Need For Intra-aortic Balloon Counterpulsation Research Articles

Pro: Metabolic Acidosis Should be Corrected With Sodium Bicarbonate in Cardiac Surgical Patients

METABOLIC ACIDOSIS, a commonly encountered acute management challenge during cardiac surgery, is typically a symptom of tissue hypoperfusion. It has many etiologies, though up to 30% of total cardiac cases have been associated with hyperlactatemia. 1 Mak NT Iqbal S de Varennes B et al. Outcomes of post-cardiac surgery patients with persistent hyperlactatemia in the intensive care unit: A matched cohort study. J Cardiothorac Surg. 2016; 11: 33 Crossref PubMed Scopus (19) Google Scholar Hypothermia, rewarming, anemia, hypoxia, shock, hypovolemia, ischemia-reperfusion injury, and gut-derived endotoxemia are all potential contributors to tissue hypoperfusion during cardiac surgery. Additionally, vasoconstrictors used commonly during cardiac surgery also may contribute to tissue hypoperfusion. Metabolic acidosis has been associated with increased morbidity and mortality, and an increased need for intraaortic balloon counterpulsation, blood product transfusion, and prolonged intubation and intensive care unit length of stay. 1 Mak NT Iqbal S de Varennes B et al. Outcomes of post-cardiac surgery patients with persistent hyperlactatemia in the intensive care unit: A matched cohort study. J Cardiothorac Surg. 2016; 11: 33 Crossref PubMed Scopus (19) Google Scholar , 2 Toraman F Evrenkaya S Yuce M et al. Lactic acidosis after cardiac surgery is associated with adverse outcome. Heart Surg Forum. 2004; 7: E155-E159 Crossref PubMed Google Scholar , 3 Basaran M Sever K Kafali E et al. Serum lactate level has prognostic significance after pediatric cardiac surgery. J Cardiothorac Vasc Anesth. 2006; 20: 43-47 Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Although exogenous sodium bicarbonate (SB) administration is a common practice for acidosis correction in cardiac surgical patients, its use is highly controversial. In this manuscript, the authors outline the rationale and merits of using SB for the treatment of metabolic acidosis after cardiac surgery.

EComment. Gastrointestinal complications in cardiac surgery

We read with interest the best evidence topic article by Shin and Abah regarding routine stress ulcer prophylaxis in cardiac surgery [1]. We agree with their recommendation of routine acid suppression therapy for the prevention of gastrointestinal (GI) complications in patients undergoing cardiac surgery. Major GI complications following cardiac surgery consist mainly of upper GI bleeding and GI ischaemia followed by peptic ulcer disease, diverticulitis, pancreatitis and cholecystitis [2, 3, 4]. We have audited our practice with regards to major GI complications in patients undergoing cardiac surgery [2]. We found out that after routine introduction of acid suppression therapy, there was a significant reduction in GI complications related to upper GI bleeding. Therefore, there was no single practice in various cardiothoracic units in the United Kingdom [2]. In their retrospective study of 51 patients with GI complications (in total of 4819 patients), Filsulfi et al. listed the following as independent predictive factors of GI complications in cardiac surgery: age, myocardial infarction, congestive heart failure, haemodynamic instability, cardiopulmonary bypass time (over 120 min), peripheral vascular disease, and renal and hepatic failure [3]. The overall hospital mortality among patients with GI complications was higher and the long-term survival was significantly decreased in these patients compared with the control group [3]. In addition, Mangi et al. performed a retrospective analysis of 46 patients (out of 8709 patients) with GI complications and found the following to be preoperative predictor factors: prior cerebrovascular accident, chronic obstructive pulmonary disease, type II heparin-induced thrombocytopenia, atrial fibrillation, prior myocardial infarction, renal insufficiency, hypertension, and need for intra-aortic balloon counterpulsation [4]. Univariate predictors of increased mortality rate in patients with GI complications included New York Heart Association class III and IV, smoking, direct bilirubin over 2.4 mg/dl, pH less than 7.30, syncope at time of presentation, chronic obstructive pulmonary disease, aspartate transaminase over 600 mg/dl and the need for two or more pressors [4]. The National Institute of Clinical Excellence has recommended the treatment with acid suppression therapy (H2-receptor antagonists or proton pump inhibitors) in all acutely ill patients (admitted to intensive care or high dependency units) for primary prevention of upper GI bleeding. Therefore, depending on the patient, the oral form of acid suppression therapy is preferable [5]. The need of acid suppression therapy should be reviewed after the discharge of the patient from the intensive care or high dependency units on an individual basis and during their recovery process [5]. Acid suppression therapy can reduce the risk of acute upper GI bleeding and blood transfusion requirements. However, it does not significantly affect the mortality rate. The adverse events of ventilation-associated pneumonia and of Clostridium difficile-associated diarrhoea do not appear to be increased significantly after the introduction of acid suppression therapy [5]. In conclusion, GI complications in patients undergoing cardiac surgery remain rare but devastating. The early identification of predictive factors and the application of all the preventive measures are of paramount importance for the better outcome of these patients.

Risk Factors Predictive of Right Ventricular Failure After Left Ventricular Assist Device Implantation

Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation appears to be associated with increased mortality. However, the determination of which patients are at greater risk of developing postoperative RVF remains controversial and relatively unknown. We sought to determine the preoperative risk factors for the development of RVF after LVAD implantation. The data were obtained for 175 consecutive patients who had received an LVAD. RVF was defined by the need for inhaled nitric oxide for >/=48 hours or intravenous inotropes for >14 days and/or right ventricular assist device implantation. An RVF risk score was developed from the beta coefficients of the independent variables from a multivariate logistic regression model predicting RVF. Destination therapy (DT) was identified as the indication for LVAD implantation in 42% of our patients. RVF after LVAD occurred in 44% of patients (n = 77). The mortality rates for patients with RVF were significantly greater at 30, 180, and 365 days after implantation compared to patients with no RVF. By multivariate logistic regression analysis, 3 preoperative factors were significantly associated with RVF after LVAD implantation: (1) a preoperative need for intra-aortic balloon counterpulsation, (2) increased pulmonary vascular resistance, and (3) DT. The developed RVF risk score effectively stratified the risk of RV failure and death after LVAD implantation. In conclusion, given the progressively growing need for DT, the developed RVF risk score, derived from a population with a large percentage of DT patients, might lead to improved patient selection and help stratify patients who could potentially benefit from early right ventricular assist device implantation.

QRS Duration and Early Hemodynamic Instability After Coronary Revascularization Surgery

The duration of the QRS interval measured by ECG is a marker of ventricular dysfunction and indicates a poor prognosis. Its value in patients undergoing coronary revascularization surgery has not been established. The study involved 203 consecutive patients (age 64+/-9 years, 74% male) scheduled for elective coronary surgery. The maximum QRS duration measured on a preoperative 12-lead ECG was recorded. Hemodynamic instability was defined as the occurrence of cardiac death, heart failure, or a need for intravenous inotropic drugs or intra-aortic balloon counterpulsation during the postoperative period. The occurrence of hemodynamic instability (n=94, 46%) was associated with a longer preoperative QRS duration (97.5+/-21.14 ms vs 88.5+/-16.9 ms; P=.001). The QRS duration was also longer in patients who developed heart failure (n=23; 104.3+/-22.9 ms vs. 91.1+/-18.5 ms; P=.002), needed inotropic drugs (n=77; 96.5+/-20.5 ms vs. 90.1+/-18.2 ms; P=.007) or developed postoperative atrial fibrillation (n=58; 98.2+/-23.8 ms vs. 90.4+/-17.0 ms; P=.018). Bundle branch block was associated with a greater need for intra-aortic balloon counterpulsation (29% vs 12%; P=.012) or inotropic drugs (58% vs 35%; P=.014) and a higher incidence of hemodynamic instability (69% vs 42%; P=.006). Multivariate analysis identified the following independent predictors of hemodynamic instability: QRS duration (adjusted odds ratio [OR] per 10 ms=1.49; 95% confidence interval [CI], 1.11-2; P=.007), the lack of an arterial graft (OR=3.6; 95% CI, 1.14-11.6; P=.029) and extracorporeal circulation time (OR per min=1.013; 95% CI, 1.003-1.023; P=.013). The intraventricular conduction delay, or QRS duration, was associated with a higher risk of postoperative hemodynamic instability following coronary surgery.

Effect of Circulatory Assistance on Premature Death and Long-term Prognosis

Background Patients undergoing urgent heart transplantation (HT) have a poorer prognosis and more long-term complications. The objective of this study was to compare the preoperative course in patients undergoing urgent HT according to the need for preoperative intra-aortic balloon counterpulsation (IABP). Materials and Methods We studied 102 consecutive patients including 23 patients with IABP who underwent urgent HT between January 2000 and September 2006. We excluded patients who received combination transplants, those who underwent repeat HT, and pediatric patients who underwent HT. The statistical methods used were the t test for quantitative variables and the χ 2 test for qualitative variables. A logistic regression model was constructed to assess the possible relationship between IABP and other variables on premature death within 30 days after HT. Results Mean (SD) patient-age was 50 (10) years. No significant differences were observed in baseline characteristics between the IABP and the non-IAPB groups. The IABP patient group had higher rates of acute graft failure (45.5% vs 35.4%; P = .46) and premature death (18.8% vs 14.8%; P = .67) and shorter long-term survival (40.6 [34.9] vs 54.5 [43.7] mo; P = .30). Multivariate analysis demonstrated no association between the need for IABP and increased frequency of premature death. Conclusions Use of IABP is not associated with premature or late death. We recommend use of IABP in patients with acute decompensated heart failure to stabilize them before HT.

In-Hospital Prognostic Value of Glomerular Filtration Rate in Patients With Acute Coronary Syndrome and a Normal Creatinine Level

Kidney failure is more prevalent in patients with ischemic heart disease than in the general population. A high serum creatinine level is known to be a predictor of an adverse outcome in acute coronary syndrome. The aim of this study was to investigate the clinical significance of the glomerular filtration rate in patients with acute coronary syndrome and a normal baseline creatinine level. The study included 583 consecutive patients admitted to a coronary care unit with acute coronary syndrome (with or without ST-segment elevation) whose baseline serum creatinine level was less than 1.3 mg/dL. The creatinine clearance rate at admission was calculated using the Cockcroft-Gault equation, and the presence of cardiovascular risk factors, coronary anatomy (from angiography), type of revascularization, maximum cardiac enzyme levels, left ventricular ejection fraction and, ultimately, in-hospital mortality were recorded. Around 50.8% of patients presented with ST-segment elevation acute coronary syndrome. The median serum creatinine level on admission was 0.98 mg/dL (0.9-1.1 mg/dL) and the median creatinine clearance rate was 81.29 mL/min (61.2-98.4 mL/min). The in-hospital mortality rate was 2.7%. Glomerular filtration rate, previous coronary disease, Killip class on admission, and the need for intraaortic balloon counterpulsation were found to be independent predictors of mortality. In patients with acute coronary syndrome and a normal creatinine level on admission, estimation of the glomerular filtration rate provided important information on short-term prognosis. This parameter should be included in the risk assessment of patients with normal serum creatinine levels.

Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients.

Gastrointestinal (GI) complications following heart operation may be life-threatening. Systematic analysis of risk factors to allow early identification of patients at risk for GI complication may lead to the development of strategies to mitigate this complication as well as to optimize management after its occurrence. Of 8709 consecutive patients undergoing heart operation during 7 years (1997-2003), 46 (0.53%) developed GI complications requiring surgical consultation. Preoperative, intraoperative, and postoperative predictors of complication and death were identified and compared with a control group. Significant (P < 0.05) preoperative predictors of complication were prior cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), type II heparin-induced thrombocytopenia, atrial fibrillation, prior myocardial infarction, renal insufficiency, hypertension, and need for intra-aortic balloon counter-pulsation. The most frequent serious GI complication was mesenteric ischemia, which developed in 31 (67%) patients. Twenty-two (71%) of these patients were explored, and 14 (64%) died within 2 days of heart operation. Of the 9 patients with mesenteric ischemia who were not explored, 7 (78%) died within 3 days of heart operation. Other complications included diverticulitis (5), pancreatitis (4), peptic ulcer disease (4), and cholecystitis (2). The mortality rate in this group of other diagnoses was lower (40%), and death occurred later (32 days) after heart operation (P = 0.03 compared with mesenteric ischemia). Predictors of death from GI complication included New York Heart Association (NYHA) class III and IV heart failure, smoking, chronic obstructive pulmonary disease, history of syncope, aspartate aminotransferase (AST) >600 U/L, direct bilirubin >2.4 mg/dL, pH < 7.30, and the need for >2 pressors. The most common catastrophic GI complication after cardiac surgery is mesenteric ischemia, which is frequently fatal. This complication may be a result of atheroembolization, heparin-induced thrombocytopenia, or hypoperfusion. Techniques to reduce the occurrence of and/or preemptively diagnosis postcardiotomy mesenteric ischemia are necessary to decrease its associated mortality.

Assessment of Continuous Cold Blood Cardioplegia in Coronary Artery Bypass Grafting

Background. A method of cold blood cardioplegia (CBCP) delivered continuously and in a retrograde manner was compared with methods differing only by their rate (intermittent) or way (antegrade) of administration. Methods. This study comprises 298 consecutive patients undergoing isolated coronary artery bypass grafting procedures performed by the same surgeon from 1992 to 1995. Three-vessel disease characterized 58.8% of the cases, and the left ventricular ejection fraction was less than 0.40 in 22.8%. In group I (n = 100), CBCP was administered in an antegrade and intermittent fashion; in group II (n = 87), CBCP was given in a retrograde and intermittent manner; in group III (n = 111), CBCP delivery was retrograde and continuous. Results. The incidence of major cardiac adverse outcome (death or need for intraaortic balloon counterpulsation) was 7.0% in group I, 8.0% in group II, and 0.9% in group III ( p = 0.040). Repeated-measures analysis of hemodynamic indices showed a marked superiority of continuous retrograde compared with antegrade intermittent blood cardioplegia regarding left ventricular stroke work index ( p < 10 −4) and compared with both methods of intermittent CBCP regarding right ventricular stroke work index ( p < 10 −5). Conclusions. The use of continuous CBCP resulted in a significant reduction in major cardiac events, better left ventricular performance, and a marked improvement of right ventricular function in comparison with similar solutions of blood cardioplegia administered intermittently, independent of their way of delivery.

Resternotomy for bleeding after cardiac operation: A marker for increased morbidity and mortality

Over a 2-year period from January 1, 1992, to December 31, 1993, of 2,221 patients undergoing cardiac operations in our unit, 85 (3.8%) were reopened for the control of bleeding (9 patients more than once). The incidence of resternotomy in coronary cases was 2.3%, but resternotomy was more than three times as likely in valve cases (odds ratio, 3.4; 95% confidence interval, 2.1 to 5.4). Previous cardiac operation was more common among resternotomy patients than among the remainder (18% versus 9%, respectively; p = 0.018). An identifiable source of bleeding was found in 57 of the 85 patients (67%), but a concurrent coagulopathy was common (45 patients). Resternotomy patients, as a group, had higher preoperative risk scores (Parsonnet) than did the other patients (p < 0.0001), stayed longer in the intensive care unit (p < 0.0001), and had greater requirements for intraaortic balloon counterpulsation (14% versus 3%) and hemofiltration (9% versus 3%) (p < 0.0001 and p < 0.01, respectively). Nineteen resternotomy patients (22%) died in the hospital, a proportion significantly greater than the risk assigned to this group of patients preoperatively (12.8%) (p = 0.008). In contrast, the observed mortality for the other 2,136 patients (5.5%) was significantly less (8.3%) (p < 0.00006). Multiple forward stepwise logistic-regression analysis confirmed resternotomy for excessive bleeding after cardiac operation to be a significant independent predictor of a prolonged stay in the intensive care unit (p < 0.0001), the need for intraaortic balloon counterpulsation (p < 0.0001), and death (p < 0.0001).

Initial experience with low-potassium cold blood cardioplegia: A clinical comparative study

This study presents the results of bypass grafting in 96 patients operated on for triple-vessel coronary artery disease between May 1988 and September 1990. In the first 54 patients a cold crystalloid solution was employed, and in the 42 more recent patients cold blood low-potassium cardioplegia was employed. There were no differences in postoperative cardiac index or left ventricular stroke work index. Yet, in patients with impaired prebypass left ventricular stroke work index, postbypass left ventricular performance correlated negatively with duration of aortic cross-clamping in the cold crystalloid group ( r = −0.441, p = 0.045). In contrast, no correlation was found in the cold blood low-potassium group ( r = 0.125, p = 0.587). The incidence of myocardial infarction, need for inotropic support, and need for intraaortic balloon counterpulsation were similar among the groups. Release of the myocardial isoenzyme creatine kinase-MB from 12 to 30 hours after operation was significantly less in the low-potassium blood cardioplegia group. The use of low-potassium blood cardioplegia resulted in a marked reduction in the operative administration of fluids (1,527 ± 87 versus 3,511 ± 148 ml; p < 0.001). In conclusion, low-potassium cold blood cardioplegia is a simple and effective method of myocardial protection. The fact that left ventricular stroke work index recovery was not dependent on the duration of aortic occlusion and that release of the MB isoenzyme of creatine kinase was reduced in the low-potassium blood cardioplegia group implies better myocardial protection.