovascular accident. In conclusion, preoperative insertion of an IABP improved the prognosis of high-risk CAD patients undergoing OPCAB.