Off-pump coronary bypass grafting following percutaneous angioplasty and intra-aortic balloon pumping insertion in a patient with severe peripheral vascular disease

We describe our 1st case of off-pump coronary artery bypass grafting following percutaneous angioplasty (PTA) and intra-aortic balloon pumping (IABP) insertion. A 66-year-old man presented with cardiogenic shock due to acute coronary syndrome. He had concomitant peripheral vascular disease (PVD). He underwent coronary artery bypass grafting following PTA and IABP insertion. Even in an emergency case with PVD, PTA and IABP insertion could be an option to facilitate off-pump coronary artery bypass grafting.     

Outcome of emergency conventional coronary surgery for acute coronary syndrome due to left main coronary disease.

BACKGROUND: Outcomes of emergency coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) due to left main coronary (LMT) disease remain unclear. This study aimed to assess prognoses for patients undergoing emergency CABG for ACS due to LMT disease. METHODS: One hundred and four patients undergoing emergency CABG for ACS due to LMT disease were retrospectively reviewed. All patients had intra-aortic balloon pumping (IABP) support and underwent surgery within 48 hours after onset. We determined predictors for operative mortality and calculated cardiac event free, actuarial survival, and cumulative graft patency rates. RESULTS: We found that 9 patients (8.7%) developed pre-operative cardiogenic shock and 7 of them required percutaneous cardiopulmonary support (PCPS). Operative mortality affected 9 patients (8.7%). Cardiac event free rate and actuarial survival rate at 10 years were 80.7 and 75.4%, respectively. Logistic regression analysis showed that pre-operative cardiogenic shock was the only predictor for operative mortality (p = 0.0146, odds 5.96). Cumulative graft patency rates for internal thoracic artery and saphenous vein (SVG) at 5 years were 92.6 and 72.4%, respectively. One year-graft patency rate for the radial artery (RA) was 100%. CONCLUSION: It is still very hard to treat patients with cardiogenic shock. We suggest that immediate percutaneous coronary intervention (PCI) with mechanical supports is required prior to CABG for survival of patients with left main shock syndrome.     

Coronary artery bypass without cardiopulmonary bypass for patients with acute myocardial infarction.

OBJECTIVE: Between January 1992 and December 1994, 57 patients having an acute myocardial infarction with coronary anatomy suitable for coronary artery bypass grafting without cardiopulmonary bypass underwent this procedure within 1 week of the infarction. We describe the surgical results of these high-risk patients. METHODS: The study population included 43 male patients (75%) and 14 female patients (25%) whose mean age was 58.5 +/- 10.4 years. Thirty-two patients (56%) underwent emergency bypass grafting within 48 hours of an acute myocardial infarction, 4 of them (12.5%) as a bailout procedure after complicated percutaneous transluminal coronary angioplasty. Of these 32 patients, 7 patients (22%) were in cardiogenic shock, and 10 patients (31%) required preoperative intra-aortic balloon pump. Twenty-five patients (44%) underwent coronary bypass grafting 2 to 7 days after an acute myocardial infarction. The mean number of grafts per patient was 1.8 (range, 1-4), and the internal thoracic artery was used in 47 patients (82%). Only 7 patients (12%) received grafts to a circumflex marginal branch. RESULTS: Operative mortality was 1.7% (1 patient), and the mean postoperative hospital stay was 6.8 +/- 3 days. One- and 5-year actuarial survivals were 94.7% and 82.3%, respectively. Angina returned in 7 patients (12%), 1 of whom underwent reoperation. Multivariate analysis revealed renal failure and preoperative cardiogenic shock to be independent predictors of overall mortality. Old myocardial infarction and operation within the first 48 hours were independent predictors of overall unfavorable outcome events. CONCLUSIONS: These results suggest that coronary artery bypass grafting without cardiopulmonary bypass is a relatively low-risk procedure for patients having an infarction with coronary anatomy suitable for this technique.     

Emergency Cardiopulmonary Bypass Support in Patients with Cardiac Arrest Caused by Myocardial Infarction

Abstract: Emergency percutaneous cardiopulmonary bypass support (PCPS) was instituted in 3 patients with acute myocardial infarction in cardiac arrest refractory to conventional resuscitation measures. All had severe double or triple vessel disease. Percutaneous transluminal coronary angioplasty (PTCA) was performed in 1 patient, and PTCA and directional coronary atherectomy (DCA) were performed in the other 2 patients on combined intraaortic balloon pumping (IABP) and PCPS. Flow rates of 2 to 5 L/min were achieved, with restoration of mean arterial pressure to more than 60 mm Hg during PCPS. The status of all patients was improved hemodynamically with PCPS. One patient died of hemorrhage during PCPS.
DCA was successfully performed in the other 2 patients, and PCPS and IABP was discontinued. Time on PCPS ranged from 10 h to 8 days. Time on IABP ranged from 10 days to 2 weeks. These 2 patients died of pneumonia or multiorgan failure after 1. 5 months. In conclusion, emergency PCPS is a powerful resuscitative tool that may stabilize the condition of patients in cardiac arrest to allow for definitive intervention.     

Emergency cardiopulmonary bypass support in patients with cardiac arrest

Emergency percutaneous cardiopulmonary bypass support was instituted in 11 patients in cardiac arrest refractory to conventional resuscitation measures. Emergency percutaneous cardiopulmonary bypass support was used in five patients in whom cardiac arrest occurred as a result of a complication in the cardiac catheterization laboratory (group 1) and in six other patients in cardiac arrest (group II). A 21F cannula and a 17F cannula were percutaneously inserted into the femoral vein and artery. Flow rates of 3 to 5 L/min were achieved with restoration of mean arterial pressure to 70 mm Hg (range 50 to 75). The status of all 11 patients was improved initially both clinically and hemodynamically with percutaneous cardiopulmonary bypass. Of the group II patients, three had anatomy unsuitable for percutaneous transluminal coronary angioplasty or coronary bypass grafting, could not be weaned from cardiopulmonary support, and died; three of these patients had coronary artery bypass grafting and two survived. All five group I patients underwent successful coronary bypass grafting and survived. Of the seven patients with anatomically correctable disease, all seven were discharged from the hospital. With conventional management nearly all seven of these patients would have died. Nine of 11 patients underwent a cardiac operation and seven of the nine survived. The operative mortality rate was 22% and the overall survival rate was 64%. At follow-up (mean 7 months), all seven patients are alive and six have resumed a normal and active life-style. In conclusion, emergency percutaneous cardiopulmonary bypass support is a powerful resuscitative tool that may stabilize the condition of patients in cardiogenic shock and cardiac arrest to allow for definitive intervention.     

Mechanical support of the failing heart

Intra-aortic balloon pumping (IABP) is presently the supportive treatment of choice for the management of refractory left ventricular power failure.

A dual-chambered intra-aortic balloon mounted on a singlelumen catheter is described, consisting of a distal spherical occluding balloon and a narrow cylindric proximal pumping balloon. This balloon, in contrast to the conventional single-chambered balloon, pumps intra-aortic blood unidirectionally toward the aortic root, thereby effecting a 66–100% greater increment in coronary blood flow. Significant improvement in all measurable indexes of ventricular work have been demonstrated both experimentally and clinically. The dual-chambered intra-aortic balloon effectively interrupts the vicious cycle of cardiogenic shock by increasing coronary blood flow and decreasing ventricular work, thereby improving the balance between oxygen supply and oxygen demand.

System 80, a failsafe mobile cardiac assist console, is discussed in detail as it applies to the total clinical system for dual-chambered IABP. The R wave of the ECG produces balloon deflation in the same diastolic interval, thereby assuring that pump systole can never coincide with ventricular systole. In addition, the system uses the safe soluble gas CO₂ for balloon driving instead of helium, which is insoluble in blood and which can cause lethal sequelae.

Patient management is specially discussed and the results of dual-chambered IABP in 63 patients with an overall survival rate of 63% is detailed.

Intra-aortic balloon pumping/with the dual-chambered intraaortic balloon is the supportive treatment of choice both in medically refractory cardiogenic shock and as an adjunct to the preand postoperative care of selected patients requiring open heart surgery or a myocardial revascularization procedure.

A new valveless pulsatile assist device (PAD) is described that converts roller pump flow into synchronized pulsatile flow. The PAD is actuated by the System 80. The PAD can also be used as an arterial counterpulsator before and after cardiopulmonary bypass. The PAD was employed in 100 adult patients undergoing open heart surgery for coronary artery and/or valvular heart disease. Seventy-three of these patients were New York Heart Association Class 3 or 4 or had ejection fractions of less than 0.3. The device functioned as a hemodynamically effective arterial counterpulsator before and after cardiopulmonary bypass. During bypass pulse pressures of 40–50 mm Hg were readily obtained. Urinary outputs during cardiopulmonary bypass were significantly increased on the PAD when compared to a control group. In addition, during bypass coronary graft blood flow increased an average of 21.4% with the PAD, and after bypass, increased an average of 25.0%. Free plasma hemoglobins after cardiopulmonary bypass were not elevated. Only 1 patient had a perioperative myocardial infarction, and this patient was successfully treated with IABP.

The initial data suggest that the PAD is a simple and reliable device for both intraoperative counterpulsation and for the creation of pulsatile cardiopulmonary bypass. More significantly, use of the PAD may decrease both the incidence of perioperative myocardial infarction and the need for postoperative IABP.     

心肌梗塞后室间隔穿孔的手术治疗

探讨急性心肌梗塞后室间隔穿孔的手术时机选择及影响手术疗效的因素。１６例急性心肌梗塞后室间隔穿孔病人接受了手术治疗。平均年龄５４．５岁。术前合并心源性休克５例，充血性心力衰竭伴肺水肿１例。１４例行冠状动脉造影，单支病变８例，多支病变６例，合并室壁瘤１３例。急症手术４例，择期手术１２例。行穿孔直接缝合２例，补片修补１３例，双侧补片修补１例；同期冠脉搭桥９例，室壁瘤切除或折叠１３例。术后应用主动脉内球囊反搏（ＩＡＢＰ）者８例。２例急症手术者早期死亡。结论：室间隔穿孔应先行内科治疗控制心源性休克，包括应用ＩＡＢＰ或左心室辅助等，使病人能坚持到穿孔４８小时后再积极手术。分流量小者应延至３～６周后手术。心源性休克是影响术后早期死亡率的主要因素     

Off-pump coronary artery bypass grafting for patients with cardiogenic shock due to acute myocardial infarction

Off-pump coronary artery bypass (OPCAB) is less invasive, so we have recently been expanding the indication. We performed OPCAB for 3 patients with cardiogenic shock due to acute myocardial infarction (AMI). PATIENTS: All patients were supported hemodynamically by intra-aortic balloon pumping (IABP) prior to surgery. RESULTS: We performed the revascularization of territories for the left anterior descending artery (LAD) and right coronary artery (RCA) in these high risk patients using OPCAB technique to improve the hemodynamic state. In all patients, IABP was removed within 48 hours after surgery and the postoperative course was uneventful. CONCLUSIONS: It seems that OPCAB is a useful and effective procedure for a selected patient even with cardiogenic shock due to AMI.     

Is use of the intraaortic balloon pump in octogenarians justified?

Increasing numbers of octogenarians are seen in the operating room or critical care unit with circumstances for which intraaortic balloon pump (IABP) assistance is appropriate, but it has been suggested that the complication rate for IABP use in octogenarians is excessive. From 1980 to 1990, 25 octogenarians needed an IABP in our institution, as an adjunct to operation in 20 patients (1 had repair of a ventricular rupture and 19 underwent coronary grafting); 5 patients did not have operation. The indications for IABP use were unstable angina, 12 (48%); cardiogenic shock, 10 (40%); and difficulty weaning off cardiopulmonary bypass, 3 (12%)--these 3 were the only ones who had insertion through a femoral cut-down. No serious insertion difficulties were noticed with the percutaneous route in the other 22 patients. Without operation, 4 of 5 patients died in the hospital (80%), and the 5th died 2 years 8 months after discharge. After operation, there were two hospital deaths (10%) and two late deaths, neither from cardiac causes. A fatal outcome occurred in 6 of 9 patients with cardiogenic shock. Intraaortic balloon pump-related complications were rare, minor, and unrelated to IABP assistance duration, which ranged from 24 to 146 hours (mean, 49.9 hours). No long-term vascular complications resulted. Hospital stay averaged 22.2 days. At follow-up from 9 to 81 months (mean, 51.8 months), of the 16 survivors, 12 (75%) were in New York Heart Association class I/II and 2 each were in classes III and IV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Routine preoperative insertion of IABP in high-risk off-pump coronary artery bypass grafting

The beneficial effects of intraaortic balloon pump (IABP) in coronary artery bypass graft surgery with cardiopulmonary bypass have been reported. However, whether preoperative insertion of IABP in high-risk off-pump coronary artery bypass grafting (OPCAB) has any beneficial effects remains to be established. We report our experience of preoperative insertion of IABP in OPCAB.     

Coronary artery bypass surgery without cardiopulmonary bypass

In the years 1994 and 1995, 1087 patients underwent coronary artery bypass grafting at our institution. Of these, 297 were operated on without cardiopulmonary bypass. 239 were male, and 58 were female. Their ages ranged from 28 to 81 years (54.43 ± 9.63). Of the total, 294 were operated on electively, two as a coronary reoperations, and one as an emergency after a failed percutaneous transluminal coronary angioplasty procedure. In all patients complete revascularization was the aim, and a cardiopulmonary bypass team was kept on standby. Median sternotomy was performed as the exposure in all patients, except a patient who underwent a coronary reoperation through a left thoracotomy incision. The average of the distal anastomoses was 1.51 ± 0.6, ranging from 1 to 3. The left internal thoracic artery was used in 292 operations, which was an individual graft in 284, a sequential graft in five, and a free graft in four. Major complications in the early postoperative period were noted in three patients as reoperation for excessive bleeding. One patient had reoperation for left internal thoracic artery spasm, and one patient had lower extremity ischemia caused by intraoartic balloon counterpulsation. Hospital mortality was 0.3% with one patient. It is our belief that in selected cases coronary artery bypass grafting without cardiopulmonary bypass is a safe procedure with the advantage of improvement in recovery during the postoperative period.     

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.     

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.     

A successful case of hybrid therapy for the left main trunk and triple coronary vessel lesions with acute myocardial infarction and cardiogenic shock

A 86-year-patient who had acute myocardial infarction and critical cardiogenic shock was diagnosed to have the left main trunk (LMT) and triple vessel disease. Emergent coronary artery bypass grafting to the left anterior descending artery was performed using saphenous vein graft without cardiopulmonary bypass through median sternotomy. On the 41st postoperative day, catheter intervention was performed to the remaining lesions by stenting of LMT and percutaneous transluminal coronary angioplasty to the right coronary artery lesions. Tl scintigraphy showed remarkable reduction of myocardial ischemia. Hybrid therapy is the effective new strategy for critical cases which cannot be successfully and securely treated by medical or surgical approach alone.     

Prophylactic Use of Intra‐Aortic Balloon Pumps in Open Heart Surgery

During a 1‐year period, intra‐aortic balloon pumps (IABPs) were used in open heart surgery on 57 patients. Indications were prophylactic usage for coronary artery bypass grafting (CABG) in 52 patients, prophylactic usage for valve replacement in three patients, and cardiopulmonary bypass (CPB) weaning during valve replacement in two patients. The 52 CABG patients comprised 94.5% of all CABG procedures during the period. Sheathless 8 Fr IABPs were used in all cases. The 57 patients using IABPs were analyzed. The mean duration of IABP use was 41.7 h. Morbidity was not associated with using IABPs. There was one case of balloon rupture. Hemostasis was performed easily after removing IABP catheters by compressing the groin for approximately 15 min. The lowest blood pressure during anastomosis or cardiac arrest was also assessed. The lowest peak pressure was 55.9 ± 17.3 mm Hg for patients with IABP still turned on, and the lowest mean pressure was 34.7 ± 6.5 mm Hg for patients with IABP temporarily turned off. Peak blood pressure after CPB was 73.8 ± 17.8 mm Hg. During open heart surgery under anesthesia with the low blood pressure presented by this series, use of IABPs enabled patients to tolerate the procedure. In conclusion, aggressive use of IABPs is easy, safe, and effective with no related morbidity.     

Therapeutic strategy of perioperative use of percutaneous cardiopulmonary bypass support (PCPS) for adult cardiac surgery

Subject and method: Percutaneous cardiopulmonary bypass support is beneficial for patients with circulatory collapse. However, therapeutic strategies of percutaneous cardiopulmonary bypass support for post-cardiotomy LOS have not been determined. We reviewed 9 patients undergoing cardiac surgery and treated with percutaneous cardiopulmonary bypass support to determine an adequate strategy for perioperative use of percutaneous cardiopulmonary bypass support. Patients included 8 males and 1 female with a mean age of 56.4 ± 3.9 years. Six patients with IHD underwent CABG for 5 and CABG + MVR for 1 patient and 3 patients with valvular disease underwent AVR, AVR + MVR, and Ross operation respectively. Indication for percutaneous cardiopulmonary bypass support was post-cardiotomy LOS in 7 and preoperative cardiogenic shock in 2 patients. All patients underwent IABP associated with percutaneous cardiopulmonary bypass support. Systemic blood pressure was regulated to 100–120 mmHg by percutaneous cardiopulmonary bypass support flow and with minimum inotropic supports.Results: Six of 9 patients (66.7%) were weaned from percutaneous cardiopulmonary bypass support and 5 patients were discharged. Five of 6 patients (83.3%) with IHD were weaned from percutaneous cardiopulmonary bypass support compared to 1 of 3 patients (33.3%) (p=0.134) with valvular disease. Hemodynamic conditions in patients weaned from percutaneous cardiopulmonary bypass support were markedly improved within 40 hours of the introduction of percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 23.9 ± 5.5 hrs). In contrast, those unable to be weaned from percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 84.3 ± 6.3 hrs) showed no improvement and developed major complications such as cerebral damage or multiorgan failure.Conclusions: Perioperative use of percutaneous cardiopulmonary bypass support may be more effective for patients undergoing coronary artery surgery. Limited use of percutaneous cardiopulmonary bypass support within 48 hours may be applicable for post-cardiotomy patients.     

Therapeutic strategy of perioperative use of percutaneous cardiopulmonary bypass support (PCPS) for adult cardiac surgery.

SUBJECT AND METHOD: Percutaneous cardiopulmonary bypass support is beneficial for patients with circulatory collapse. However, therapeutic strategies of percutaneous cardiopulmonary bypass support for post-cardiotomy LOS have not been determined. We reviewed 9 patients undergoing cardiac surgery and treated with percutaneous cardiopulmonary bypass support to determine an adequate strategy for perioperative use of percutaneous cardiopulmonary bypass support. Patients included 8 males and 1 female with a mean age of 56.4 +/- 3.9 years. Six patients with IHD underwent CABG for 5 and CABG + MVR for 1 patient and 3 patients with valvular disease underwent AVR, AVR + MVR, and Ross operation respectively. Indication for percutaneous cardiopulmonary bypass support was post-cardiotomy LOS in 7 and preoperative cardiogenic shock in 2 patients. All patients underwent IABP associated with percutaneous cardiopulmonary bypass support. Systemic blood pressure was regulated to 100-120 mmHg by percutaneous cardiopulmonary bypass support flow and with minimum inotropic supports. RESULTS: Six of 9 patients (66.7%) were weaned from percutaneous cardiopulmonary bypass support and 5 patients were discharged. Five of 6 patients (83.3%) with IHD were weaned from percutaneous cardiopulmonary bypass support compared to 1 of 3 patients (33.3%) (p = 0.134) with valvular disease. Hemodynamic conditions in patients weaned from percutaneous cardiopulmonary bypass support were markedly improved within 40 hours of the introduction of percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 23.9 +/- 5.5 hrs). In contrast, those unable to be weaned from percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 84.3 +/- 6.3 hrs) showed no improvement and developed major complications such as cerebral damage or multiorgan failure. CONCLUSIONS: Perioperative use of percutaneous cardiopulmonary bypass support may be more effective for patients undergoing coronary artery surgery. Limited use of percutaneous cardiopulmonary bypass support within 48 hours may be applicable for post-cardiotomy patients.     

Acute traumatic myocardial infarction with cardiogenic shock in severe polytrauma--a case report

A 41-year-old man suffered severe polytrauma and developed a traumatic myocardial infarction with cardiogenic shock. Thrombolysis as well as coronary bypass grafting was contraindicated due to accompanying injuries. An attempted early coronary revascularization by percutaneous transluminal coronary angioplasty (PTCA) failed due to dissection of the left interventricular coronary artery. Treatment of cardiac insufficiency was complicated by intraabdominal haemorrhage enforcing emergency laparotomy. Intraaortic balloon counterpulsation proved to be efficient in supporting circulation in these circumstances. The case report documents the practicability and importance of treating both myocardial ischaemia and attending injuries in an equivalent and coordinated manner in traumatic myocardial infarction.     

Disrupted coronary artery caused by angioplasty: supportive and surgical considerations

Of 2,859 patients having percutaneous transluminal coronary angioplasty, 201 (7%) underwent emergency coronary artery bypass grafting. Two categories of patients were reviewed. Group 1 consisted of 126 patients of 2,304 who had immediate coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Ninety-eight of these patients had angiographic evidence of occlusion of a coronary artery, and 28 had angiographic evidence of coronary artery dissection. Epicardial hemorrhage was observed at operation in 20% (25 patients). Three deaths (2.4%) occurred in group 1, and an average of 3.3 grafts was performed per patient. Group 2 comprised 75 of 555 patients who had unsuccessful attempted percutaneous transluminal coronary angioplasty during an evolving myocardial infarction and required immediate coronary artery bypass grafting. Angiography revealed coronary artery occlusion in 61 patients with dissection in 14. All group 2 patients had evidence of myocardial injury by electrocardiographic and enzymatic (myocardial-specific isoenzyme of creatine kinase) criteria. Three deaths (4%) occurred in this group, and there was an average of 3.4 grafts per patient. Percutaneous transluminal coronary angioplasty is routinely performed without surgical consultation, although an operating room and team are usually available. Supportive techniques include the intraaortic balloon pump and percutaneous cardiopulmonary bypass. In those patients with coronary artery dissection, care must be taken to reestablish the true lumen of the coronary artery. Hemopericardium should be surgically explored and broken guidewires or other foreign bodies or debris removed. From 1979 through 1986, the number of patients requiring emergency coronary artery bypass grafting after percutaneous transluminal coronary angioplasty steadily declined to less than 5%.     

Evolving Indications for Preoperative Intraaortic Balloon Pump Assistance

Over a two-year period about 1,000 operations were performed with cardiopulmonary bypass. Intraaortic balloon pump assistance (IABP) was employed on 150 occasions, and a review of these has permitted clarification of the indications for its use.Sixty patients had IABP for cardiogenic shock either after infarction or after cardiotomy, and 37 (62%) survived. Preoperative IABP in 90 high-risk patients resulted in survival for 79 (88%). The indications for prophylactic IABP included: (1) relief of severe pain, which occurred in 42 patients with acute coronary insufficiency, (2) improvement in the coronary perfusion pressure, which was accomplished in 20 patients with significant left main coronary artery occlusion or its equivalent, and (3) protection of left ventricular function, which was carried out in 28 patients with an LV ejection fraction of less than 0.40. The significance of the preoperative endocardial viability ratio (EVR) in relation to prophylactic IABP was also assessed: an EVR below 0.70 appears to be an indication for preoperative IABP.