Preoperative Intra-aortic Balloon Pump Research Articles

Acute Mesenteric Ischemia after Cardiac Surgery: An Analysis of 52 Patients

Objective. Acute mesenteric ischemia (AMI) is a rare but serious complication after cardiac surgery. The aim of this retrospective study was to evaluate the incidence, outcome, and perioperative risk factors of AMI in the patients undergoing elective cardiac surgery. Methods. From January 2005 to May 2013, all patients who underwent cardiac surgery were screened for participation, and patients with registered gastrointestinal complications were retrospectively reviewed. Univariate analyses were performed. Results. The study included 6013 patients, of which 52 (0.86%) patients suffered from AMI, 35 (67%) of whom died. The control group (150 patients) was randomly chosen from among cases undergoing cardiopulmonary bypass (CPB). Preoperative parameters including age (P = 0.03), renal insufficiency (P = 0.004), peripheral vascular disease (P = 0.04), preoperative inotropic support (P < 0.001), poor left ventricular ejection fraction (P = 0.002), cardiogenic shock (P = 0.003), and preoperative intra-aortic balloon pump (IABP) support (P = 0.05) revealed significantly higher levels in the AMI group. Among intra- and postoperative parameters, CPB time (P < 0.001), dialysis (P = 0.04), inotropic support (P = 0.007), prolonged ventilator time (P < 0.001), and IABP support (P = 0.007) appeared significantly higher in the AMI group than the control group. Conclusions. Prompt diagnosis and early treatment should be initiated as early as possible in any patient suspected of AMI, leading to dramatic reduction in the mortality rate.

Management of patients with hematological malignancies undergoing coronary artery bypass grafting

The number of patients with a previously diagnosed malignancy who need cardiac surgery is increasing. Patients with hematological malignancies represent only 0.38% of all patients undergoing cardiac surgery. The literature in this subset of patients is limited to only a few retrospective case series, with limited number of patients undergoing emergency cardiac surgery. We describe three cases with hematological malignancies namely chronic myelogenous leukemia, acute promyelocytic leukemia and chronic lymphocytic leukemia presenting for coronary artery bypass grafting (CABG). Two patients were taken up for emergency CABG in view of ongoing ischemia, one of them was on preoperative intra-aortic balloon pump support. No mortality was observed. Two patients needed transfusion of blood products which was guided by thromboelastography. One patient developed superficial sternal wound infection requiring antibiotic therapy.

Delayed sternal closure does not increase late infection risk in patients undergoing left ventricular assist device implantation

Delayed sternal closure (DSC) is employed after conventional cardiac surgery without a significantly increased risk of late mediastinitis or sternal wound infection. There are no data specifically examining its late effects on patients undergoing implantation with a ventricular assist device (VAD). Between October 1996 and October 2010, 364 patients underwent primary VAD implant and DSC was utilized in 184 (51%) patients for coagulopathy (n = 155; 84%), hemodynamic instability (n = 103; 56%), isolated right ventricular dysfunction (n = 15; 8%) or unspecified reasons (n = 17; 9%). Median duration of DSC was 1 day (range 1 to 7 days). Patients with DSC were older (54.5 vs. 50.3 years, p = 0.002), had a higher incidence of previous sternotomy (42% vs. 28%, p = 0.005), pre-operative intra-aortic balloon pump (50% vs. 30%, p < 0.001), pre-operative temporary extracorporeal mechanical circulatory support (23% vs 10%, p < 0.001), lower platelet counts (171,000 vs. 209,000, p < 0.001) and lower hematocrit levels (32% vs. 36%, p < 0.001). Operative (11% vs. 9%, p = 0.65) or late (2 years; 66 ± 7% vs 66 ± 7%, p = 0.720) mortality; composite incidence of mediastinitis, percutaneous drive-line infection, pocket infection and VAD-related endocarditis (15% vs. 16%, p = 0.79); re-exploration for bleeding (18% vs. 18%, p = 0.99); urgent transplantation for infection (4% vs. 3%, p = 0.99); or need for device exchange (9% vs. 10%, p = 0.16) was not increased after DSC when compared with immediate sternal closure. DSC increased ICU stay (10 vs. 5 days, p = 0.001). DSC was performed most commonly for coagulopathy and/or hemodynamic instability, and patients were older with a greater severity of illness as shown by the higher incidence of right-sided circulatory failure and history of prior sternotomy. Although DSC was associated with longer ICU stay, DSC was not associated with a significantly increased risk of death or infection.

Variability in Surgeons’ Perioperative Practices May Influence the Incidence of Low-Output Failure After Coronary Artery Bypass Grafting Surgery

Postoperative low-output failure (LOF) is an important contributor to morbidity and mortality after coronary artery bypass grafting surgery. We sought to understand which pre- and intra-operative factors contribute to postoperative LOF and to what degree the surgeon may influence rates of LOF. We identified 11 838 patients undergoing nonemergent, isolated coronary artery bypass grafting surgery using cardiopulmonary bypass by 32 surgeons at 8 centers in northern New England from 2001 to 2009. Our cohort included patients with preoperative ejection fractions >40%. Patients with preoperative intraaortic balloon pumps were excluded. LOF was defined as the need for ≥2 inotropes at 48 hours, an intra- or post-operative intraaortic balloon pumps, or return to cardiopulmonary bypass (for hemodynamic reasons). Case volume varied across the 32 surgeons (limits, 80-766; median, 344). The overall rate of LOF was 4.3% (return to cardiopulmonary bypass, 2.6%; intraaortic balloon pumps, 1.0%; inotrope usage, 0.8%; combination, 1.0%). The predicted risk of LOF did not differ across surgeons, P=0.79, and the observed rates varied from 1.1% to 10.2%, P<0.001. Patients operated by low-rate surgeons had shorter clamp and bypass times, antegrade cardioplegia, longer maximum intervals between cardioplegia doses, lower cardioplegia volume per anastomosis or minute of ischemic time, and less hot-shot use. Patients operated on by higher LOF surgeons had higher rates of postoperative acute kidney injury. Rates of LOF significantly varied across surgeons and could not be explained solely by patient case mix, suggesting that variability in perioperative practices influences risk of LOF.

Risk stratification and prognostic effects of internal thoracic artery grafting during acute myocardial infarction

Surgeons are occasionally requested to perform coronary artery bypass grafting during acute myocardial infarction. We intended to test the safety of coronary artery bypass grafting and internal thoracic artery grafting early after myocardial infarction using the Society of Thoracic Surgeons database. The database was queried for isolated coronary artery bypass grafting less than 24 hours after a myocardial infarction from 2002 to 2008. By using multivariable logistic regression and classification trees, risk models were created to stratify this group of patients. The independent prognostic effect of internal thoracic artery grafting was examined using standard risk-adjusted mortality comparisons. A total of 44,141 patients were identified, with an overall operative mortality of 7.9%. Cardiogenic shock occurred in 21%, percutaneous coronary intervention within 6 hours before surgery was performed in 11%, myocardial infarction within 6 hours before surgery occurred in 37%, preoperative intra-aortic balloon pump was used in 50%, and internal thoracic artery grafting was performed in 79% of the patients. Myocardial infarction in less than 24 hours was associated with higher operative mortality (odds ratio, 3.25) and major morbidity (odds ratio, 2.54). Emergency/salvage status (odds ratio, 6.43), age more than 80 years (odds ratio, 4.07), dialysis (odds ratio, 3.08), and cardiogenic shock (odds ratio, 2.79) were independent mortality predictors. Patients with nonemergence salvage status, absence of cardiogenic shock, creatinine less than 1.5 mg/dL, and age less than 70 years represented 48% of the population and exhibited a lower mortality rate of 2%. Internal thoracic artery grafting was independently associated with a lower risk of mortality (odds ratio, 0.52; P<.0001) and did not seem to compromise outcomes. Coronary artery bypass grafting less than 24 hours after myocardial infarction carries a higher operative risk but can be performed safely in selected patients. Although confounding variables may exist, internal thoracic artery grafting was associated with improved outcomes. Internal thoracic artery use in this setting is less than ideal, and taking time to harvest internal thoracic artery grafts in patients with acute myocardial infarction might be encouraged.

Early and late results of entire septal patch technique for post infarction ventricular septal rupture

Surgical results for post-infarction ventricular septal rupture (VSR) remain poor, even today. The aim of this study was the establishment and clinical evaluation of a simple, standardized septal patch technique for this disease. From 1999 to 2011, 16 consecutive patients with a mean age of 73.1±10.1 (range 55-89) underwent emergency repair of VSR following anterior myocardial infarction. Entire septal patch technique, in which a large pericardial patch is fixed reciprocally between transmural sutures placed in the posterior free wall adjacent to the ventricular septum and anterior left ventriculotomy closing sutures, thus almost entirely covering the septal wall, was used in all cases. Mean interval between the onset of septal rupture and surgery was 1.3±0.6(range 1-3)days. Eight patients presented cardiogenic shock and 14 patients underwent preoperative intra-aortic balloon pumping. Average operation, cardiopulmonary bypass, and aortic clamp time were 233±71(145-360), 128±51(82-240), and 46±15(29-76)min, respectively. Coronary artery bypass grafting was performed concomitantly in five cases. Average intra-operative blood loss was 340±184(123-740)g. Thirty-day mortality was 0%, and in-hospital mortality was 13.3% (2/16). Significant residual shunt occurred in one patient. All hospital survivors were followed up with a mean period of 44.5±40(5-131)months. Five-year survival of all operated patients was 69±14%. Entire septal patch technique proved to be an easily reproducible method for anterior VSR that demonstrated stable early and late results.

Intra‐Aortic Balloon Counterpulsation in the Treatment of Infarction‐Related Cardiogenic Shock—Review of the Current Evidence

The European ST-elevated myocardial infarction (STEMI) guideline suggested the intra-aortic balloon pump (IABP) with a recommendation level I and a level of evidence C as an effective measure in combination with balloon angioplasty in patients with cardiogenic shock (CS), stent implantation, and inotropic and vasopressor support. Similarly, upon mechanical complication due to myocardial infarction (MI), the guideline suggests that in patients with a ventricular septal defect or in most patients with acute mitral regurgitation, preoperative IABP implantation is indicated for circulatory support. The American College of Cardiology/American Heart Association STEMI guideline recommends the use of the IABP with a recommendation level I and a level of evidence B if CS does not respond rapidly to pharmacological treatment. The guideline notes that the IABP is a stabilizing measure for angiography and early revascularization. Even in MI complications, the use of preoperative IABP is recommended before surgery. Within this overview, we summarize the current evidence on IABP use in patients with CS complicated by MI. From our Cochrane data analysis, we conclude that in CS due to acute MI (AMI) treated with adjuvant systemic fibrinolysis, the IABP should be implanted. In patients with CS following AMI, treated with primary percutaneous coronary intervention (PCI), the IABP can be implanted, although data are not distinctive (i.e., indicating positive and negative effects). In the future, randomized controlled trials are needed to determine the use of IABP in CS patients treated with PCI. When patients with CS are transferred to a PCI center with or without thrombolysis, patients should receive mechanical support with an IABP. To treat mechanical MI complications-in particular ventricular septal defect-patients should be treated with an IABP to stabilize their hemodynamic situation prior to cardiac surgery. Similar recommendations are given in the German Austrian guidelines on treatment of infarction-related CS patients (http://www.awmf.org/leitlinien/detail/ll/019-013.html).

Very-low-dose continuous drip infusion of landiolol hydrochloride for postoperative atrial tachyarrhythmia in patients with poor left ventricular function

Three patients with poor left ventricular function (left ventricular ejection fraction <30 %) developed postoperative atrial tachyarrhythmia in intensive care. Case 1 was a 64-year-old man who underwent a modified Bentall procedure and mitral valve annuloplasty. Case 2 was a 63-year-old woman who underwent quintuple coronary artery bypass grafting. Case 3 was a 65-year-old man who underwent mitral valve replacement. Preoperative intra-aortic balloon pumping was required in Cases 2 and 3. Excellent heart rate control with no hemodynamic deterioration was achieved in all three cases by very-low-dose continuous drip infusion of landiolol hydrochloride (2-5 μg/kg/min). Very-low-dose continuous drip infusion of landiolol hydrochloride is a safe and useful alternative for the control of perioperative atrial tachyarrhythmias in patients with poor left ventricular function.

Preoperative intra-aortic balloon pump in high-risk coronary bypass grafting

Prophylactic intra-aortic balloon pumping prior to coronary artery bypass grafting is employed variably despite some evidence to support its use. The aim of this study was to describe the characteristics, preoperative balloon pump utilization, and outcomes of high-risk patients undergoing coronary artery bypass. The study cohort included all patients in the Australian National Cardiac Surgery Database over an 8 year period. The primary outcome was 30-day mortality adjusted for preoperative illness severity. Coronary artery bypass was performed in 18,662 patients including 2,348 (12.6%) identified as high-risk. Of these high-risk patients, 359 (15.3%) received a balloon pump preoperatively. For high-risk patients, 30-day mortality was significantly higher in those with a preoperative balloon pump than in those who did not receive a preoperative balloon pump (15.3% vs. 4.9%). After adjusting for preoperative illness severity, there was no significant association between preoperative balloon pumping and 30-day mortality. High-risk patients represent a significant proportion of those undergoing coronary artery bypass grafting. Despite their increased risk of postoperative mortality, only a small minority currently receive a preoperative balloon pump. After adjusting for illness severity, there was no significant association between preoperative balloon pumping and 30-day mortality, although we could not rule out a 20% reduction in mortality.

Preoperative Intraaortic Balloon Pump for Off-Pump Coronary Arterial Revascularization

Prophylactic intraaortic balloon pump (IABP) support showed better outcomes in critical patients undergoing coronary revascularization compared with intraoperative or postoperative insertion. We conducted a prospective, randomized study to determine the optimal timing for preoperative IABP insertion in high-risk patients undergoing off-pump coronary artery revascularization. The study enrolled 230 consecutive high-risk patients (having a logistic European System for Cardiac Operative Risk Evaluation score of ≥10) undergoing off-pump coronary artery revascularization. They were randomized for preoperative IABP starting at 2 hours (2T, n=115) or 12 hours (12T, n=115). Clinical, biochemical, and hemodynamic results, and the need for inotropic drug support, were markers of outcome and compared between groups. Hospital mortality in group 12T was reduced by 60%, but the difference between groups was not statistically significant (hazard ratio, 0.4; 95% confidence interval, 0.1 to 1.5; p=0.1). Twelve hours of preoperative IABP therapy reduced postoperative low output syndrome (hazard ratio, 0.4; 95% confidence interval, 0.1 to 0.9; p=0.03) and biomarker leakage upper normal limit (hazard ratio, 0.3; 95% confidence interval, 0.1 to 0.7; p=0.001). Postoperative left ventricular function was similar between the groups. Group 2T patients required higher inotropic support for a longer average duration and prolonged postoperative intensive care unit and hospital length of stay. Twelve hours preoperative IABP therapy improved treatment efficacy. Postoperative morbidity was reduced, but hospital mortality rate was not affected. The IABP-related complication rate was low and not related to the length of treatment.

Beneficial effect of preoperative intra-aortic balloon pumping in patients with low-ejection fraction undergoing coronary artery bypasses grafting

Objective: We evaluated the association between the preoperative use of intraaortic balloon pumping in patients with severely impaired left ventricular function (<30%) undergoing coronary artery bypass grafting.

Preoperative Intra-Aortic Balloon Pumping in High-Risk Cardiac Surgery Patients

Intra-aortic balloon pumping increases myocardial oxygen supply and decreases myocardial oxygen demand by inflation and deflation of the balloon. This leads to increased perfusion of the coronary arteries during diastole. This technology has been used for critically ill cardiac patients for more than 30 years. The literature suggests that preoperative use of an intra-aortic balloon pump can be effective in high-risk coronary artery bypass grafting patients. Preoperative benefits of this technology may yield positive outcomes in terms of hemodynamic effect, decreased length of stay in both the intensive care unit and the hospital, and the reduction of complications. However, the intra-aortic balloon pump must be used with a profound understanding of proper mechanism and function, monitoring, and observation for potential complications. This requires excellent critical care nursing management.

Long Term Results of ST-Segment Elevation Myocardial Infarction versus Non-ST-Segment Elevation Myocardial Infarction after Off-Pump Coronary Artery Bypass Grafting: Propensity Score Matching Analysis

There is no consensus as to which acute myocardial infarction subtype poses a greater risk after coronary artery bypass grafting (CABG). We compared the early and the long term results of off-pump coronary artery bypass grafting (OPCAB) between patients with STEMI (group I, n = 83), and NSTEMI (group II, n = 237). Group I had higher EuroSCORE, prevalence of emergency surgery, preoperative intra-aortic balloon pump use, preoperative emergency percutaneous transluminal coronary angioplasty, and preoperative thrombolytic use than group II. There were no significant differences in 30-day mortality and major adverse cardiac and cerebrovascular event (MACCE) between groups. Overall 8-yr survival was 93% and 87% in groups I and II, respectively. Freedom from MACCE after 8 yr was 92% and 93% in groups I and II, respectively. After propensity score matching analysis, there were no significant differences in preoperative parameters, postoperative in-hospital outcomes, and long-term clinical outcomes. Surgical results of OPCAB in patients with acute myocardial infarction show good results in terms of long-term survival and freedom from MACCE, with no significant differences in clinical outcomes between STEMI and NSTEMI groups.

Levosimendan Versus an Intra-Aortic Balloon Pump in High-Risk Cardiac Patients

To test the hypothesis that levosimendan is more effective than intra-aortic balloon pump (IABP) support in cardiac surgical patients with low left ventricular ejection fraction to decrease cardiac troponin I levels (primary endpoint) and improve hemodynamics. Prospective randomized trial. Tertiary cardiothoracic referral center. Ninety patients with coronary artery disease and left ventricular ejection fraction <35% who underwent surgery with cardiopulmonary bypass. Patients were assigned randomly to 1 of 3 groups. Group A received a prophylactic IABP one day before surgery. Group B received a prophylactic IABP one day before surgery and a levosimendan infusion at a dose of 0.1 μg/kg/min with an initial bolus (12 μg/kg for 10 minutes) after anesthesia induction. Group C received a levosimendan infusion at a dose of 0.1 μg/kg/min with an initial bolus (12 μg/kg for 10 minutes) after anesthesia induction. Hemodynamic and biochemical data and rate of complications were analyzed. The cardiac troponin I level in group C 6 hours after surgery was lower than in group A (p = 0.048). The cardiac index in group A was significantly lower than in groups B and C. The intensive care unit stay was significantly shorter in group C than in groups A and B (p = 0.001). The need for inotropic support, the rate of complications, and mortality among groups did not differ. The infusion of levosimendan after anesthesia induction in cardiac surgical patients contributes to lower cardiac troponin I levels and improved hemodynamics compared with a preoperative IABP.

Levosimendan Versus Intra-aortic Balloon Pump in High-Risk Cardiac Surgery Patients

Patients with severe left ventricular dysfunction receive inotropic and mechanical circulatory support with an intra-aortic balloon pump (IABP) during the perioperative phase of cardiac surgery. The authors performed the first comparison of levosimendan versus an IABP in patients with poor left ventricular function undergoing cardiac surgery. A case-matched study. A teaching hospital. Twenty-two heart failure patients scheduled to undergo elective coronary artery bypass graft surgery with or without concomitant mitral surgery. Eleven patients received levosimendan at a dose of 0.1 μg/kg/min for 24 hours without an initial bolus. The control group, also 11 patients, received a preoperative IABP. The intensive care unit stay was the major endpoint of this study. Biochemical, hemodynamic, and echocardiographic data were collected together with the time on mechanical ventilation and 30-day mortality. The length of intensive care unit stay was reduced in patients receiving levosimendan (median, 2.5; range, 1-3 days) compared with those receiving an IABP (median, 5; range, 3-6 days; p = 0.01). No deaths occurred in the levosimendan group; 1 patient died in the intra-aortic balloon pump group. Patients receiving levosimendan had a shorter duration of intensive care stay than peers who received a preoperative IABP. The findings of this pilot study should be investigated further in a large randomized controlled study.

Early, middle and long-term clinical outcomes of coronary artery bypass grafting for left main coronary stenosis

To evaluate the early, middle and long-term clinical outcomes of coronary artery bypass grafting (CABG) for a special subset of left main coronary stenosis (LMS). A total of 626 LMS patients, recruited at our hospital between January 1998 and March 2008, were classified them into the statin therapy group (Group A, n = 322) or the non-statin therapy group (Group B, n = 304) according to whether or not taking statins pre-operatively. Then their clinical data were retrospectively analyzed. The inhospital mortality was 4.31% (n = 27). And the mortality was 1.90% (n = 6) for Group A and 6.91% for Group B (n = 21) (χ² test, χ² = 9.642, P = 0.002). Preoperative statin therapy could lower the all-cause mortality rate (1.90% vs 6.91%, P = 0.002), the prevalence of new atrial fibrillation or flutter (14.69% vs 19.61%, P = 0.016, χ ²= 5.780) and disabling stroke (2.50% vs 4.58%, P = 0.047, χ(2) = 3.94). Among 599 CABG survivors, 565 cases (94.3%) were actually followed up with a mean duration of 55.5 ± 26.1 months (range: 2 - 98). During the follow-up period, there were 29 (4.63%) cardiac events, including 12 deaths and 17 myocardial infarctions. There were 43 (7.18%) cases with relapsing angina pectoris. The univariate analysis showed that emergency procedure, abnormal C-reactive protein (CRP), abnormal troponin I(TnI), complicated LMS pathology, preoperative IABP (intra-aortic balloon pump) support, preoperative cardiac arrest, preoperative history of myocardium infarction and no preoperative statin therapy were the risk factors for perioperative death while complicated LMS pathology, preoperative IABP support, preoperative cardiac arrest, preoperative myocardium infarction and no preoperative statin therapy were the risk factor for late cardiac events. The multivariate binary logistic regression showed that emergency procedure, preoperative IABP support, no preoperative statin therapy and preoperative IABP support were independent predictors for peri-operative death. And preoperative IABP support, preoperative cardiac arrest, no preoperative statin therapy and complicated LMS pathology were independent predictors for late cardiac events. There was no statistical significance in inhospital mortality between on pump CABG and OPCAB (off pump coronary artery bypass). The CABG procedure for LMS carries a relative high mortality. However preoperative statin therapy may offer such protective effects as lowering the all-cause mortality rate and reducing the prevalence of new atrial fibrillation or flutter and disabling stroke.

Preoperative placement of an Intra-Aortic Balloon Pump (IABP) in patients with acute coronary syndrome (ACS): A follow-up

Objectives: Effectiveness of preoperative intra-aortic balloon pump (IABP) placement concerning the survival rate and postoperative complications for high-risk patients suffering from ACS.

Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting.

The intra aortic balloon pump (IABP) is a mechanical assist device which improves cardiac function. The device has a well-established place in algorithms for managing low cardiac output following cardiac surgery. There is increasing evidence that certain cardiac surgery patients benefit from a period of preoperative augmentation with the intra aortic balloon pump. To determine the effect of the preoperative intra aortic balloon pump on mortality and morbidity in a number of different patients groups undergoing coronary artery bypass grafting. The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 3, 2009), MEDLINE (2000 to August 2009), EMBASE (1998 to August 2009), BIOSIS previews (1969 to August 2009) and ISI Proceedings (1990 to August 2009) were searched. References and ongoing registers of studies were checked. No language restrictions were applied. Randomised controlled trials (RCTs) of any size or length were included. Papers were assessed for inclusion by two authors independently and differences were settled by consensus with a third author. Date are presented in the form of odds ratios (OR) and 95% confidence intervals (CI). Six trials were included (five on-pump and one off-pump). This update adds the results of one further trial. Data from a total of 255 patients were included in the meta-analysis of mortality outcomes; all on-pump. Generally, the patients were considered as "high risk" and 132 were treated preoperatively with IABP and 123 served as controls. There were four hospital deaths in the intervention arm and 23 in the non-intervention arm (OR 0.18, 95% CI 0.08 to 0.41; P<0.0001). In a subgroup analysis, low cardiac index (<2.0 L/min/m(2)) was noted in 21 out of 105 patients in the treatment arm and 59 patients out of 88 in the non-treatment arm (OR 0.14, 95% CI: 0.08 to 0.25; P<0.00001). An off-pump versus on-pump analysis was not possible due to the limited number of off-pump studies. However a single well-conducted RCT suggested favourable effect of the preoperative IABP in off-pump patients. Evidence suggests that preoperative IABP may have a beneficial effect on mortality and morbidity in specific high risk patient groups undergoing coronary artery bypass grafting, however there are many problems with the quality, validity and generalisability of the trials. However, the available evidence is not robust enough to extend the use of IABP to truly elective, high risk patients. Defining more precisely which patient groups may benefit would be the challenge for the future.

Impact of prophylactic intra-aortic balloon counter-pulsation on postoperative outcome in high-risk cardiac surgery patients: a multicentre, propensity-score analysis☆

The aim of this multicentre study was to determine whether the prophylactic use of intra-aortic balloon pump (IABP) translates into better early and long-term results in high-risk patients undergoing cardiac surgery. From January 2000 to March 2009, 6121 high-risk patients (EuroSCORE >8), at six different institutions, underwent cardiac surgery. Propensity-score computer matching was performed, based on 10 variables representing patients characteristics and preoperative risk factors to correct for and minimise selection bias (Hosmer-Lemeshow goodness of fit, p=0.3; c=0.94). A total of 956 patients were successfully matched and consisted of 478 pairs either undergoing preoperative IABP (group A) or not receiving IABP preoperatively (group B). Multivariate logistic regression (odds ratio) revealed that group B had a 64% higher risk of in-hospital mortality (p=0.001), 57% higher risk of 30-day mortality (p=0.003), 45% higher risk of perioperative myocardial infarction (p=0.01), 57% higher risk of postoperative low-output syndrome (p=0.003), 45% higher risk of intensive care unit (ICU) length of stay (p=0.001) and 44% higher risk of hospital length of stay (p=0.001). Patients in group A showed, at follow-up, significant improvements in left ventricular (LV) ejection fraction (p<0.001), wall-motion score index (p<0.001) and LV dimensions (p<0.001). Five- and 8-year survivals did not differ between groups (5-year survival: 91.7 ± 3.1% vs 95 ± 2.1% in groups A and B, respectively, log-rank p=0.34; 8-year survival: 84.3 ± 5.5% vs 85.9 ± 6.1% in groups A and B, respectively, log-rank p=0.2). Prophylactic IABP support, in this multicentre experience, was showed to enhance perioperative management and outcome of high-risk cardiac surgery patients.

Immediate Extubation After Off-Pump Coronary Artery Bypass Graft Surgery in 1,196 Consecutive Patients: Feasibility, Safety and Predictors of When Not To Attempt It

The purpose of this study was to evaluate the feasibility and safety of immediate extubation (ultrafast-track anesthesia [UFTA]) in the operating room, and the predictors of when not to attempt it in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB). Case series. A private hospital. One thousand one hundred ninety-six patients undergoing OPCAB surgery, representing 4 years of a single anesthesia service's practice (3 anesthesiologists), were evaluated for immediate extubation. All patients were considered amenable to immediate extubation if specific criteria were met. Patients received general anesthesia (UFTA protocol) and underwent off-pump coronary artery bypass graft surgery. One thousand sixty-five patients (89%) met extubation criteria and were extubated successfully in the operating room. By multivariate analysis, the following independent predictors of avoiding immediate extubation were identified: reoperation (odds ratio [OR] = 3.9, p < 0.001), pre-existing renal disease (OR = 3.1, p < 0.0001), diabetes (OR = 1.7, p < 0.007), preoperative intra-aortic balloon pump placement (OR = 7.4, p < 0.0001), and total surgical time (OR = 3.7, p < 0.0001). Patients who met extubation criteria had lower in-hospital reintubation (2.5% v 16%, p < 0.001), myocardial infarction (1.03% v 4.58%, p = 0.001), renal insufficiency (2.2% v 7.63%, p < 0.001), stroke (0.4% v 2.29%, p = 0.032), and mortality rates (1.2% v 10.7%, p < 0.001) than patients who did not. UFTA is feasible and safe in most patients undergoing OPCAB surgery. Baseline and intraoperative data predicted when immediate extubation should not be attempted.