Intra-aortic Balloon Counterpulsation Research Articles

Outcome of coronary artery bypass graft surgery in patients with low ejection fraction

Background: Patients with low ejection fraction (EF) are at high risk for postoperative complication and mortality. Our aim was to assess the effect of low EF on clinical outcome after surgery. Objective: The present study evaluates our experience with coronary artery bypass grafting in patients with low EF. Materials and Methods: We analyzed the data of 35 patients with EF <35%. All participants were assessed preoperatively with respect to patient characteristics, risk factors, and preoperative two dimension echocardiography (2D ECHO). Depending on findings of 2D ECHO patients were divided into three groups: in Group 1, we included patients with EF 30%–35%, Group 2 comprised patients with EF of 25%–30%, and Group 3 consisted of patients with EF <25%. Patients were operated by off-pump coronary artery bypass grafting; only three patients were operated by on-pump beating heart surgery. We noted a mean number of grafts required, use of intra-aortic balloon counterpulsation (intra-aortic balloon pump) intraoperatively and postoperatively, postoperative complication, mortality, mean hospital stay, postoperative improvement in EF, and postoperative control of angina and symptomatic improvement. Results: Hospital mortality rate in present series was 11%. Mean grafts were 3.02 per patient. Fourteen (40%) patient had a postoperative complication. EF improved in 78% of patients. Canadian Cardiovascular Society Angina class improved in 42% of patients. Conclusion: In patients with coronary artery disease and low EF, CABG can be performed safely, and improvement in left ventricular function can be achieved with this procedure improving the quality of life.

Prophylactic Intra-Aortic Balloon Counterpulsation in High Risk Cardiac Surgery: The Pinball Program of Research and Linked-Data Pilot RCT

Purpose: Prophylactic intra-aortic balloon pump (IABP) therapy in high risk patients undergoing CABG surgery may reduce mortality. However, the quality of the available evidence is low and there is substantial variability in use. Although there is a need to generate high quality evidence, several issues first need to be addressed, including equipoise for enrolment into a RCT, delivery of prophylactic IABP in a trial setting and study recruitment rate. The aim of the PINBALL pilot RCT is to address these issues and assess the feasibility of a definitive trial. Methodology: PINBALL is a multidisciplinary collaboration involving the ANZSCTS Database Program. The current pilot study builds on a program of registry-linked research, nesting an RCT within a high quality database. Patients are screened for eligibility i.e. they have no exclusion criteria and are listed for CABG surgery, the treating surgical team is uncertain as to the benefit of prophylactic IABP and there is one or more of: severely impaired left ventricular function, recent or ongoing myocardial ischaemia, or critical coronary artery stenosis. Results: The pilot RCT has screened 100 and enrolled 17 participants at five centres (planned sample size is 40), randomising patients to either prophylactic IABP in addition to standard care, or standard care alone. Recruitment rate is currently 0.5 (range 0.1-0.7) participants per site per month. Treatment according to enrolment status occurred in 7/8 (88%) and 9/9 (100%) of participants in the IABP and no IABP arms respectively. Conclusion: Randomisation to an IABP trial appears feasible, however current recruitment rate is low, suggesting a definitive trial would require a substantial number of sites and time.

Preserved autoregulation of coronary flow after off-pump coronary artery bypass grafting: retrospective assessment of intraoperative transit time flowmetry with and without intra-aortic balloon counterpulsation.

BackgroundIntra-aortic balloon pumping (IABP) markedly increases graft flow after coronary artery bypass grafting (CABG) with cardiopulmonary bypass. We sought to delineate the effects of IABP on graft flow after off-pump CABG (OPCAB).MethodsThe clinical records of 32 patients (25 male, 7 female; mean age: 70 ± 9 years) who underwent OPCAB with IABP between January 2011 and May 2015 were retrospectively reviewed. Thirteen patients (41%) had a history of myocardial infarction, and 13 patients (41%) had a history of percutaneous coronary intervention. In total, there were 76 bypass grafts with 102 distal anastomoses. These included 50 in situ or pedicled grafts and 26 aortocoronary grafts. After completion of the anastomoses, the heart was positioned normally, and graft flow with IABP was measured using transit-time flowmetry under stable circulation. Then, IABP was turned off for 30 s to a few minutes, until graft flow was constant, for measurement of flow off IABP.ResultsThe angiographic patency rate was 100% (47/47). Overall, graft flow was 55 ± 36 ml/min on IABP and 53 ± 36 ml/min off IABP (p = 0.37). The pulsatility index was 4.1 ± 2.1 on IABP and 2.7 ± 1.5 off IABP (p < 0.001). There was no significant difference in graft flow between on and off IABP for aortocoronary bypass or in situ grafts. Graft flow was 57 ± 36 ml/min on IABP and 55 ± 37 ml/min off IABP (p = 0.41) in in situ grafts and 52 ± 34 ml/min on IABP and 49 ± 35 off IABP (p = 0.41) in aortocoronary grafts. Graft flow on IABP was more than 5 ml/min greater in 28 (37%) bypass grafts, and more than 5 ml/min lower in 20 (26%) bypass grafts.ConclusionIn contrast to previous reports for conventional CABG, graft flow after OPCAB was not necessarily increased by IABP, regardless of elevated diastolic arterial pressure. It is suggested that preserved autoregulation of coronary flow contributes to a lower impact on the heart and early functional recovery, and consequently, greater perioperative safety of OPCAB.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) in postcardiotomy cardiogenic shock: how much pump flow is enough?

Post-cardiotomy cardiogenic shock (PCCS) is a complication of heart surgery associated with a poor prognosis: veno-arterial extracorporeal membrane oxygenation (VA ECMO) ensures end-organ perfusion while fully replacing heart and lung function, though it is associated with unsatisfactory results. Few studies have identified reliable predictors of poor prognosis early in the course of extracorporeal support. A recent study showed the strong prognostic power of urine output in the first 24 hours of VA ECMO in predicting early and late mortality of PCCS. Urine output is a commonly collected parameter in all intensive care units (ICU) and has a defined role in the diagnosis of acute kidney injury (AKI) and is inexpensive. These findings offer the possibility to summarize some aspects regarding the adequacy of extracorporeal support early in the course of cardiogenic shock and to shed light about cardio-renal interactions in ECMO patients. Finally, it is our opinion that a timely implantation of mechanical circulatory support in post cardiotomy shock should be considered if systemic perfusion is not ensured by low or medium dose inotropic support and intra-aortic balloon counterpulsation.

Myocardial protection during CABG: Warm blood versus cold crystalloid cardioplegia, is there any difference?

BackgroundUp till now there is lack of consensus to the optimal method for cardioplegia delivery in coronary artery bypass graft (CABG) patients. Various strategies have been developed to minimize ischemic-reperfusion injury.The aim of this study was to compare cold crystalloid cardioplegia and warm blood cardioplegia in patients undergoing CABG. MethodsPatients (n = 100) undergoing CABG were prospectively randomized into group 1 (n = 50) which received antegrade cold crystalloid cardioplegia, group 2 (n = 50) which received antegrade warm blood cardioplegia. Blood samples were collected immediately, 12, and 24 h postoperatively and CK, CKMB, and Cardiac Troponin I were measured and compared between the two groups which were the indicator of myocardial cell injury (the primary end point of this study). Other indicators such as spontaneous defibrillation, use of intra-aortic balloon counter pulsation (IABC), and use of inotropic support were also documented. ResultsPreoperative demographic and clinical variables were matched in both groups. However, intraoperatively, the use of inotropic support was significantly higher in Group I compared to Group II (P = 0.032). Postoperative CK, CKMB and Troponin I were significantly higher in group (I) compared to group (II). ConclusionA significant reduction in the release of cardiac enzymes in patients who received antegrade warm blood cardioplegia suggests better myocardial protection compared to cold crystalloid cardioplegia.

Impact of Non-Infarct-Related Artery Disease on Infarct Size and Outcomes (from the CRISP-AMI Trial)

BackgroundNon-infarct-related artery (non-IRA) disease is prevalent in patients with ST-segment elevation myocardial infarction (STEMI). We aimed to assess the impact of non-IRA disease on infarct size and clinical outcomes in patients with acute STEMI. MethodsThe Counterpulsation to Reduce Infarct Size Pre-PCI Acute Myocardial Infarction (CRISP-AMI) trial randomized patients to intra-aortic balloon counterpulsation (IABC) vs no IABC prior to percutaneous coronary intervention in patients with acute STEMI. Infarct size (% left ventricular mass) at 3-5 days post percutaneous coronary intervention and 6-month clinical outcomes were compared between patients with and without non-IRA disease (defined as ≥50% stenosis in at least one non-IRA). ResultsA total of 324 (96.1%) patients had anterior STEMI, of whom 34.9% had non-IRA disease. There was no difference in infarct size (% left ventricular mass) between patients with and without non-IRA disease (median 39% vs 39%; P = .73). At 6 months, there was no difference in rates of recurrent myocardial infarction (0.9% vs 0.9%; P = .78), major Thrombolysis In Myocardial Infarction bleeding (0.9% vs 0.5%; P = .77), or all-cause death (3.5% vs 2.4%; P = .61) in patients with and without non-IRA disease, respectively. Patients with non-IRA disease had a higher rate of new/worsening heart failure with hospitalization (8.8% vs 1.9%; P = .0050). ConclusionsMore than one-third of patients with anterior STEMI in the CRISP-AMI study had non-IRA disease. These patients had similar infarct sizes and rates of recurrent myocardial infarction, major bleeding, and all-cause death. Patients with non-IRA disease did have a higher rate of new/worsening heart failure with hospitalization. Further study is needed to understand the mechanisms of outcomes of patients with non-IRA disease.

Efficacy of intra-aortic balloon counterpulsation in patients with acute myocardial infarction according to the type of revascularization: a meta-analysis

To evaluate the effects of intra-aortic balloon counterpulsation (IABP) on mortality in patients with acute myocardial infarction according to the type of revascularization. Recruited randomized controlled trials of IABP compared with no-IABP controls in acute myocardial infarction patients from January 1970 to May 2015 were searched from Medline, Embase and Cochrane Library, according to inclusion criteria and exclusion criteria. These data were analyzed using the methods recommended by the Cochrane Collaboration's software RevMan 5.0. Revascularization included thrombolytic therapy, percutaneous coronary intervention (PCI), or coronary artery bypass grafting. (1) Eleven randomized controlled trials were enrolled for analysis with 1 102 patients in IABP group, 1 123 in no-IABP control group. (2) Compared with no-IABP control group, IABP could not significantly decrease the in-hospital or 30 day mortality (OR=0.84, 95%CI 0.65-1.09, P=0.20). (3)Compared with no-IABP control group, IABP could not significantly decrease the in-hospital or 30 day mortality in thrombolytic patients(OR=0.64, 95%CI 0.25-1.61, P=0.34), in PCI patients (OR=0.89, 95%CI 0.68-1.18, P=0.42), and in coronary artery bypass grafting patients(OR=0.46, 95%CI 0.13-1.63, P=0.23). (4)The difference reached borderline signiicance between no-IABP control group and IABP group in patients using IABP before PCI(OR=0.47, 95%CI 0.22-1.00, P=0.05), but not in case of after PCI(OR=1.33, 95%CI 0.63-2.79, P=0.45). IABP does not decrease the in-hospital or 30 day mortality of acute myocardial infarction patients who received thrombolytic therapy, PCI, or coronary artery bypass grafting. But IABP might decreases the in-hospital or 30 day mortality in patients when used before PCI.

074 - Acute Hemodynamic Effects of Large Capacity Intra-Aortic Balloon Counterpulsation Pumps in Patients with Advanced Heart Failure

074 - Acute Hemodynamic Effects of Large Capacity Intra-Aortic Balloon Counterpulsation Pumps in Patients with Advanced Heart Failure

Prognostic implications of fluid balance in ST elevation myocardial infarction complicated by cardiogenic shock.

Positive fluid balance has been associated with adverse outcomes in patients admitted to general intensive care units. We analysed the relationship between a positive fluid balance and its persistence over time in terms of in-hospital outcomes among ST elevation myocardial infarction (STEMI) patients complicated by cardiogenic shock. We retrospectively studied fluid intake and output for 96 hours following hospital admission in 48 consecutive adult patients with STEMI complicated by cardiogenic shock, all undergoing primary angioplasty. Daily and accumulated fluid balance was registered at up to 96 hours following admission. The cohort was stratified into two groups based on the presence or absence of positive fluid balance on day 4. Patients' records were assessed for in-hospital adverse outcomes, as well as 30-day all-cause mortality. A positive fluid balance was present in 19/48 patients (40%). Patients with positive fluid balance were older and more likely to be treated by intra-aortic balloon counter-pulsation and antibiotics. These patients were more likely to develop acute kidney injury and to need new intubation and were less likely to have renal function recovery as well as successful weaning from mechanical ventilation ( p < 0.05 for all). Patients with positive fluid balance had higher 30-day mortality (68% vs. 10%; p < 0.001). In a multivariate Cox regression model, for every 1-L increase in positive fluid balance, the adjusted risk for 30-day mortality increased by 24% (hazard ratio: 1.24, 95% confidence interval: 1.07-1.42; p = 0.003). A positive fluid balance was strongly associated with higher 30-day mortality in STEMI complicated by cardiogenic shock.

Mechanical strategies to enhance myocardial salvage during primary percutaneous coronary intervention in patients with STEMI.

Primary percutaneous coronary intervention (PPCI) has become the mainstay of reperfusion therapy in patients with ST-segment elevation myocardial infarction (STEMI). Despite timely reperfusion by PPCI and restoration of epicardial blood flow in up to 95% of patients, tissue reperfusion remains suboptimal in a sizeable proportion of patients with STEMI. Over the years mechanical and pharmacological strategies to enhance myocardial salvage during PPCI have been developed and used in patients with STEMI. The most common mechanical strategies used in the setting of PPCI include: coronary stenting, direct stenting, mesh-covered stents, self-expanding stents, deferred stenting, thrombectomy, distal protection devices, intra-aortic balloon pumping, left ventricular assist devices and ischaemic conditioning. These strategies are thought to enhance myocardial salvage via improving acute procedural success, attenuation of distal embolisation, microvascular obstruction and reperfusion injury, and providing haemodynamic support. Coronary (direct) stenting is almost the default approach of reperfusion during PPCI procedures. Evidence on the use of mesh-covered stents, self-expanding stents, deferred stenting or left ventricular assist devices is scant and their use in the setting of PPCI remains limited. Mechanical thrombectomy, distal protection devices or routine intra-aortic balloon counterpulsation seem to offer no clinical benefit when used in the setting of PPCI. Although manual aspiration may improve indices of tissue reperfusion, recent research showed no clinical benefit of routine use of this strategy in patients with STEMI undergoing PPCI. Ischaemic conditioning, although promising, remains at an investigational stage and needs further research.

Echocardiographic Predictors of Immediate Postoperative Outcomes in Patients With Severe Left Ventricular Systolic Dysfunction Undergoing On-Pump Coronary Artery Bypass Grafting.

The postoperative course following on-pump coronary artery bypass grafting (CABG) in patients with severe left ventricular (LV) systolic dysfunction is often unpredictable. Therefore, the aim of this study was to identify predictors of poor postoperative outcome in this subset of patients. Prospective observational study SETTING: Single university hospital PARTICIPANTS: Forty patients with severe LV systolic dysfunction undergoing isolated on-pump CABG INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Comprehensive transesophageal echocardiographic examination was performed to obtain the indices of systolic and diastolic LV function after induction of anesthesia. A poor postoperative outcome was defined as patient death or vasoactive inotropic score≥20 for at least 6 hours and/or requiring intra-aortic balloon counterpulsation and/or mechanical ventilation for≥24 hours. Poor postoperative outcome was observed in 40% (16/40) of patients. Patients with poor postoperative outcomes had a significantly higher systolic dyssynchrony index, septal-lateral delay with a significantly lower global longitudinal strain and isovolumic acceleration, end-diastolic volume, end-systolic volume, and lateral and medial mitral annulus systolic velocity. In a binary logistic regression model, global longitudinal strain (odds ratio, 1.5, confidence interval [CI] 95%, 1.19-1.88, p = 0.001), septal-lateral delay (odds ratio, 1.02, 95% CI, 1.01-1.03; p = 0.001) and systolic dyssychrony index (odds ratio, 1.3, 95% CI, 1.13-1.48; p = 0.000) were found to be predictors of poor postoperative outcome. Global longitudinal strain, systolic dyssynchrony index, and septal-lateral delay were reliable and accurate predictors of adverse outcomes in patients with severe LV systolic dysfunction undergoing on-pump CABG.

Progress of intra-aortic balloon counterpulsation application in patients with acute myocardial infarction

Progress of intra-aortic balloon counterpulsation application in patients with acute myocardial infarction

ИЗМЕНЕНИЕ ПОДХОДА К ИСПОЛЬЗОВАНИЮ ВНУТРИАОРТАЛЬНОЙ БАЛЛОННОЙ КОНТРПУЛЬСАЦИИ ПРИ СОЧЕТАННЫХ ОПЕРАЦИЯХ НА СЕРДЦЕ

Perioperative acute myocardial dysfunction is an actual problem of cardiac surgery. Rational use of inotropes and&#x0D; mechanical circulatory support in the postoperative period remains a subject of debate. The outcomes of the combined&#x0D; coronary artery bypass grafting and heart valve prosthesis were analyzed in Irkutsk Cardiac Surgery Center after 80 patients&#x0D; were operated on. As a result of the conducted research, authors proposed a method of differentiated approach&#x0D; to the treatment of acute heart failure in the early postoperative period. Failure to escalate therapy beta agonists in&#x0D; the absence of adequate response hemodynamics and the transition to a mechanical circulatory support improves&#x0D; performance of the cardiovascular system and clinical outcomes, reduces hospitalization duration in the department&#x0D; of intensive therapy. The study showed the superiority of an early beginning of an intra-aortic balloon counterpulsation&#x0D; before traditional inotropic therapy in the treatment of postcardiotomy heart failure at combined cardiac surgery.

Effects of Additional Intra-aortic Balloon Counter-Pulsation Therapy to Cardiogenic Shock Patients Supported by Extra-corporeal Membranous Oxygenation.

Extra-corporeal membranous oxygenation (ECMO) has been applied in patients with cardiopulmonary failure. One critical drawback of peripheral ECMO is an increase in left ventricular (LV) afterload which could be counterbalanced by the combination of intra-aortic balloon counter-pulsation (IABP) therapy. We hypothesized that an add-on therapy with IABP could improve outcomes in patients receiving ECMO support. We included patients (>18 years old) from 2002 to 2013 requiring ECMO support due to cardiogenic shock in a medical center. A total of 529 patients (227 ECMO alone and 302 combined IABP plus ECMO) were included. The mortality rates at 2 weeks (48.5 vs. 47.7%) after ECMO implantation were not different between the two groups (ECMO vs. combined group). After adjustment for propensity score and potential confounders, the odds ratios of outcomes within 14 days (combined group vs. ECMO) for poor LV systolic function, high preload, multi-organ failure and mortality were not different. The results remained similar for subgroup analysis. Compared with ECMO alone, combined IABP and ECMO treatment did not improve outcomes in patients with circulatory failure.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

In vivo impact of intra-aortic balloon counterpulsation on reducing ischemia and improving myocardial blood flow: Proof from a PET rubidium-82 study

In vivo impact of intra-aortic balloon counterpulsation on reducing ischemia and improving myocardial blood flow: Proof from a PET rubidium-82 study

(758) - Are All Patients Equal in Response to Intra-Aortic Balloon Counterpulsation?

(758) - Are All Patients Equal in Response to Intra-Aortic Balloon Counterpulsation?

(898) - Acute Hemodynamic Effects of Percutaneously-Deployed Axillary Intra-aortic Balloon Counterpulsation Pumps in Patients with Advanced Heart Failure

(898) - Acute Hemodynamic Effects of Percutaneously-Deployed Axillary Intra-aortic Balloon Counterpulsation Pumps in Patients with Advanced Heart Failure

Intra-aortic balloon counterpulsation in acute coronary syndromes: the thin line between use and over-use: intra-aortic balloon counterpulsation is an essential tool if properly used

Intra-aortic balloon counterpulsation in acute coronary syndromes: the thin line between use and over-use: intra-aortic balloon counterpulsation is an essential tool if properly used

Simultaneous coronary and carotid revascularisation

IntroductionCoronary artery disease is the most frequent cardiovascular disease at all. Combination of coronary and carotid artery disease due to multisystem atherosclerosis is an indicator of impaired prognosis. Patients with existing coronary artery disease who undergo carotid endarterectomy (CEA) are at high risk of developing perioperative myocardial infarction. There is also increased risk of perioperative stroke in patients with severe carotid artery stenosis who undergo coronary artery bypass grafting (CABG). There is possibility to perform simultaneous CEA/CABG in selected cases to prevent these severe complications. Materials and methodsDuring 5 years period, between January 2010 and December 2014, 54 patients (46 males, 8 females, mean age 70.3 years, range 52–85) underwent simultaneous CEA/CABG surgery for significant coexisting carotid and coronary artery disease in our institution. Demographic and clinical characteristics of the patients as well as a history of previous myocardial infarction, hypertension, diabetes mellitus, hyperlipidaemia, peripheral arterial disease and smoking were recorded. Carotid pathology was diagnosed by ultrasound scan and CT angiography. The combined procedures were performed with the patients under general anesthesia. The CEA was completed first, and than CABG was performed. ResultsThe mean postoperative hospital stay was 14.5 days (range 7–95 days). We recorded one death due to colon necrosis in our group of patients. The hospitalization mortality was 1.9%. There was no perioperative myocardial infarction. One patient with symptomatic unilateral carotid stenosis developed reversible ischemic neurologic deficit. One patient required intraaortic balloon counterpulsation as a result of postoperative heart failure. We observed impaired wound heeling in 5 patients. Other perioperative morbidity included atrial fibrilation in 17 patients, transient delirium in 15 patients and postoperative hemopericardium in 1 patient. ConclusionAccording to our experiences and results, the simultaneous performance of CEA and CABG in patients with severe coexisting carotid artery disease who require coronary revascularization has proved to be a safe and efficacious operative strategy in these high-risk patients.