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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 4  |  Page : 1392-1396

Preoperative intra-aortic balloon pumping in poor left ventricular function patients undergoing coronary bypass graft surgery


1 Cardiothoracic Surgery Department, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Menoufia, Egypt
2 Cardiothoracic Surgery Department, Faculty of Medicine, Cairo University, Shobra, Cairo, Egypt
3 Cardiac Surgery Unit, Nasser Institute, Shobra, Cairo, Egypt

Date of Submission19-May-2017
Date of Acceptance24-Jul-2017
Date of Web Publication14-Feb-2019

Correspondence Address:
Mohamed A. A . Salama
Yosofia-Bani-Ebeid, Bani-Ebeid
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_347_17

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  Abstract 


Objective
Assessment of the effectiveness associated with preoperative intra-aortic balloon pump (IABP) treatment on postoperative cardiac performance, morbidity, and mortality.
Background
Preoperative IABP enhances the end result in poor left ventricular function patients undergoing coronary artery bypass grafting (CABG).
Patients and methods
A prospective analytical cohort study was conducted on 40 patients with preoperative left ventricular ejection fraction (<40%) who experienced myocardial revascularization (CABG) at Nasser Institute Hospital between February 2014 and July 2016. There was a random allocation of patients before surgery, where group I (N = 20) had been inserted with the IABP 1–2 h before aortic cross-clamp and group II (N = 20) was the control group, which did not have IABP inserted preoperatively.
Results
The mean cardiac index in group I (IAB) before cardiopulmonary bypass time was 2.49 ± 0.21 and in group II (control) it was 1.99 ± 0.34, with a statistically considerable enhancement among two groups (P = 0.003). The mean ischemic time in group I was 54.20 ± 17.63 and in group II it was 57 ± 10.64, with no statistically significant difference among two groups (P = 0.2). The mean cardiopulmonary bypass time in group I was 75.60 ± 22.73, with a statistically substantial enhancement among two organizations (P = 0.015). The mean mechanical ventilation time (h) was 24.7 ± 1.80 in group I compared with 81.9 ± 31.09 in group II, with a highly statistically significant difference among two groups (P = 0.001). The mean ICU stay (hours) in group II was 138.10 ± 50.27, with a highly statistically significant difference (P = 0.001). The mean NYHA class and the mean left ventricular ejection fraction in group I postoperatively was 1.20 ± 0.40 and 54.78 ± 3.75, respectively, with a highly statistically significant difference in group I (P = 0.001) regarding preoperative and postoperative periods.
Conclusion
Poor left ventricular function patients undergoing CABG possibly require perioperative IABP assistance to decrease morbidity and mortality.

Keywords: coronary artery bypass graft, intra-aortic balloon pump, poor left ventricle


How to cite this article:
Dokhan AL, Helmy MA, Allama AM, Salama MA. Preoperative intra-aortic balloon pumping in poor left ventricular function patients undergoing coronary bypass graft surgery. Menoufia Med J 2018;31:1392-6

How to cite this URL:
Dokhan AL, Helmy MA, Allama AM, Salama MA. Preoperative intra-aortic balloon pumping in poor left ventricular function patients undergoing coronary bypass graft surgery. Menoufia Med J [serial online] 2018 [cited 2024 Mar 28];31:1392-6. Available from: http://www.mmj.eg.net/text.asp?2018/31/4/1392/252048




  Introduction Top


The intra-aortic balloon pump (IABP), discovered in the late1960s, has become the most widely used circulatory assist device[1],[2]. Nowadays, cardiac surgeons are increasingly being faced with patients presenting with more serious clinical complications, such as poor cardiovascular function or diffuse coronary artery disease[3]. Simply, this reflects the fact that less seriously compromised patients are often treated in the invasive cardiology setting. In addition, further medical problems of many surgical candidates were exacerbated because of advanced age of the overall patients experiencing coronary artery bypass grafting (CABG)[4]. These patients are at a substantially increased risk of developing low cardiac output following myocardial revascularization[5]. Hibernating myocardium was introduced a decade ago by Braunwald and Rutherford[6]. The term describes persistent myocardial dysfunction at rest because of under perfusion, with subsequent improvement upon revascularization[6]. Recently, IAB as a preoperative support for risky patients experiencing CABG is expanded in clinical applications. The high-risk factor for mortality and almost postoperative morbidity is poor left ventricular function less than 0.40. These studies have shown that the preoperative use of IABP therapy in these poor left ventricle coronary patients is efficient in significantly decreasing hospital mortality, postoperative morbidity, shortening the length of stay in the ICU, and overall required period of hospitalization[7]. The aim of the study was the assessment of the effectiveness associated with preoperative IABP treatment on postoperative cardiac performance, morbidity, and mortality.


  Patients and Methods Top


This is an analytical prospective cohort study that was conducted after being approved from Menoufia Ethics Committee and Nasser Ethics Committee, in multiple centers including Menoufia University Hospitals and Nasser Institute Hospital, after obtaining informed consent from patients, between February 2014 and July 2016. The sample size was 40 patients with preoperative left ventricular ejection fraction (LVEF <40%) (20 patients in each group) having 80% Power, assuming true values for two proportion, and confidence interval at 95% for the detection of significant difference at 0.05 using two-tailed test. It was calculated online (http://epitools.ausvet.com.au). The inclusion criteria included isolated CABG patients with poor left ventricular function (ejection fraction ≤40%), whereas the exclusion criteria were CABG patients with any cardiac procedures, urgent CABG, previous CABG operation, previous cardiac operation, and off-pump procedure. All patients received a peripheral line, an arterial line, and a Swan–Ganz thermodilution catheter (introduced percutaneously through the internal jugular vein) under local anesthesia. Cardiac output and cardiac index were measured with a cardiac output computer. There was a random allocation of these patients before surgery, where group I (IAB) (N = 20) had been inserted with an IABP 1–2 h before aortic cross-clamp and group II (N = 20), the control group, did not have IABP inserted preoperatively. The intra-aortic balloon was inserted primarily by the percutaneous seldinger technique. Sheathless insertion technique was used in all IABP insertions. The intra-aortic balloon used was a Datascope True sheathless DL-7.5 (Didage Sales Company, Warsaw, IN) Fr. 40 CC IAB catheter connected to a Datascope pump. Patients undergoing preoperative insertion were therapeutically anticoagulated with heparin after IABP placement. Regular examination of peripheral pulses, temperature, and color of the leg was done to detect impaired circulation and leg ischemia as early as possible to avoid loss of the limb. If the pulses were not palpable clinically or if there was any evidence of ischemia, peripheral Doppler was performed. If the Doppler showed any obstruction to the flow in the femoral artery, the balloon was removed and inserted into the other artery, if the patient still needed IABP therapy.

The collected data have been coded, processed, and analyzed using IBM statistical package for the social sciences (SPSS) program for Windows (version 22; SPSS Inc., Chicago, Illinois, USA). Quantitative data were presented as mean and SD. Qualitative variables are presented as number and percentage. χ2-Test was used for testing significance of categorical data. Student's t-test was used for testing significance of quantitative data for parametric distribution.


  Results Top


The mean ischemic time in group I was 54.20 ± 17.63, whereas in group II it was 57 ± 10.64, with no statistically significant difference between both groups (P = 0.2). As regards cardiopulmonary bypass time (CPB), the mean CPB in group II was 85.70 ± 19.60 compared with 75.60 ± 22.73 in group I, with a statistically significant difference between both groups (P = 0.015) [Table 1]. As regards the cardiac index, the mean cardiac index after weaning in group I and group II was 2.85 ± 0.17 and 2.1 ± 0.38, respectively, with a highly statistically significant difference between both groups (P = 0.002). Moreover, the mean cardiac index after 24 h in group I was 3.58 ± 0.30 compared with 2.32 ± 0.57 in group II, with a highly statistically significant difference between both groups (P = 0.001) [Table 2]. The mean mechanical ventilation time (h) was 24.7 ± 1.80 in group I compared with 81.9 ± 31.09 in group II, with a highly statistically significant difference among two groups (P = 0.001) [Table 3]. The mean ICU stay (h) in group II was 121.70 ± 26.39, with a highly statistically significant difference (P = 0.001). It was found that total hospital stay was significantly shorter in group I (10.49 ± 1.52) compared with group II (15.70 ± 4.85), with a highly statistically significant difference (P = 0.001) [Figure 1] and [Figure 2]. It was demonstrated that the mortality rate was statistically significantly higher in group II, five (25%) patients, compared with group I, one (5%) patients (P = 0.05) [Figure 3]. The mean NYHA class and the mean LVEF in group I postoperatively was 1.20 ± 0.40 and 54.78 ± 3.75, respectively, with a highly statistically significant difference in group I (P = 0.001) regarding preoperative and postoperative periods. In addition, the mean Canadian Cardiovascular Society (CCS) angina class was significantly lower in group I postoperatively (1.25 ± 0.40) compared with preoperative CCS class in the same group (2.17 ± 0.38), with a statistically significant difference in the same group (P = 0.01) [Table 4].
Table 1: Mean ischemic and cardiopulmonary bypass time among both groups of the study

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Table 2: Shows mean cardiac index in the different stages among patients of the study

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Table 3: Shows mean ventilation time among patients of the study

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Figure 1: Mean ICU stay (h).

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Figure 2: Mean total hospital stay (days).

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Figure 3: Mortality rate.

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Table 4: Shows comparison between preoperative New York Heart Association Functional Class, Canadian Cardiovascular Society, and left ventricular ejection fraction and 3 months postoperatively for both groups of the study

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  Discussion Top


Our research work aimed to assess the importance of the use of counter-pulsation IABP, which is an elective preoperative cardiac support, as a way of efficient preparation of poor left ventricle patients where we can anticipate greater morbidity and mortality. The current study showed that the mean ischemic time in group I was 54.20 ± 17.63 compared with 57 ± 10.64 in group II, with no statistically significant difference between both groups. As regards CPB, the mean CPB in group II was 85.70 ± 19.60 compared with 75.60 ± 22.73 in group I, with a statistically significant difference between both groups. These results of research agreed with Ranucci et al.[8], who found that CPB time was significantly longer in the group without IAB (89.60 ± 20.61) in comparison with the group with IAB (79.00 ± 19.99).

The present study showed that the mean cardiac index after weaning in group I and group II was 2.85 ± 0.17 and 2.1 ± 0.38, respectively, with a highly statistically significant difference between both groups. Moreover, the mean cardiac index after 24 h in group I was 3.58 ± 0.30 compared with 2.32 ± 0.57 in group II, with a highly statistically significant difference between both groups. This was similar to results illustrated by Christenson et al.[9]. Preoperative cardiac index has been observed to increase after preoperative intra-aortic balloon insertion (1.70 ± 0.57 vs. 2.84 ± 0.63), and 30 min after cardiopulmonary bypass (2.53 ± 0.71 vs. 3.74 ± 0.85) 64% of patients in the control group needed IABP support in the postoperative period. In contrast to our study, Castelvecchio et al.[10] did not agree with these data, as the postoperative cardiac index did not change between the different groups. His study looking after patients by fluid volume and inotrope by these measurement there is no difference observed between two groups[11].

Regarding the mechanical ventilation time (h), our study demonstrated that the mean was 24.7 ± 1.80 in group I compared with 81.9 ± 31.09 in group II, with a highly statistically significant difference among two groups. Christenson et al.[12] reported that the mean was 18 ± 03 in group I compared with 36 ± 05 in group II, with a statistically significant difference among two groups. The mean ICU stay (h) in group II was 121.70 ± 26.39, with a highly statistically significant difference. It was found that total hospital stay was significantly shorter in group I (10.49 ± 1.52) compared with group II (15.70 ± 4.85), with a highly statistically significant difference. Dietl et al.[13] showed that the ICU stay and hospital stay were significantly shorter in this group with IAB compared with controls (group II). The mortality rate was statistically significantly higher in group II, five (25%) patients, compared with group I one (5%) patients. These results of research agreed with those of Rao et al.[14], who illustrated a higher mortality rate (17%) in group II in comparison with group I (1%). The mean NYHA class and the mean LVEF in group I postoperatively was 1.20 ± 0.40 and 54.78 ± 3.75, respectively, with a highly statistically significant difference in group I regarding preoperative and postoperative periods. In addition, the mean CCS angina class was significantly lower in group I postoperatively (1.25 ± 0.40) compared with preoperative CCS class in the same group (2.17 ± 0.38), with a statistically significant difference in the same group. Similarly, Christenson et al.[15] reported that the mean NYHA class and the mean LVEF in group I postoperatively was 1.10 ± 0.30 and 50 ± 0.05, respectively, with a highly statistically significant difference in group I regarding preoperative and postoperative periods. In addition, the mean CCS angina class was significantly lower in group I postoperatively (0.2 ± 0.50) compared with preoperative CCS class in the same group (3.7 ± 0.5), with a statistically significant difference in the same group.

The IABP complication rate has been documented in the current studies as 4–11%[13],[14]. In the current study, IABP complication rate was 7.5% (three patients out of 40) without group difference: in group I (with preoperative IABP) one patient out of 20 (5%) and in group II (without preoperative IABP) two patients out of six patients (had postcardiotomy IABP). All IABP complications were limb ischemia. In two patients, the intra-aortic balloon was removed, and one patient required removal of IAB and thromboembolectomy using fougarty catheter. Our relatively low IABP-related complication rate, without major complication, might be as result of preoperative assessment of peripheral arterial status, using sheathless insertion technique, as well as close surveillance of peripheral circulation with unique focus on observing earlier signs of severe ischemia to permit earlier intervention[16].


  Conclusion Top


Poor left ventricular function patients undergoing CABG possibly require perioperative IABP assistance to decrease morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ferguson JJ, Cohen ME, Freedman RJ, Stone GW, Joseph DL, Miller MF. The current practice of intra-aortic balloon counter pulsation: results from the Benchmark Registry. J Am Coll Cardiol 2011; 38:1456–1462.  Back to cited text no. 1
    
2.
Kantrowitz A, Wasfie T, Tjonneland S, Feed PS, Phillips SJ, Butner AN, et al. Intraaortic balloon pumping 1967 through 1982: analysis of complications in 733 patients. Am J Cardiol 1986; 59:564–568.  Back to cited text no. 2
    
3.
Naunheim KS, Schwartz MT, Pennington DG, Fiore AC, McBride LR, Peigh PS, et al. Intra-aortic balloon pumping in patients requiring cardiac operations. Risk analysis and long-term follow up. J Throrac Cardiovasc Surg 2009; 104:1654–1660.  Back to cited text no. 3
    
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Baskett RJ, Ghali WA, Maitland A, Hirsch GM. The intra-aortic balloon pump in cardiac surgery. Ann Throac Surg 2015; 74:127–187.  Back to cited text no. 4
    
5.
Ferrari G, Gorczynska V, Mimmo R, De Lazzari C, Clemente F, Tosti G, et al. IABP assistance: a test bench for the analysis of its effects on ventricular energetics and hemodynamics. Int J Artif Organs 2010; 24:274–280.  Back to cited text no. 5
    
6.
Braunwald E, Rutherford JD. Reversible ischemic left ventricular dysfunction: evidence for the 'hibernating myocardium'. J Am Coll Cardiol 1986; 8:1467–1470.  Back to cited text no. 6
    
7.
Stone GW, Marsalese D, Brodie BR, Griffin JJ, Donohue B, Costantini C, et al. Second Primary Angioplasty in Myocardial Infarction (PAMI-II) Trial Investigators. A prospective, randomized evaluation of prophylactic intraaortic balloon counterpulsation in high risk patients with acute myocardial infarction treated with primary angioplasty. J Am Coll Cardiol 2010; 29:1459–1467.  Back to cited text no. 7
    
8.
Ranucci M, Castelvecchio S, Biondi A, de Vincentiis C, Ballotta A, Varrica A, et al. Surgical and Clinical Outcome Research (SCORE) Group A randomized controlled trial of preoperative intra-aortic balloon pump in coronary patients with poor left ventricular function undergoing coronary artery bypass surgery. Crit Care Med 2013; 41:2476–2483.  Back to cited text no. 8
    
9.
Christenson JT, Maurice J, Simont F, Badel P, Schmuziger M. Effect of lowleft ventricular ejection fractions on outcome of primary coronary artery bypass grafting in end-stage coronary artery disease. J Cardiovasc Surg 1997; 36:45–51.  Back to cited text no. 9
    
10.
Castelvecchio S, Lorenzo M, de Vincentiis C, Andrea B, Alessandro V, Alessandro F, et al. A randomized controlled trial of preoperative intra-aortic balloon pump in coronary patients with poor left ventricular function undergoing coronary artery bypass surgery. Crit Care Med 2013; 41:2476–2483.  Back to cited text no. 10
    
11.
Khan I, Hadia M, Madiha I, Zafar T, Hira I. Prophylactic use of a preoperative intra-aortic balloon pump in patients with severe left ventricular dysfunction undergoing coronary artery bypass grafting. Egypt J Cardiothorac Anesth 2014; 8:97–100.  Back to cited text no. 11
    
12.
Christenson JT, Badel P, Christakis GT, Weisel RD, Fremes SE. Evaluation of preoperative intraaortic balloon pump support in high risk coronary patients. Eur J Cardiothorac Surg 1997;11:1097–1103.  Back to cited text no. 12
    
13.
Dietl CA, Berkheimer MD, Woods EL, Gilbert CL, Pharr WF, Benoit CH. Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Ann Thorac Surg 1996;62:401–409.  Back to cited text no. 13
    
14.
Rao V, Ivanov J, Weisel RD, Ikonomidis JS, Christakis GT, David TE. Predictors of low cardiac output syndrome after coronary bypass. J Thorac Cardiovasc Surg 2006; 112:38–51.  Back to cited text no. 14
    
15.
Christenson JT, Cohen M, Ohman EM, Reddy RC, Stone GW, Urban PM, et al. Trends in intraaortic balloon counter pulsation complications and outcomes in cardiac surgery. Ann Thorac Surg 2010; 74:1086–1091.  Back to cited text no. 15
    
16.
Barnett MG, Swartz MT, Peterson GJ, Naunheim KS, Pennington DG, Vaca KJ, Fiore AC, et al. Vascular complications from intra-aortic balloons: risk analysis. J Vasc Surg 2010; 19:81–89.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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