The use of preoperative intra-aortic balloon pump in open heart surgery

AIM: Intra-aortic balloon pump (IABP) therapy before open heart surgery has been suggested for 'high risk' patients. METHODS: Records from patients undergoing open heart surgery at our institution between June 1999 and February 2002 were reviewed. Indication for IABP insertion was severely impaired left ventricular function, acute myocardial infarction (MI) or unstable angina. RESULTS: Fifty-five patients were included in the study: 41 male, 14 female, age 64+/-9 years. Fifty-one (92.7%) required coronary artery bypass brafting (CABG) alone or as a combined procedure, 2 (3.6%) required mitral valve surgery, and 2 (3.6%) needed more complex cardiac procedures. Thirty-two patients (58%) underwent emergency cardiac surgery and 11 patients (20%) suffered from acute preoperative MI. The overall 30 days mortality was 9%. Mean intensive care unit (ICU) stay was 6+/-8 days. Four patients (7.2%) developed postoperative renal failure requiring temporary hemodialysis. Three patients (5.4%) developed IABP related peripheral vascular complications. CONCLUSIONS: Perioperative morbidity and mortality is increased despite preoperative IABP, particularly in patients with acute MI. In contrast to studies not using this approach, preoperative IABP reduces morbidity and mortality of high risk patients. IABP related complications are low. Our data suggest that high risk patients profit from preoperative IABP therapy, however, prospective studies are needed to confirm these findings.     

Vascular complications of prolonged intra-aortic balloon counterpulsation in cardiac surgical patients

Background. Use of intra-aortic balloon pump (IABP) is associated with certain vascular complications, which are likely to develop more frequently in patients where IABP is used for prolonged period. The present study was undertaken to analyze vascular complications after prolonged IABP use in patients undergoing various cardiac surgical procedures. Methods. Between January 1995 and February 2001, a total of 1130 patients (7.4% of all adult patients undergoing cardiac procedures) required IABP counterpulsation, out of which 220 patients required IABP for more than 4 days. The vascular complications in these patients were studied. The IABP was inserted by percutaneous technique in 211 (95.5%) patients. The mean age of the patients was 57.5±9.5 years and 15% patients were female. The prevalence of peripheral vascular disease was 11.8%. Results. The duration of IABP therapy ranged from 5 days to 21 days with mean duration of 9.71±4.29 days. A total of 41 complications developed in 38 (17.3%) patients. Acute lower limb ischemia, requiring urgent surgical intervention, was the commonest major complication, which developed in 17 patients. This required thromboembolectomy in 11 patients and femoro-femoral bypass in 3 patients. One patient developed gangrene of the leg, requiring below knee amputation. On multivariate analysis, peripheral vascular disease, preoperative serum creatinine, surgery for LV aneurysm and unstable angina and hemodynamic instability (as the indications for IABP) were found as the predictors of vascular complications. Conclusions. Prolonged use of IABP counterpulsation is associated with significant incidence of vascular complications. Proper assessment of peripheral circulation before IABP insertion and appropriate management of ischemic complications are important to avoid limb loss to the patient.     

Hemostatic assessment of patients undergoing intraaortic balloon pump therapy

Patients undergoing intraaortic balloon pump (IABP) therapy are at risk for developing coagulopathies due to the adverse effects of prolonged exposure of the synthetic surface of the polyurethane balloon to blood components. Hemorrhagic risk has been attributed to a number of factors including thrombocytopenia, vascular injury, and/or platelet degranulation which increase the potential of receiving autogeneic blood transfusions. The present study is a prospective evaluation of coagulation using a viscoelastic monitor (Thrombelastograph--TEG) that measures functional aspects of clot development and stabilization in patients being treated with IABP therapy. Following Institutional Review Board approval, six patients undergoing IABP therapy for hemodynamic instability were enrolled in this study. Blood samples were taken prior to balloon insertion, at 8, 16, 24, 48, 72, and 96 hours on IABP therapy, and 24 hours following the removal of the balloon when applicable. Samples were incubated with heparinase to degrade heparin and TEG profiles were subsequently determined in duplicate. Measured parameters on the TEG included R-time, K-time, maximum amplitude, alpha angle, and lysis at 30 and 60 minutes with calculation of the TEG index. Mortality was 33% following IABP discontinuation. Transfusion of packed red blood cells occurred in 50% of the patients during their balloon pump therapy. Patients demonstrated a significant deviance in fibrinolytic potential from pre-IABP lysis (1.6% +/- 1.8) at both 24 hours (18.8% +/- 22.9) and 48 hours (21.9% +/- 28.5) of therapy (p < 0.05) which returned to baseline shortly after balloon removal. Activation of coagulation factors appeared evident by a steadily increasing alpha angle from pre-IABP data (3.1 +/- 9.2) throughout the duration of therapy and 24 hour recovery (53 +/- 14; p < .005), and by a steadily trending increase in the TEG index pre-IABP (.251 +/- 1.4) to post-IABP (2.6 +/- 1.7; p < 0.05). The results indicate that IABP therapy induces an increase in fibrinolytic potential at 24 to 48 hours of balloon pump therapy with a paradoxical trend toward increased coagulability, potentially predisposing the patient to hemorrhagic risk.     

Vascular complications following intra-aortic balloon pump insertion.

The intra-aortic balloon pump (IABP) has been used for 23 years to treat cardiogenic shock from various causes. A retrospective review was conducted to evaluate the morbidity, mortality, and risk factors associated with insertion of this device. Over a recent 3-year period, 415 such pumps were inserted either by percutaneous (323) or cut-down (92) technique in 404 patients. Indications for placement included intraoperative pump failure (46%), cardiac instability before coronary artery bypass grafting (28%), perioperative support (13%), cardiac transplantation (7%), and cardiogenic shock (6%). Noncardiac vascular complications occurred in 67 patients, 55 per cent of whom required surgical correction. Operative procedures included femoral artery thrombectomy, bypass grafting, fasciotomy, and amputation. Major risk factors for vascular complications included diminished or absent femoral pulses on initial examination, being a woman, and obesity. In patients with known peripheral vascular disease, the risk of a vascular complication was 17.9 per cent when a surgical cut-down technique was used to insert the IABP, and 38.9 per cent when a percutaneous insertion was performed. The mortality doubled in those patients who had a vascular complication as compared to those who did not (34% vs 17%). A more liberal use of an open surgical technique in those patients with peripheral vascular disease, obesity, and who are women may help to reduce complications after the insertion of the intra-aortic balloon pump.     

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

Abstract 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. (J Card Surg 2012;27:434‐437)     

In Which Patients Should Sheathless IABP be Used? An Analysis of Vascular Complications in 1211 Cases

OBJECTIVE: The purpose of our study is to compare the results of the sheathed and sheathless techniques for intraaortic balloon pump (IABP) insertion and to determine the rate of vascular complications in both conditions. METHODS: A total of 1211 patients were examined representing a period of 19 years. Three hundred five sheathless (Group I) and 906 sheathed (Group II) IABP catheters were evaluated retrospectively. Data were analyzed with univariate analysis and logistic regression. Relative risk (RR) values were calculated in order to examine the effect of sheath. RESULTS: Limb ischemia was seen in 129 patients (10.9%). Although the incidence of peripheral arterial disease (PAD) was relatively higher in Group I (11.1% vs. 3.6%), the ischemic complication rate was lower in Group I (5.2% vs. 12.4%; p = 0.001). Presence of PAD (p = 0.001) and diabetes mellitus (DM) (p = 0.007) was found to be the risk factors of ischemia related to IABP use in all cases. In logistic regression analysis, presence of PAD, DM, and sheathed method was found to be the risk factors of ischemia. The patients who had all of these risk factors suffered from limb ischemia (RR value: 35.17). CONCLUSION: PAD, DM, and sheathed insertion technique are the major risk factors of ischemia during IABP use. Among all these risk factors, the only modifiable risk factor is the use of introducer sheath. With the presence of PAD and DM, the choice of sheathed method would increase the probability of ischemia almost 35 times. Sheathless method of insertion should be preferred in patients with DM and PAD.     

Vascular complications of the intraaortic balloon pump in patients undergoing open heart operations: 15-year experience

BACKGROUND: The beneficial effects of the intraaortic balloon pump (IABP) in providing circulatory support must be weighed against its complications, particularly its vascular trauma. METHODS: Five hundred nine patients who underwent open heart operations at our institution and who were treated with the IABP from January 1980 through December 1994 were studied retrospectively to assess IABP-related vascular complications and their independent preoperative predictors and the implications of IABP-related vascular complications on the patients' mortality, morbidity (clinical sepsis and organ failure), and long-term survival. RESULTS: Early vascular complications occurred in 56 patients (11%) and major complications occurred in 41 patients (8%). The latter consisted of aortic perforation in 1 patient, aortoiliac dissection in 2 patients, and limb ischemia in 38 patients. Logistic regression analysis identified concomitant peripheral vascular disease (p<0.001), elevated preoperative end-diastolic pressure, small body surface area, and large catheter size (p<0.05) as independent risk factors for IABP-related major vascular complications in patients who survived the day of operation. Late IABP-related sequelae occurred in 10 patients, 9 of whom had had early vascular complications. The presence of vascular complications per se was not a significant independent factor among other risk factors for mortality, morbidity, or long-term survival. CONCLUSIONS: Careful clinical assessment of the aortofemoral vascular tree is a cornerstone of early diagnosis and early intervention and usually prevents limb loss. The significant decrease in major vascular complications that has occurred over the last 5 years can be explained by the increased use of catheters with smaller diameters. The timing of IABP insertion in relation to operation and the duration of IABP use were the only device-related risk factors identified for morbidity and survival.     

Early mortality predictors in coronary artery bypass grafting patients required intra-aortic balloon pump in perioperative and postoperative periods

AIM: The intra-aortic balloon pump (IABP) is commonly used for decreasing myocardial oxygen demand by systolic unloading in perioperative heart failure. The aim of this study was to determine perioperative prognostic factors for in-hospital mortality in coronary artery bypass grafting patients who received the intraaortic balloon pump. METHODS: A total of 271 patients who underwent coronary artery bypass grafting and received intra-aortic balloon pump perioperatively between January 2002 and September 2006 were studied. The preoperative, operative and postoperative risk factors for early death were evaluated. RESULTS: Early mortality rate in the study population was 17.3%. From variables entered into multivariate logistic regression the following parameters were identified as prognostic factors for early death: left main disease, diabetes, postoperative renal failure and cardiac arrest (P<0.05). The minor and major intra-aortic balloon pump related complications were not significant in univariate and multivariate analysis and its rate was 3.6%. CONCLUSION: According to our study the mortality of IABP group is low compared to other studies, as well as IABP-associated complications. Also it revealed that there is no correlation between IABP-associated complications and early mortality.     

Extended duration of brachially inserted intra-aortic balloon pump for myocardial protection in two patients undergoing urgent coronary artery bypass grafting

Intra-aortic balloon pump (IABP) provides myocardial protection for patients who are at risk of myocardial injury during cardiac surgery. The haemodynamic support is crucial in patients with significant and critical coronary artery disease undergoing revascularisation procedures. Traditionally, the femoral arterial access is the preferred route for IABP insertion. This is, however, not always feasible especially in patients with concomitant occlusive peripheral vascular disease. The trans-brachial route can be used as an alternative for percutaneous insertion of the IABP. We report the technique for left trans-brachial insertion of an IABP, and illustrate our experience with two patients requiring urgent coronary artery bypass grafting (CABG) and for whom the IABP duration was over 50 h.     

Incidence and precipitating factors of delirium after coronary artery bypass grafting

OBJECTIVE: To analyze large contemporary patient population, undergoing on-pump coronary artery bypass grafting at our institution, and identify the prevalence and precipitating factors of delirium development. DESIGN: Baseline demographics, operative data and postoperative outcomes of 1367 consecutive patients were recorded prospectively and analysed using multivariate logistic regression analysis, to determine independent predictors of postoperative delirium development. RESULTS: Delirium was detected in 42 (3.07%) patients. Eight factors: age more than 65 years, peripheral vascular disease, Euroscore>/=5, preoperative IABP support, postoperative blood product usage and postoperative low cardiac output syndrome were independently predicting delirium development after coronary artery bypass procedures. Postoperative delirium was associated with significantly higher mortality rate (16.6% vs. 3.9%, p=0.013), prolonged mechanical ventilation time (9.2+/-3.1 vs. 5.05+/-7.6, p=0.04) and increased length of intensive care unit stay (6.8+/-4.9 vs. 2.0+/-2.7 days, p=0.001). CONCLUSIONS: Delirium is a dangerous complication, prolonging intensive care unit stay and postoperative mortality. Factors associated with delirium development are advanced age, peripheral vascular disease, diminished cardiac function and blood product usage.     

Ischaemic complications with intra-aortic balloon counter-pulsation: incidence and management

The most important limitation of the use of the intra-aortic balloon pump is the risk of vascular complications. The aim of this study was to identify risk factors and aspects of diagnosis and management that may decrease the risk of vascular morbidity associated with intra-aortic balloon pumps. Risk factors, surgical techniques, complications and other variables were retrospectively evaluated in 524 patients who had an intra-aortic balloon pump inserted between January 1988 and December 1998. Of the total, 140 (26.7%) patients with an intra-aortic balloon pump had ischaemic complications that needed surgery. The mean age was 65.2 +/-12.3 years (66.7% men and 27.5% women). The mortality rate was 28.1%. The mortality for patients with ischaemic vascular complications was significantly higher than in those patients without (59.6 versus 30.1%, P = 0.001). One-hundred and eight (77.2%) ischaemic complications occurred during therapy with an intra-aortic balloon pump and 32 (22.8%) complications after intra-aortic balloon pumping had been stopped. Thromboembolectomy was required in 71 (50.7%) patients. Associated surgical procedures were performed in 69 (49.3%) patients. A history of peripheral vascular disease (43.6 versus 23.6%, P < 0.05) and the presence of diabetes mellitus (49.2 versus 16.9%, P < 0.05) increased the risk of limb ischaemia significantly. Limb ischaemia remains the major complication after intra-aortic balloon pump insertion. Independent predictors for vascular complications included peripheral vascular disease and diabetes. Intra-aortic balloon pump removal and thrombectomy is usually sufficient to provide revascularization. Identification of subclinical disease may aid in the management of subsequent acute limb ischaemia.     

Complications Related to Intra-aortic Balloon Pump in Cardiac Surgery: A Decade Later

BACKGROUND: Our centre in 1995 reported 26% of vascular complications in cardiac surgical patients treated with intra-aortic balloon pump (IABP). However, during the last decade there have been improvements in IABP technology and insertion techniques. We aimed to evaluate the impact of these changes on the incidence of IABP-related complications in cardiac surgery. METHODS: Demographics, indications, technique and complication rate in 186 consecutive patients treated with IABP from January 1994 to December 1998 (Group I) were compared with 323 consecutive patients treated with IABP from January 1999 to December 2003 (Group II) at our regional cardiothoracic centre. Data was variably expressed as mean with or without range and either standard deviation or range. Statistical significance was accepted at P<0.05. RESULTS: There were 121 (65%) and 194 (60%) males in Group I and II, respectively. The mean age was 66+/-12.1 (17-88) years and the mean duration of IAPB use was 43.5h (range 3-144 h). Overall complication rate was 10% in Group I and 2% in Group II whereas vascular complications accounted for 3% in Group-I and 1% in Group-II. Logistic regression analysis demonstrated cardiogenic shock being strongly correlated to in-hospital mortality (OR 4.68; P=0.004) followed by older age (OR 3.12; P=0.034) and ejection fraction <35% (OR 1.78; P=0.03). CONCLUSION: The study demonstrated a significant decrease in the IABP-related complications even though complexity of cases referred for surgery has increased. Henceforth, the risk of 1% vascular complications should play little influence on decision-making regarding the use of IABP.     

The incidence and risk of acute renal failure after cardiac surgery

OBJECTIVE: To evaluate outcome and risk factors of acute renal failure in a surgical population with or without preoperative renal dysfunction. DESIGN: Observational study. SETTING: Intensive care unit at a University Hospital. PARTICIPANTS: Five thousand sixty-eight consecutive adult patients who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Perioperative variables measured were age, sex, basic pathology, preoperative renal impairment defined as creatinine >1.4 mg/dL, ventricular dysfunction, preoperative neurologic event, chronic obstructive pulmonary disease, diabetes, type of surgery, use of intra-aortic balloon pump (IABP), cardiopulmonary bypass (CPB) duration, redo or emergency surgery, hemorrhage, blood transfusion, surgical revisions, and postoperative complications. MEASUREMENTS and MAIN RESULTS: Acute renal failure (100% creatinine increase) developed in 171 (3.4%) patients, whereas 94 patients (1.9% of the population) had renal replacement therapy. Hospital mortality was 40.9% in patients with acute renal failure and increased to 63.8% when renal replacement therapy was requested. Sex, age, emergency surgery, low ejection fraction, IABP device, redo, diabetes, mitral valve surgery, CPB duration, and preoperative renal disease were independently associated with acute renal failure at a multivariate analysis. CONCLUSION: This study confirms that acute renal failure is one of the major complications of cardiac surgery, identifies the risk factors, and suggests that optimizing cardiac output and reducing CPB time could improve the outcome of patients at high risk of acute renal failure.     

The Intraaortic Balloon Pump: An Analysis of Five Years' Experience

During a five-year period, 178 patients had the intraaortic balloon pump (IABP) inserted for circulatory support. The IABP was used most frequently as an adjunct for weaning patients from cardiopulmonary bypass. Seventy-seven of 103 patients (75%) were successfully weaned from cardiopulmonary bypass with the IABP, and 36 of them (35%) ultimately survived hospitalization. Other indications for the IABP included circulatory support before cardiac operation (16 patients), operative prophylaxis in high-risk patients (13), and postoperative hemodynamic support (23). Additionally, the IABP was placed in 23 patients who did not undergo cardiac operation.The incidence of IABP-related complications was significantly less when the IABP was inserted through the ascending aorta (4%) intraoperatively compared with the femoral or iliac artery (25%) (p < 0.05). This was due primarily to vascular complications and groin wound infections that occurred with the femoral or iliac artery approach. IABP-related spinal cord paralysis developed in 3 patients (1.7%).We conclude that the IABP is an effective support device for treating patients with left ventricular failure particularly when weaning them from cardiopulmonary bypass. However, the risk of complications, including paraplegia, must be carefully weighed when use of the IABP is considered, especially in situations in which its efficacy is less clear.     

Experience with intraaortic balloon counterpulsation

An eleven-year experience with intraaortic balloon pumping (IABP) or counterpulsation in 637 patients was analyzed with respect to early and late results. Intraaortic balloon pumping was employed for left ventricular pump failure, for coronary insufficiency, and in association with cardiac operations. Late results were analyzed by follow-up of 283 (93%) of the 304 patients leaving the hospital, and were studied with respect to duration of survival, activity status, occupational status, presence of cardiac symptoms, use of cardiac medications, and presence of lower extremity claudication. Early results were analyzed for hospital survival (304/637 [48%]). Patient complications of IABP included wound infection (1/637 or 0.2%), vascular complications (66/637 or 10.4%), and balloon failure (8/637 or 1.3%). No deaths were attributable to complications of IABP. Survival did not correlate with the duration of IABP. Survival was improved in patients who had revascularization in association with IABP.     

Vascular complications from intraaortic balloons: Risk analysis

Purpose: The purpose of this study was to assess the incidence of and predictors for vascular complications in patients who required perioperative intraaortic balloon pump (IABP) support.Methods: Data from 580 patients collected with a retrospective review were statistically analyzed with 25 perioperative parameters, and significant variables were evaluated with multivariate analysis. These data were also statistically compared with data from a 1983 study from our institution.Results: Vascular complications occurred in 72 patients (12.4%). The three aortic perforations were fatal. Ipsilateral leg ischemia occurred in 69 patients. Of these, ischemia was resolved in 82% of patients by IABP removal (21), thrombectomy (21), vascular repair (13), fasciotomy (2), or without intervention (2). Six patients died with the intraaortic balloon in place. Four patients required amputation for ischemia, but all survived.Conclusions: Vascular complications were not predictive of operative death (p = 0.26). Risk analyses with 25 perioperative parameters revealed that history of peripheral vascular disease, female sex, history of smoking, and postoperative insertion were independent predictors of vascular complications. However, most risk for vascular complications cannot be explained by these factors because of a low R² value. Compared with the results of our 1983 study, the incidence of IABP-related complications has not changed, but the severity of complications has decreased significantly, and IABP-induced death has decreased significantly. (J VASC SURG 1994;19:81-9.)     

Beneficial Effect of Preventative Intra-Aortic Balloon Pumping in High-Risk Patients Undergoing First-Time Coronary Artery Bypass Grafting—A Single Center Experience

Although intra‐aortic balloon pumping (IABP) has been used widely as a routine cardiac assist device for perioperative support in coronary artery bypass grafting (CABG), the optimal timing for high‐risk patients undergoing first‐time CABG using IABP is unknown. The purpose of this investigation is to compare preoperative and preventative IABP insertion with intraoperative or postoperative obligatory IABP insertion in high‐risk patients undergoing first‐time CABG. We reviewed our IABP patients' database from 2002 to 2007; there were 311 CABG patients who received IABP treatment perioperatively. Of 311 cases, 41 high‐risk patients who had first‐time on‐pump or off‐pump CABG (presenting with three or more of the following criteria: left ventricular ejection fraction less than 0.45, unstable angina, CABG combined with aneurysmectomy, or left main stenosis greater than 70%) entered the study. We compared perioperatively the clinical results of 20 patients who underwent preoperative IABP placement (Group 1) with 21 patients who had obligatory IABP placement intraoperatively or postoperatively during CABG (Group 2). There were no differences in preoperative risk factors, except left ventricular aneurysm resection, between the two groups. There were no differences in indications for high‐risk patients between the two groups. The mean number of grafts was similar. There were no significant differences in the need for inotropes, or in cerebrovascular, gastrointestinal, renal, and infective complications postoperatively. There were no IABP‐related complications in either group. Major adverse cardiac event (severe hypotension and/or shock, myocardial infarction, and severe hemodynamic instability) was higher in Group 2 (14 [66.4%] vs. 1 [5%], P < 0.0001) during surgery. The time of IABP pumping in Group 1 was shorter than in Group 2 (72.5 ± 28.9 h vs. 97.5 ± 47.7 h, P < 0.05). The duration of ventilation and intensive care unit stay in Group 1 was significantly shorter than in Group 2, respectively (22.0 ± 1.6 h vs. 39.6 ± 2.1 h, P < 0.01 and 58.0 ± 1.5 h vs. 98.5 ± 1.9 h, P < 0.005). There were no differences in mortality between the two groups (n = 1 in Group 1 and n = 3 in Group 2). Preoperative and preventative insertion of IABP can be performed safely in selected high‐risk patients undergoing CABG, with results comparable to those in patients who received obligatory IABP intraoperatively and postoperatively. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome in high‐risk first‐time CABG patients.     

Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting

BACKGROUND: The use of the intraaortic balloon pump (IABP) in patients undergoing coronary artery bypass grafting has been traditionally associated with a high complication rate and adverse outcomes. However, recent reports show that many of these catastrophic outcomes can be avoided by preoperatively placing the IABP in high-risk patients. To further validate these reports, we defined a set of liberal criteria for preoperative IABP insertion and applied them to a series of elderly patients (70 years or older) undergoing isolated coronary artery bypass grafting. METHODS: Two hundred six consecutive patients who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass were retrospectively reviewed. A rapid recovery protocol emphasizing reduced cardiopulmonary bypass time, an anesthetic protocol for early extubation, perioperative administration of corticosteroids and thyroid hormone, and aggressive diuresis was applied to all patients. Patients who required an urgent operation because of failed percutaneous transluminal coronary angioplasty, a critical left main stenosis (70% or greater), pronounced left ventricular dysfunction (left ventricular ejection fraction 40% or less), or unstable angina refractory to medical therapy or who required an emergency reoperation received preoperative IABP support. RESULTS: The 30-day mortality rate for the entire group was 4.4%. There were 97 patients (47%) who received a preoperative IABP (group II) in comparison with 109 patients (53%) who did not fulfill the preoperative insertion criteria (group I). Patients in group II had a lower left ventricular ejection fraction (mean, 46% versus 59%, p<0.001) and a higher incidence of congestive heart failure (35% versus 17%, p<0.01) and acute myocardial infarction (37% versus 17%, p<0.01) than patients in group I. The average postoperative hospital length of stay for patients in group II was slightly longer than for those in group I (9.0+/-10.5 versus 6.0+/-3.7 days, p<0.01). However, there were no statistically significant differences in complication or mortality rates between the two groups. Only 2 patients (2.2%) had complications related to IABP insertion. Lower extremity ischemia occurred in both patients, and both were treated successfully with thromboembolectomy. CONCLUSIONS: Liberal preoperative insertion of the IABP can be performed safely in high-risk elderly patients undergoing coronary artery bypass grafting, with results comparable to those in lower risk patients.     

Intra-aortic balloon counterpulsation in Denmark 1988–1991 : Early results and complications

During the years 1988–1991 6319 patients underwent cardiac surgical procedures in Denmark. In 183 patients (2.9%) with left ventricular failure intra-aortic balloon counterpulsation (IABP) was used. Four percent of the IABP were placed preoperatively, 86% intraoperatively and 10% postoperatively. Severe complications occurred in 16 patients (8.7%) and were mainly vascular due to limb ischemia. The incidence of complications was independent of the duration of balloon pumping. Sixty percent of the patients were weaned from IABP. The 30-day mortality rate was 54%. During the observation period we found a gradual decrease in the use of IABP as well as a reduction in mortality.     

Vascular complications of the intra-aortic balloon pump.

The lower extremity complications of 100 consecutive patients who required the placement of an intra-aortic balloon pump (IABP) during a 3-year period were studied. Indications for the IABP included hypotension during cardiac catheterization (33%) or coronary angioplasty (13%), hemodynamic instability after open heart surgery (35%), unstable angina (5%), and cardiac arrest (14%). The incidence of IABP morbidity was 29%. Complications included ischemia (25%), bleeding (2%), lymph fistula (1%), and femoral neuropathy (1%). Twenty patients required 1 or more surgical interventions for lower extremity vascular complications. The majority of patients who underwent operation (70%) had significant pre-existing arterial occlusive disease. Local femoral artery reconstruction or repair was performed in 18 patients. Two patients had adjunctive bypasses. Continued IABP support was required in four patients after treatment of complications. One patient (1%) had an above-knee amputation. Limb ischemia was treated nonoperatively by removal of the IABP in five patients. Color-flow duplex scans were useful in distinguishing hematomas from pseudoaneurysms as well as for assessing femoral artery flow. We conclude that: (1) limb ischemia remains the primary complication of the IABP; (2) pre-insertion documentation of the severity of existing peripheral arterial disease by noninvasive studies may aid in the management of subsequent acute limb ischemia; (3) femoral artery thrombectomy or endarterectomy is usually sufficient for revascularization; and (4) noninvasive color flow studies are an important diagnostic tool in the nonoperative management of limb complications.