High-risk Coronary Artery Bypass Graft Patients Research Articles

A Frailty Index to Predict Mortality, Resource Utilization and Costs in Patients Undergoing Coronary Artery Bypass Graft Surgery in Ontario

BackgroundPeople living with frailty are vulnerable to poor outcomes and incur higher health care costs after coronary artery bypass graft (CABG) surgery. Frailty-defining instruments for population-level research in the CABG setting have not been established. The objectives of the study were to develop a preoperative frailty index for CABG (pFI-C) surgery using Ontario administrative data; assess pFI-C suitability in predicting clinical and economic outcomes; and compare pFI-C predictive capabilities with other indices. MethodsA retrospective cohort study was conducted using health administrative data of 50,682 CABG patients. The pFI-C comprised 27 frailty-related health deficits. Associations between index scores and mortality, resource use and health care costs (2022 Canadian dollars [CAD]) were assessed using multivariable regression models. Capabilities of the pFI-C in predicting mortality were evaluated using concordance statistics; goodness of fit of the models was assessed using Akakie Information Criterion. ResultsAs assessed by the pFI-C, 22% of the cohort lived with frailty. The pFI-C score was strongly associated with mortality per 10% increase (odds ratio [OR], 3.04; 95% confidence interval [CI], [2.83,3.27]), and was significantly associated with resource utilization and costs. The predictive performances of the pFI-C, Charlson, and Elixhauser indices and Johns Hopkins Aggregated Diagnostic Groups were similar, and mortality models containing the pFI-C had a concordance (C)-statistic of 0.784. Cost models containing the pFI-C showed the best fit. ConclusionsThe pFI-C is predictive of mortality and associated with resource utilization and costs during the year following CABG. This index could aid in identifying a subgroup of high-risk CABG patients who could benefit from targeted perioperative health care interventions.

Coronary artery bypass grafting in active or recent COVID-19 infection: a systematic review.

Even though there have been few studies on coronary artery bypass grafting (CABG), data on patients with coronavirus disease-2019 (COVID-19) infection show that cardiac surgery has poor outcomes in this subset. From the available studies in the literature, we conducted a systematic review with the aim of determining the outcome of COVID-19 patients who underwent CABG. Between December 2019 and October 2022, searches were conducted in PubMed, the Directory of Open Access Journals, and Google Scholar to find studies reporting results of COVID-19 patients undergoing CABG. We extracted data on the clinical profile and outcomes of the patients from the eligible studies. The quality of the studies was assessed using a standardised tool. The total sample size across the 12 included studies was 99 patients who underwent CABG in active disease or within 30days of COVID-19 infection. The median and interquartile range (IQR) for the length of time spent on a mechanical ventilator, stay in the intensive care unit (ICU), and the total hospital stay were 0.9 (0.47-2), 4.5 (2.5-8), and 12.5 (8.5-22.5) days respectively. Seventy-six patients developed postoperative complications, and there were eleven deaths. The findings of the present study indicate that mortality risk goes down when the time between COVID-19 diagnosis and surgery increases. When compared to data from other high-risk urgent or emergent CABG patients around the world who were not infected with COVID-19, patients who underwent CABG in the COVID-19 subgroup had similar postoperative outcomes. The online version contains supplementary material available at 10.1007/s12055-023-01495-7.

Computed Tomography Imaging Assessment of the Effect of Vancomycin Paste on Poststernotomy Healing.

PurposeTo assess vancomycin paste effect on poststernotomy healing in high-risk coronary artery bypass grafting (CABG) patients compared to bone wax using the 6-point computed tomography (CT) score. Additionally assessed the reliability of this score and its relationship to the occurrence of infection.Patients and MethodsA prospective comparative analysis included 126 high-risk CABG patients. The patients were randomly assigned into bone wax or vancomycin paste for sternal haemostasis. All patients were submitted to CT examinations 6-months postoperative. Two radiologists independently reviewed all CT scans to assess sternal healing using the 6-point CT score. The CT healing score of the two groups was compared. The kappa statistics were used to calculate the inter-reader agreement (IRA) of the 6-point CT score.ResultsThe final analysis included 61 patients in each group. The main CT score for sternal healing was 3.9±0.4 in the vancomycin group and 3.3±0.8 in the bone wax group. Patients in the vancomycin group had a higher statistically significant improvement in CT healing score than those in the bone wax group (p<0.001). There was no statistically significant relationship (p = 0.79) between the occurrence of infection and the 6-point CT score in the vancomycin group. The overall IRA of the 6-point CT score was good in two groups (κ = 0.79 in the vancomycin group and = 0.78 in the bone wax group).ConclusionVancomycin paste had a better CT healing score and can be used as a sternal haemostatic material instead of bone wax. The 6-point CT healing score is a reliable diagnostic tool for evaluating sternal healing.

Temporary mechanical circulatory support prevents the occurrence of a low-output state in high-risk coronary artery bypass grafting: A case series.

Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population. Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration. All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 hpostoperatively with cardiac indices of 2.9-3.6 L/min/m2 , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h). Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.

The effect of remote patient monitoring on discharge outcomes in post-coronary artery bypass graft surgery patients.

Coronary artery bypass graft (CABG) surgery is a lifesaving procedure for patients with coronary artery disease but ranks highest (13.5%) for preventable hospital readmissions and second highest in average Medicare payment ($8,136) per readmission. Care transitions after hospital discharge warrant exploration to improve outcomes. The purpose of this brief report was to compare the effect of remote patient monitoring (RPM) on 30-day outcomes in Medicare beneficiaries after isolated CABG surgery. Results demonstrated no statistically significant difference in 30-day readmission (p = .568) or emergency department encounters (p = .785) between groups. However, time to achieve a cardiology follow-up appointment decreased from 19.8 to 13.7 days (p = .062) in the RPM group. Although the findings were not statistically significant, this study demonstrated a reduction in CABG readmissions and timely provider follow-up with RPM. In addition, study findings contribute to the body of nursing knowledge and support the need for further studies to identify high-risk CABG patients who may benefit from RPM after hospital discharge.

Low Wall Shear Stress Is Associated with Saphenous Vein Graft Stenosis in Patients with Coronary Artery Bypass Grafting.

Biomechanical forces may play a key role in saphenous vein graft (SVG) disease after coronary artery bypass graft (CABG) surgery. Computed tomography angiography (CTA) of 430 post-CABG patients were evaluated and 15 patients were identified with both stenosed and healthy SVGs for paired analysis. The stenosis was virtually removed, and detailed 3D models were reconstructed to perform patient-specific computational fluid dynamic (CFD) simulations. Models were processed to compute anatomic parameters, and hemodynamic parameters such as local and vessel-averaged wall shear stress (WSS), normalized WSS (WSS*), low shear area (LSA), oscillatory shear index (OSI), and flow rate. WSS* was significantly lower in pre-diseased SVG segments compared to corresponding control segments without disease (1.22 vs. 1.73, p = 0.012) and the area under the ROC curve was 0.71. No differences were observed in vessel-averaged anatomic or hemodynamic parameters between pre-stenosed and control whole SVGs. There are currently no clinically available tools to predict SVG failure post-CABG. CFD modeling has the potential to identify high-risk CABG patients who may benefit from more aggressive medical therapy and closer surveillance. Graphical Abstract.

Abstract WP133: Intra Cerebral Atherosclerosis is the Major Risk Factor for Stroke in Post Coronary Artery Bypass Graft Surgery Patients

Introduction: Stroke is one of the most severe complications after Coronary artery bypass grafting (CABG) and is associated with high rates of morbidity and mortality. Hypothesis: We aimed to define the relationship between extracranial and intracranial carotid artery stenosis and the risk of stroke after CABG. Methods: A retrospective analysis of 1245 consecutive patients who underwent coronary artery bypass grafting (CABG) in our institution from March 2015 till March 2017 was performed. All of them had carotid duplex ultrasound as a routine preoperative assessment. Those patients who had severe extracranial carotid stenosis (&gt;70%), underwent computed tomography angiogram of head and neck cerebral vessels. Our analysis was mainly focused on assessing the relation between incidence of post-CABG stroke and severity of intra and extra cranial cerebral atherosclerosis. Results: Of the 1245 patients who underwent coronary artery bypass grafting(CABG) the routine preoperative carotid Doppler revealed severe extracranial carotid artery stenosis of &gt;70% in 160 patients, who eventually underwent computed tomography angiogram which has shown both extra and intracranial cerebral vascular stenosis in 124 patients. Total number of patients who had post CABG strokes are 42 (3.37%), out of which 39 (3.13%) had extensive extra and intracranial vascular stenosis whereas only 3 (0.24%) had isolated extracranial vascular stenosis. Patients with extensive extra and intracranial cerebral atherosclerosis has high rate of in-hospital strokes (within 14 days) compared with patients with isolated extracranial atherosclerotic disease. Conclusion: Extensive atherosclerosis including intra and extracranial cerebral arteries are major risk factors for stroke in patients undergoing CABG. Pre-operative assessment of both intra and extracranial cerebral arteries increases the probability of risk assessment in high risk CABG patients.

The Effects of Intra-Aortic Balloon Pumps on Mortality in Patients Undergoing High-Risk Coronary Revascularization: A Meta-Analysis of Randomized Controlled Trials of Coronary Artery Bypass Grafting and Stenting Era.

BackgroundIntra-aortic balloon pumps (IABP) have generally been used for patients undergoing high-risk mechanical coronary revascularization. However, there is still insufficient evidence to determine whether they can improve outcomes in reperfusion therapy patients, mainly by percutaneous coronary intervention (PCI) with stenting or coronary artery bypass graft (CABG). This study was designed to determine the difference between high-risk mechanical coronary revascularization with and without IABPs on mortality, by performing a meta-analysis on randomized controlled trials of the current era.MethodsPubmed and Embase databases were searched from inception to May 2015. Unpublished data were obtained from the investigators. Randomized clinical trials of IABP and non-IABP in high-risk coronary revascularization procedures (PCI or CABG) were included. In the case of PCI procedures, stents should be used in more than 80% of patients. Numbers of events at the short-term and long-term follow-up were extracted.ResultsA total of 12 randomized trials enrolling 2155 patients were included. IABPs did not significantly decrease short-term mortality (relative risk (RR) 0.66; 95% CI, 0.42–1.01), or long-term mortality (RR 0.79; 95% CI, 0.47–1.35), with low heterogeneity across the studies. The findings remained stable in patients with acute myocardial infarction with or without cardiogenic shock. But in high-risk CABG patients, IABP was associated with reduced mortality (71 events in 846 patients; RR 0.40; 95%CI 0.25–0.67).ConclusionIn patients undergoing high-risk coronary revascularization, IABP did not significantly decrease mortality. But high-risk CABG patients may be benefit from IABP. Rigorous criteria should be applied to the use of IABPs.

The Impact of High-Risk Cases on Hospitals’ Risk-Adjusted Coronary Artery Bypass Grafting Mortality Rankings

Risk-adjusted mortality (RAM) models are increasingly used to evaluate hospital performance, but the validity of the RAM method has been questioned. Providers are concerned that these methods might not adequately account for the highest levels of risk and that treating high-risk cases will have a negative impact on RAM rankings. Using cases of isolated coronary artery bypass grafting (CABG) performed at 1002 sites in the United States participating in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from 2008 to 2010 (N= 494,955), the STS CABG RAM model performance in high-risk patients was assessed. The ratios of observed to expected (O/E) perioperative mortality were compared among groups of hospitals with varying expected risks. Finally, RAM rates during the overall study period for each site were compared with itsperformance in a simulated "nightmare year" in whichthe site's highest risk cases over a 3-year periodwere concentrated into a 1-year period of exceptional risk. The average predicted mortality for center risk groups ranged from 1.46% for the lowest risk quintile to 2.87% for the highest. The O/E ratios for center risk quintiles 1 to 5 during the overall period were 1.01 (95% confidence interval, 0.96% to 1.06%), 1.00 (0.95% to 1.04%), 0.98 (0.94% to 1.03%), 0.97 (0.93% to 1.01%), and 0.80 (0.77% to 0.84%), respectively. The sites' risk-adjusted mortality rates were not increased when the centers' highest risk cases were concentrated into a single "nightmare year." Our results show that the current risk-adjusted models accurately estimate CABG mortality and that hospitals accepting more high-risk CABG patients have equal or better outcomes than do those with predominately lower-risk patients.

Travel Distance and Health Outcomes for Scheduled Surgery

Changes in the location and availability of surgical services change the distances that patients must travel for surgery. Identifying health effects related to travel distance is therefore crucial to evaluating policies that affect the geographic distribution of these services. We examine the health outcomes of coronary artery bypass graft (CABG) patients in Pennsylvania for evidence that traveling further to a hospital for a one-time, scheduled surgical procedure causes harm. We perform instrumental-variable regressions to test for the effect of distance to the admitting hospital on the in-hospital mortality and readmission rates of 102,858 CABG patients in Pennsylvania during 1995-2005, where the instrumental variables are constructed based on the quality of and distance to nearby CABG hospitals. We found that patients living near a CABG hospital with acceptable quality traveled significantly less and if they were high-risk, had lower in-hospital mortality rates. Readmission rates in general are not affected by patients' travel distance. The positive correlation between travel distance and health outcomes observed by previous studies may reflect the confounding effects of behavioral factors and patient health risks. We found instead that living further from the admitting hospital increases in-hospital mortality for high-risk CABG patients. More research on the possible causes of these effects is necessary to identify optimal policy responses.

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.

Variation in perioperative vasoactive therapy in cardiovascular surgical care: Data from the Society of Thoracic Surgeons

The appropriate use of vasoactive cardiovascular drugs in high-risk coronary artery bypass grafting (CABG) patients has not been well characterized. We performed a detailed chart analysis on 2,390 randomly selected patients undergoing CABG between January 2004 and June 2005 at 55 hospitals participating in the Society of Thoracic Surgeons' National Adult Cardiac Surgery Database. Patients were eligible if they had elective/urgent CABG with an ejection fraction (EF) <40%, or if they had an elective or urgent CABG at > or =65 years with diabetes, or a glomerular filtration rate <60 mL/min per 1.73 m(2). Logistic regression modeling was used to determine predictors of and provide risk-adjusted frequencies of postoperative vasoactive therapies. Vasoactive therapy was used in 90% of patients. Inotropes/vasopressors were used in 28% (668), vasodilators in 18% (430), and the combination in 43% (1,037). Predictors of any inotrope use were preoperative atrial fibrillation (odds ratio [OR] 1.48), other arrhythmia (OR 2.09), EF (OR 1.09 per 5-unit decrease), severe mitral regurgitation (OR 2.56), 3-vessel coronary artery disease (OR 1.35), New York Heart Association class IV (1.38), on-pump (OR 1.86), other procedure (OR 2.51), and peripheral vascular disease (OR 1.28) (all OR P < .05). Hospital-level risk-adjusted rates of any inotrope use varied significantly from 100% to 35% (P < .01) and vasodilator rates varied from 100% to 10% (P < .01). There is marked hospital variation in the use of vasoactive therapies in high-risk CABG patients in clinical practice, indicating an important area for further research to better clarify best practice.

Early Readmission of Low-Risk Patients after Coronary Surgery

Early readmission after coronary artery bypass grafting (CABG) is an expensive adverse outcome. Although the perioperative experience of high-risk CABG patients has been studied extensively, little attention has been paid to low-risk CABG patients. The primary goal of this study was to identify the preoperative characteristics and to define risk predictors of readmission and preventive factors for readmission in low-risk isolated-CABG patients. We identified 2157 patients who underwent CABG between January 2000 and December 2005 at Washington Hospital Center, Washington, DC, and defined as low risk patients who had a Parsonnet bedside risk score lower than the 25th percentile. Patients who were rehospitalized within 30 days after surgery were compared with those who were not rehospitalized during this period. The overall readmission rate for this study cohort was 6.3%. Compared with non-readmitted patients, early-readmitted patients were more likely to have diabetes mellitus (27.94% versus 20.88%, P = .05) and less likely to have hypertension (42.65% versus 51.36%, P = .05). Blood product transfusion (P < .01), postoperative length of intensive care unit stay (P = .01), and length of hospital stay (P = .05) were all significantly increased in the readmitted patients. The use of beta-blockers (P = .03) and angiotensin-converting enzyme inhibitors (P = .04) was significantly lower at discharge in this group of patients; however, multivariate regression analysis demonstrated diabetes (odds ratio, 1.59; 95% confidence interval, 1.08-2.42) to be the only independent predictor of early readmission. For low-risk CABG patients, diabetes mellitus is the risk predictor of early readmission. Early discharge was not associated with early readmission.

Impact of an early recovery management intervention on functioning in postoperative coronary artery bypass patients with diabetes

Approximately 30% of patients undergoing coronary artery bypass graft (CABG) procedures have diabetes and, as such, are at increased risk for postoperative complications and a lengthy recovery. To test the feasibility of an in-home early recovery management intervention to improve physical and psychosocial functioning in the diabetic CABG population. This pilot study was a 2-group, randomized, experimental study. The 6-week in-home early recovery intervention was delivered by way of a device called the Health Buddy (Health Hero Network, Redwood City, CA). Subjects were 49 diabetic patients who had undergone a first-time CABG procedure. Although no statistical differences between groups were found, descriptively, the intervention group's baseline means on Medical Outcomes Study Short Form-36 subscales measuring physical functioning were lower but improved to levels comparable with that of the control group. Improvements in psychosocial functioning were comparable between the 2 groups. This in-home telehealth intervention may have promise for improving functioning outcomes in high-risk CABG patients with diabetes. However, weaknesses of the intervention and the need for a more focused, directive intervention were identified.

Are High‐Quality Cardiac Surgeons Less Likely to Operate on High‐Risk Patients Compared to Low‐Quality Surgeons? Evidence from New York State

It is unknown whether high-risk cardiac surgical patients have less access to high-quality surgeons compared with lower-risk patients. To determine whether high-quality surgeons are less likely to perform coronary artery bypass graft (CABG) surgery on high-risk patients compared with low-quality surgeons. Retrospective cohort study using the New York State (NYS) CABG Surgery Reporting System (CSRS) of all patients undergoing CABG surgery in NYS who were discharged between 1997 and 1999 (51,750 patients; 2.20 percent mortality). Regression modeling was used to estimate the association between surgeon quality and patient risk of death. Surgeon quality was quantified using the observed-to-expected mortality ratio (O-to-E ratio). Higher-risk patients are more likely to receive CABG surgery from higher-quality surgeons. For every 10 percentage point increase in patient risk of death (e.g., from 5 to 15 percent), there is an absolute reduction of 0.034 in the surgeon O-to-E ratio (p < .001). This study suggests that high-risk CABG patients are significantly more likely to receive care from high-quality surgeons compared with lower risk patients.

Diabetes and Coronary Revascularization

Patients with diabetes mellitus account for approximately 25% of the nearly 1.5 million coronary revascularization procedures performed each year in the United States and experience worse outcomes compared with nondiabetic patients. To summarize the current state of evidence comparing the effectiveness and safety of coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) in diabetic patients and to examine developments that may affect future outcomes in this high-risk group. Using the key terms diabetes mellitus, revascularization, coronary artery bypass, angioplasty, and coronary intervention, we searched MEDLINE from 1985 to 2004 for all randomized controlled trials (RCTs) comparing CABG surgery and PCI that reported outcomes in diabetic patients. Bibliographies and the Web sites of cardiology conferences were also reviewed. Studies comparing drug-eluting stents and bare-metal stents were identified in a similar fashion. The literature was reviewed to identify clinical measures that may impact revascularization outcomes in diabetic patients. We identified 6 RCTs comparing CABG surgery and PCI in a total of 950 diabetic patients. A mortality benefit for CABG over balloon-only PCI has been demonstrated in diabetic patients with multivessel coronary artery disease but has not been clearly established against stent-assisted PCI or in high-risk CABG patients. Use of glycoprotein IIb/IIIa receptor inhibitors has improved survival in diabetic patients undergoing PCI. Restenosis after PCI in diabetic patients has led to substantially higher repeat revascularization rates than after CABG. The use of drug-eluting stents has led to dramatic reductions in restenosis in diabetic patients. Ongoing RCTs comparing CABG and PCI using drug-eluting stents in diabetic patients will clarify the impact of these advances on outcomes. There is a relative lack of data from RCTs specifically comparing CABG surgery and PCI as currently practiced in diabetic patients. The mortality advantage and decreased rates of revascularization seen with CABG in subgroups from early trials may not be applicable in the era of drug-eluting stents, glycoprotein IIb/IIIa inhibitors, and the latest medical therapies.

Retrospective analysis of the clinical trends and current indications for perioperative intraaortic balloon pumping in high-risk coronary artery bypass surgery

We clinically evaluated the current indications for perioperative intraaortic balloon pumping (IABP) in high-risk patients undergoing coronary artery bypass grafting (CABG). Over the past 22 years, 196 CABG patients received perioperative IABP at our institution. We divided the 22 years into periods I–IV (earliest to latest) and investigated the annual changes in the indications for and mortality from IABP. In periods I and II, IABP was mainly employed for postoperative low-output syndrome (LOS) or perioperative myocardial infarction (PMI). The hospital mortality rate was 13.2%–18.5%. In period III, the mortality rate was markedly reduced by the use of preoperative scheduled IABP. In period IV, however, scheduled IABP was used less often for high-risk CABG, and IABP was mainly employed in patients having emergency CABG for acute coronary syndrome (ACS). The hospital mortality rate was reduced to 3.7%. In the last 2 years, 19 (65.5%) of 29 patients who received preoperative IABP had emergency CABG for ACS, while 27 high-risk CABG patients with poor left ventricular (LV) function or left main trunk (LMT) disease were treated successfully without scheduled IABP. There were no significant differences between the IABP and non-IABP patients in age, sex, number of bypasses, and aortic cross-clamp time. Because of improvements in anesthesia, operative techniques, perioperative management, and cardioplegic solutions, preoperative support with IABP is less often needed for high-risk CABG, except in patients undergoing emergency surgery for ACS.