Preoperative Intra-aortic Balloon Pump Research Articles

Preoperative Statin Therapy Decreases Risk of Postoperative Renal Insufficiency

Although current guidelines recommend withholding statins in perioperative patients, little information is available on whether perioperative statin use increases risk for postoperative renal failure. We examined the relation between preoperative statin therapy and postoperative risk for renal insufficiency in patients undergoing cardiac surgery. Retrospective cohort review from the Texas Heart Institute research database was performed. Patients were divided into two groups: those who received preoperative statins and those who did not. Primary outcome was the development of postoperative renal insufficiency (requiring dialysis or not). Outcomes were assessed in the entire cohort and in subgroups undergoing isolated coronary artery bypass grafting (CABG), isolated valve surgery, or combined CABG and valve surgery. Of 3001 patients, 56% received preoperative statins. In multivariate logistic regression analysis, preoperative statins were associated with significant reductions in risk for postoperative renal insufficiency in the entire cohort (odds ratio [OR]= 0.60, 95% confidence interval [CI] 0.38-0.95) and in patients undergoing isolated CABG (OR = 0.34, 95% CI 0.17-0.68). In patients undergoing isolated valve surgery (OR = 1.35, 95% CI 0.61-2.96) or combined CABG and valve surgery (OR = 1.39, 95% CI 0.48-3.99), preoperative statins were not associated with decreased incidence of postoperative renal insufficiency. Age >65 years, preoperative renal insufficiency, history of congestive heart failure, preoperative intra-aortic balloon pump insertion, and total cardiopulmonary bypass time >80 min were also independent predictors associated with increased risk for postoperative renal insufficiency. Preoperative statin therapy was associated with decreased incidence of postoperative renal insufficiency in patients undergoing cardiac surgeries, particularly in patients undergoing isolated CABG.

EurosSCORE-guided preoperative elective intra-aortic balloon pump implantation in high risk patients does not reduce In-hospital mortality after cardiac surgery

EurosSCORE-guided preoperative elective intra-aortic balloon pump implantation in high risk patients does not reduce In-hospital mortality after cardiac surgery

Influence of timing of intraaortic balloon placement in cardiac surgical patients

The study objective was to evaluate the association between timing of intraaortic balloon pump insertion and outcomes in patients undergoing cardiac surgery. All patients aged 18 years or more who underwent coronary artery bypass surgery, cardiac valve surgery, or thoracic aortic surgery between January 2002 and December 2007 were included. Data were obtained from cardiac surgery and intensive care databases. Patients were categorized as receiving a preoperative, intraoperative, or postoperative intraaortic balloon pump and compared with a reference group who did not receive an intraaortic balloon pump. Summary and descriptive statistics were used to compare the groups. Logistic regression was used to model in-hospital mortality, and survival methods were used to model time to event data, such as length of stay. There were 7440 patients included over a 6-year period, of whom 217 (2.9%) received a preoperative intraaortic balloon pump, 184 (2.4%) received an intraoperative intraaortic balloon pump, and 42 (0.56%) received a postoperative intraaortic balloon pump. Logistic European System for Cardiac Operative Risk Evaluation-derived predicted risk of death was higher across all intraaortic balloon pump groups compared with the group with no intraaortic balloon pump. Observed in-hospital mortality was significantly lower in the preoperative group (10%) and the group with no intraaortic balloon pump (0.8%) compared with the intraoperative (16%) and postoperative (29%) groups. Risk-adjusted mortality was also lower in the preoperative group. This study comparing outcomes in patients undergoing cardiac surgical procedures with timing of intraaortic balloon pump placement revealed that the use of preoperative intraaortic balloon pumps was associated with a strong trend toward reduction in in-hospital mortality despite a higher predicted mortality in this group. The study provides support to the growing body of literature advocating preoperative use of intraaortic balloon pumps in carefully selected patients.

Endoscopic vein harvest in elective off-pump coronary artery bypass grafting

While traditional open vein harvest was related to postoperative wound complications, endoscopic vein harvest was developed to minimize the morbidity in the greater saphenous vein harvest procedure. In this study, these two procedures were compared for postoperative wound healing and long-term graft patency. We reviewed all consecutive patients undergoing elective off-pump coronary artery bypass grafting from January 2004 to December 2005 and collected data regarding wound complications and coronary events. Wound complications included dehiscence, excessive discharge, edema, altered sensation, cellulitis, hematoma, pain scale, and superficial and deep wound infection. Coronary events were defined as diagnosis of myocardial infarction during the first year's follow-up. A total of 392 patients were included in our series, among whom 44 were excluded from the study due to emergent operation, preoperative intra-aortic balloon pump support, or the greater saphenous vein varicose characteristic, 78 belonged to open vein harvest group, and 270 to endoscopic vein harvest group. Wound complications were significantly less in the endoscopic group (5.2%) compared to the open group (19.2%) (P=0.0002). There was no significant difference on preoperative risk factors, total operative time, or hospitalization days. During one-year follow-up, both the early and late graft patency rates were similar between the two groups. Endoscopic vein harvest is safe and effective, which carries less risk for wound complications and is associated with better satisfaction and cosmetic result than the traditional greater saphenous vein harvest procedure. The endoscopic vein harvest also demonstrates a great long-term patency.

Prospective, Comprehensive Assessment of Cardiac Troponin T Testing After Coronary Artery Bypass Graft Surgery

The significance and clinical role of cardiac troponin testing after coronary artery bypass grafting remain unclear. Cardiac troponin T (cTnT) was measured during the first 24 hours after coronary artery bypass graft surgery in 847 consecutive patients. Only 17 patients (2.0%) had new Q waves or left bundle-branch block after surgery; however, cTnT elevation was observed in nearly all subjects, with a median cTnT concentration of 1.08 ng/mL overall. Direct predictors of postoperative cTnT values included preoperative myocardial infarction (P<0.001), preoperative intraaortic balloon pump (P<0.001), intraoperative/postoperative intraaortic balloon pump (P<0.001), number of distal anastomoses (P=0.005), bypass time (P<0.001), and number of intraoperative defibrillations (P=0.009), whereas glomerular filtration rate (P<0.001), off-pump coronary artery bypass grafting (P=0.003), and use of warm cardioplegia (P=0.02) were inversely associated with cTnT values. A linear association was seen between cTnT levels and length of stay and ventilator hours, and in an analysis adjusted for the Society for Thoracic Surgery Risk Model, cTnT remained independently prognostic for death (odds ratio, 3.20; P=0.003), death or heart failure (odds ratio, 2.04; P=0.008), death or need for vasopressors (odds ratio, 2.70; P<0.001), and the composite of all 3 (odds ratio, 2.57; P<0.001). In contrast to consensus-endorsed cTnT cut points for postoperative evaluation, a cTnT <1.60 ng/mL had a negative predictive value of 93% to 99% for excluding various post-coronary artery bypass graft surgery complications. cTnT concentrations after coronary artery bypass graft surgery are nearly universally elevated, are determined by numerous factors, and are independently prognostic for impending postoperative complications when used at appropriate cut points.

Intra aortic balloon pump insertion through left axillary artery in patients with severe peripheral arterial disease

Intra aortic balloon pump (IABP) is the mechanical assist device most frequently used in cardiac surgery. Recent demonstration of better outcome following preoperative IABP insertion in high-risk patients has further extended its indication. However, due to an increasing complexity of patients currently referred for cardiac surgery, several patients with potential indication for preoperative and/or postoperative IABP present severe peripheral vascular disease which usually contraindicates IABP insertion. Here we present an alternative technique for IABP insertion in patients with severe peripheral vessel disease.

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.

Evaluation of preoperative intra-aortic balloon pump in coronary patients with severe left ventricular dysfunction undergoing OPCAB surgery: early and mid-term outcomes

BackgroundThe purpose of the present study was to evaluate the safety and the cost-effectiveness of using preoperative IABP as support compared with postoperative IABP treatment in coronary patients with severe left ventricular dysfunction (SLVD) who is undergoing off-pump coronary artery bypass surgery (OPCAB), including early outcomes, hospital mortality and morbidity, and mid-term follow-up outcomes.MethodsBetween March 2000 and December 2008, we prospectively and randomly studied the insertion of preoperative IABP in 115 (7.4%) and postoperative IABP in 106 (6.8%) of the 1560 consecutive patients. Group A is preoperative IABP therapy. Group B is postoperative IABP therapy.ResultsThere was no significant difference in the number of grafts used between the two groups. Completeness of revascularization did not differ between the two groups. The statistically significant difference was hospital mortality (2.6% in group A vs. 3.8% in group B) (p < 0.05). And there was significant reduction in postoperative low cardiac output, malignant arrhythmia, acute renal failure and length of stay in ICU in group A, compared with group B (p < 0.05). In the two groups, six-, 12-, 24- and 48-month survival rates were similar. In the study the degree of improvement in angina and quality of life did not differ significantly between the two groups.ConclusionThe use of preoperative IABP in SLVD patients undergoing OPCAB is of safety and effectiveness. The combined use of preoperative IABP and OPCAB allows complete revascularization in SLVD patients with an important reduction in operative mortality and excellent mid-term results.

Repeat Surgery for Coronary Artery Bypass Grafting: The Role of the Left Thoracotomy Approach

Repeat coronary artery bypass surgery has increased risks compared with the first operation, including low cardiac output and injury to patent grafts. The left thoracotomy approach has been advocated specifically in patients with intact grafts of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) needing lateral wall grafting. We have evaluated this technique in conjunction with an off-pump procedure in all patients. There were 55 patients over an 8-year period, and 6 (10.9%) were female. The mean age was 63.2 years (range, 41-82 years), and the age at the time of the previous operation was 51.7 years (range, 31-69 years). Four patients (7.2%) underwent a third operation. Comorbidities were diabetes mellitus (25 patients, 45.5%), renal impairment (8 patients, 14.5%), calcified ascending aorta (9 patients, 16.4%), carotid disease (4 patients, 7.2%), and peripheral vascular disease (11 patients, 20.0%). Fifteen patients (27.2%) had previous coronary stents. Nine patients (16.4%) had a preoperative intra-aortic balloon pump. Predicted mortality (logistic EuroSCORE) was 14.2%. Forty-three patients (78.1%) had intact LIMA-to-LAD grafts. Twenty-two patients (40.0%) required a major posterolateral thoracotomy, and 33 patients (60.0%) had a minor thoracotomy. Thirteen patients (23.6%) had stents placed as a hybrid procedure during the same admission. Thirteen patients (23.6%) additionally underwent anterior wall grafting (LAD to the first marginal area). The LIMA was used in 7 patients where it had not been used before. There were 91 distal grafts (including 4 sequentials). We performed 54 venous grafts and 26 radial artery grafts. Twenty-one patients (38.1%) had 1 distal graft, 32 patients (58.1%) had 2 grafts, and 2 patients (3.6%) had 3 distal grafts performed (mean, 1.6 grafts/patient). The proximal graft site was the proximal descending aorta in 20.0% of the patients, the distal aorta in 67.5%, and the subclavian artery in 12.5%. In 10 patients (18.2%), the distal branches of the right coronary (posterior descendens or right posterolateral) were grafted. No patient required conversion to cardiopulmonary bypass or sternotomy. No patient needed an intra-aortic balloon pump postoperatively. The mean blood loss (24 hours) was 380 mL (range, 125-1100 mL), the mean ventilation time was 4.8 hours (range, 0-12 hours), the mean intensive care unit stay was 2.7 days (range, 2-8 days), and the mean hospital stay was 6.3 days (range, 5-20 days). There was 1 postoperative death (1.8% mortality). One late death occurred on follow-up. Four patients underwent cardiac catheterization for chest pain, and the grafts were shown to be open. The procedure is safe, especially in patients with intact LIMA-to-LAD grafts needing lateral and inferior wall revascularization. Multislice computed tomography scanning allows better preoperative planning, especially regarding the site of implantation of the proximal graft, allowing a less invasive incision. The off-pump technique preserves cardiac and pulmonary function. The in-hospital death rate (1.8%) compares very well with the EuroSCORE-predicted mortality (14.2%).

Long-Term Results After Surgical Repair of Postinfarction Ventricular Septal Rupture by Infarct Exclusion Technique

Ventricular septal defect (VSD) is one of the most serious and life-threatening complications of acute myocardial infarction. The aim of this study was to evaluate the early and long-term results of the patients after surgical repair of postinfarction VSD by infarct exclusion technique. A total of 32 consecutive patients (mean age, 62.5 +/- 10.5 years) underwent postinfarction VSD repair using a standardized technique in our department. A retrospective analysis of clinical and operative data, predictors of early mortality, and long-term survival was performed. The localization of VSD was posterior in 50% and anterior in 50% of the patients. The hospital mortality was 31.2% (10 patients). The most common cause of hospital death was persistent low cardiac output. The mortality of the posterior VSD group was significantly lower than that of the anterior VSD group (18.7% and 43.7%, respectively, p = 0.01). Intra-aortic balloon pump support and absence of cardiac shock were significantly associated with a lower risk of hospital mortality (p = 0.0001 and p = 0.0009, respectively). The actuarial survival rates of in-hospital survivors at 5 and 10 years were 79% +/- 2% and 51% +/- 3%, respectively. The repair of postinfarction VSD by the infarct exclusion is feasible and safe. This technique seems to offer sufficient favorable early and long-term results compared with other techniques. Early indication, preoperative intra-aortic balloon pump support may improve the surgical results. Preoperative cardiogenic shock carries a poor prognosis for this patient group.

An 11-Year, Single-institution Analysis of Intra-aortic Balloon Pump Use in Cardiac Surgery

The primary objective of this study was to analyze perioperative intra-aortic balloon pump (IABP) insertion in patients undergoing cardiac surgery in the authors' institution from 1995 to 2005 and to propose an explanation for changes in use over this period. A secondary objective was to assess patient variables associated with IABP use. This is a retrospective study including patients who underwent cardiac surgery between 1995 and 2005. The Cardiothoracic Anesthesia Patient Registry of a single teaching institution was queried to obtain the required information. Thirty thousand two hundred sixty-nine cardiac surgery patients. Intra-aortic balloon pump insertion before surgery, after cardiopulmonary bypass, or in the cardiovascular intensive care unit was assessed in patients who underwent isolated coronary artery bypass graft surgery, valve surgery, or both. Select patient variables were analyzed for their association with IABP insertion. Transesophageal echocardiography (TEE) examinations, milrinone use, and mortality rates also were determined. Among 30,269 cardiac surgery patients, 1,310 (4.32%) underwent IABP insertion. Combined preoperative, intraoperative, and postoperative IABP use decreased from 7.8% in 1995 to 3.0% in 2005. Simultaneously, the intraoperative use of milrinone increased from 4.8% to 8.8% and postoperative use increased from 5.2% to 7.8%. The number of intraoperative TEE examinations more than doubled from approximately 1,700 to 3,500. The overall mortality for patients with preoperative, intraoperative, and postoperative IABP insertion was 12.6%, 17.5%, and 47.7%, respectively. From 1995 to 2005, preoperative, intraoperative, and postoperative IABP use decreased by approximately 60% in cardiac surgery patients. Simultaneously, the use of TEE and milrinone each doubled. Although a cause-effect relationship cannot be established from the present study's observational data, the trends coincide and may be related.

Intra-aortic balloon pump induced pulsatile perfusion reduces endothelial activation and inflammatory response following cardiopulmonary bypass

Intra-aortic balloon pump (IABP)-induced pulsatile perfusion has demonstrated that it can preserve organ function during cardiopulmonary bypass (CPB). We evaluated the role of IABP pulsatile perfusion on endothelial response. Forty consecutive isolated CABG undergoing preoperative IABP were randomized to receive IABP pulsatile CPB during aortic cross-clamping (group A, 20 patients) or standard linear CPB (group B, 20 patients) during cross-clamp time. Hemodynamic results were analyzed by Swan-Ganz catheter [mean arterial pressure (MAP), cardiac index (CI), indexed systemic vascular resistances (ISVR), indexed pulmonary vascular resistances (IPVR), wedge pressure (PCWP)]. Inflammatory/endothelial response was analyzed by pro-inflammatory (IL-2, IL-6, IL-8), anti-inflammatory cytokines (IL-10), and endothelial markers [vascular endothelial growth factor (VEGF) and monocyte chemotactic protein-1 (MCP-1)]. All measurements were recorded preoperatively (T0), before aortic declamping (T1), at the end of surgery (T2), 12h (T3) and 24h (T4) postoperatively. ANOVA for repeated measures was used to evaluate the differences of means. Hemodynamic response was comparable except for higher MAP (p=0.01 at T1) and lower ISVR (p=0.001 at T1, p=0.003 at T2) in group A. No differences were found in perioperative leakage of IL-2, IL-6, and IL-8 between the two groups (within-group p=0.0001 either in group A and group B; between-groups p=NS at 2-ANOVA). Group A showed significantly lower VEGF (between-groups p=0.001 at 2-ANOVA, p=0.001 at T1, T2) and MCP-1 (between-groups p=0.001 at 2-ANOVA, p=0.001 at T1, T2) with higher IL-10 secretion (between-groups p=0.001 at 2-ANOVA, p=0.01 at T1, T2, T3). IABP-induced pulsatile perfusion allows lower endothelial activation during CPB and higher anti-inflammatory cytokines secretion.

Preoperative Intraaortic Balloon Pumping Improves Outcomes for High-Risk Patients in Routine Coronary Artery Bypass Graft Surgery

We evaluated the association between the preoperative use of intraaortic balloon pumping and in-hospital and long-term outcomes in high-risk patients undergoing coronary artery bypass grafting. From 714 total patients undergoing coronary artery bypass grafting during a 4-year period, we compared the clinical, biochemical, and echocardiographic findings up to 1 year after surgery between 111 patients who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 12 or greater and received intraaortic balloon pumping preoperatively (group A) and 130 patients who had a EuroSCORE of 5 or less and received no preoperative intraaortic balloon pumping (group B). Group A patients were significantly older, had significantly more comorbid conditions, and had a significantly lower mean preoperative ejection fraction (all p < 0.001). Intraoperative data were comparable between groups, as were lactate and troponin I levels sampled from the coronary sinus. Lactate, troponin I, creatine kinase, and creatine kinase-MB mass showed comparable leakage at all postoperative times. The incidences of in-hospital mortality, perioperative myocardial damage, and acute myocardial infarction and duration of hospital stay were comparable. High-risk patients showed significant improvements in ejection fraction (p < 0.001) and wall-motion score index (p = 0.06) after surgery, but low-risk patients showed no significant change in these variables. The incidences of death, recurrent angina, myocardial infarction, and repeat coronary procedures did not differ significantly between groups. The preoperative use of intraaortic balloon pumping appears to shift high-risk patients undergoing coronary artery bypass grafting into a lower-risk category and is associated with comparable perioperative troponin leakage and short-term and long-term outcomes similar to low-risk patients not receiving intraaortic balloon pumping.

Acute Kidney Injury After Cardiac Surgery

Acute kidney injury (AKI) after cardiac surgery is a major health issue. Lacking effective therapies, risk factor modification may offer a means of preventing this complication. The objective of the present study was to identify and determine the prognostic importance of such risk factors. Data from a multicenter cohort of 3500 adult patients who underwent cardiac surgery at 7 hospitals during 2004 were analyzed (using multivariable logistic regression modeling) to determine the independent relationships between 3 thresholds of AKI (>25%, >50%, and >75% decrease in estimated glomerular filtration rate within 1 week of surgery or need for postoperative dialysis) with death rates, as well as to identify modifiable risk factors for AKI. The 3 thresholds of AKI occurred in 24% (n=829), 7% (n=228), and 3% (n=119) of the cohort, respectively. All 3 thresholds were independently associated with a >4-fold increase in the odds of death and could be predicted with several perioperative variables, including preoperative intra-aortic balloon pump use, urgent surgery, and prolonged cardiopulmonary bypass. In particular, 3 potentially modifiable variables were also independently and strongly associated with AKI. These were preoperative anemia, perioperative red blood cell transfusions, and surgical reexploration. AKI after cardiac surgery is highly prevalent and prognostically important. Therapies aimed at mitigating preoperative anemia, perioperative red blood cell transfusions, and surgical reexploration may offer protection against this complication.

On-pump beating heart coronary surgery for high risk patients requiring emergency multiple coronary artery bypass grafting

BackgroundCardiopulmonary bypass (CPB) with aortic cross-clamping and cardioplegic arrest remains the method of choice for patients requiring standard myocardial revascularization. Therefore, very high-risk patients presenting with acute coronary syndrome, unstable angina, onset of cardiac decompensation and requiring emergency multiple myocardial revascularization, can have a poor outcome. The on-pump beating heart technique can reduce the mortality and the morbidity in such a selected group of patients and this report describes our clinical experience.MethodsOut of 290 patients operated for CABG from January 2005 to January 2006, 25 (8.6%) selected high-risk patients suffering from life threatening coronary syndrome (mean age 69 ± 7 years) and requiring emergency multiple myocardial revascularization, underwent on-pump beating heart surgery. The mean pre-operative left ventricle ejection fraction (LVEF) was 27 ± 8%. The majority of them (88%) suffered of tri-vessel coronary disease and 6 (24%) had a left main stump disease. Nine patients (35%) were on severe cardiac failure and seven among them (28%) received a pre-operative intra-aortic balloon pump. The pre-operative EuroScore rate was equal or above 8 in 18 patients (73%).ResultsAll patients underwent on-pump-beating heart coronary revascularization. The mean number of graft/patient was 2.9 ± 0.6 and the internal mammary artery was used in 23 patients (92%). The mean CPB time was 84 ± 19 minutes. Two patients died during the recovery stay in the intensive care unit, and there were no postoperative myocardial infarctions between the survivors. Eight patients suffered of transitorily renal failure and 1 patient developed a sternal wound infection. The mean hospital stay was 12 ± 7 days. The follow-up was complete for all 23 patients survived at surgery and the mean follow-up time was 14 ± 5 months. One patient died during the follow-up for cardiac arrest and 2 patients required an implantable cardiac defibrillator. One year after surgery they all had a standard trans-thoracic echocardiogram showing a mean LVEF rate of 36 ± 11.8%.ConclusionStandard on-pump arrested heart coronary surgery has higher mortality and morbidity in emergencies. The on-pump beating heart myocardial revascularization seems to be a valid alternative for the restricted and selected cohort of patients suffering from life threatening coronary syndrome and requiring multiple emergency CABG.

Intra-aortic balloon pumping increases renal blood flow in patients with low left ventricular ejection fraction

Intra-aortic balloon pumping (IABP) has, for decades, been one of the key treatment modalities following impaired cardiac function after cardiac surgery. IABP increases cardiac output, decreases oxygen consumption of the heart and relieves the left ventricle. However, a number of complications have been reported in connection with IABP treatment. Only a few studies have evaluated renal blood flow and the purpose of this prospective study was to evaluate whether renal blood flow was affected by IABP treatment in high-risk patients. After approval from the county ethical committee and informed consent, seven consecutive patients with low left ventricular ejection fraction and scheduled for preoperative IABP treatment were allocated to the study. Assessment of renal blood flow was based on ultrasound spectral Doppler estimation of the flow velocity profiles in the interlobar kidney arteries. The result was described as balloon index (BI), which is maximal systolic velocity divided by the temporal mean velocity. Typical velocity profiles were demonstrated in all patients before, during and after IABP. BI measurement changed with time (p <0.05). BI was lower during IABP compared to both pre-IABP and post-IABP (p <0.025), indicating a higher renal blood flow. No statistically significant changes were seen in s-creatinine or creatinine clearance. Assuming unchanged diameter of kidney arteries and no considerable decrease in renal resistance and/or compliance, we conclude that the interlobar renal blood flow was significantly increased during IABP treatment, measured by ultrasound Doppler technique, but without a simultaneously significant change in creatinine clearance.

Survival After Sequential Mechanical Complications of Acute Myocardial Infarction, Complicated with Heparin-Induced Thrombocytopenia and Multiple Organ Failure: Report of a Case

Ventricular wall rupture and acute mitral regurgitation due to papillary muscle rupture post-acute myocardial infarction are rare and dramatic mechanical complications. The operative mortality of both complications remains extremely high but this is the only treatment which has greatly improved the prognosis. We describe the course of a patient, who survived after left ventricular free wall rupture two days post-acute myocardial infarction. He underwent left ventricular rupture repair plus two coronary artery bypass grafting. On the fifth postoperative day he developed papillary muscle rupture and acute mitral valve regurgitation. He was reoperated as an emergency case for mitral valve replacement. The patient sustained numerous complications, such as renal failure, heparin-induced thrombocytopenia, sepsis, acute respiratory distress syndrome, and multiple organ failure. He was on continuous venous-venous hemofiltration for one week and underwent a tracheostomy on the ninth postoperative day. He remained on a ventilator for three weeks. The patient survived, was discharged home after six weeks, and remains in very good condition on follow-up so far. The operative mortality of both complications remains high but this is the only treatment which improves the prognosis. Surviving both events is rare and few cases have been reported in the literature. This case highlights the necessity of careful echocardiographic examination in any patient presented with post-myocardial infarction new onset of hemodynamic instability. Identification of a single site of rupture does not eliminate the possibility of additional ruptures in the papillary muscle and intraventricular septum, and transesophageal echocardiography should be used to search for these entities. Although repair of each of these complications carries a high mortality, failure to address them will almost certainly result in death. Using standard surgical techniques, including preoperative intraaortic balloon pump insertion and careful postoperative management, successful outcome is possible.

Case report: Pre-operative intra-aortic balloon pump for elective abdominal perineal resection in a patient with poor left ventricular function

Case report: Pre-operative intra-aortic balloon pump for elective abdominal perineal resection in a patient with poor left ventricular function

Intra‐aortic Balloon Pump‐induced Pulsatile Flow Reduces Coagulative and Fibrinolytic Response to Cardiopulmonary Bypass

The aim of this study is to evaluate if a simple intra-aortic balloon pump (IABP)-induced pulsatile perfusion reduces activation of coagulative system during cardiopulmonary bypass (CPB). Ninety-six patients undergoing preoperative IABP were randomized to nonpulsatile CPB with IABP discontinued during cardioplegic arrest (Group A) or IABP-induced pulsatile CPB (Group B). White blood cells (WBC), hematocrit (Ht), platelets (PLTs), International Normalized Ratio (INR), fibrinogen, activated partial thromboplastin time (aPTT), antithrombin III (AT-III) activity, and D-dimer were measured at the end of surgery (ES) and postoperatively. Chest drainage, need for reexploration, and transfusions were compared. Group B showed lower chest drainage (1st day P = 0.038; 2nd day P = 0.044), transfusions (P = 0.031), WBC (P < 0.05 at all time points), and INR (P < 0.05 at all time points), together with a higher Ht (P < 0.05 at ES, 12 h), platelets (P < 0.04 at all time points), fibrinogen (P < 0.05 at ES, 12 h, 24 h), and aPTT (P < 0.05 at all time points). AT-III activity lowered in Group A (P = 0.001 at ES, 12 h, 24 h), together with higher D-dimer levels (P < 0.05 at all time points). IABP-induced pulsatile perfusion ameliorates coagulative system activation following CPB.

On-pump beating-heart coronary artery bypass grafting after acute myocardial infarction has lower mortality and morbidity

The mortality of conventional coronary artery bypass grafting after acute myocardial infarction remains high. This study compared the clinical outcomes of patients undergoing conventional and on-pump beating-heart coronary artery bypass grafting and evaluated the efficacy of an on-pump beating-heart technique for the surgical treatment of these critically ill patients. Between January 1999 and March 2005, 61 patients underwent emergency coronary artery bypass grafting for acute myocardial infarction. In the first 23 patients, the conventional cardioplegic method was performed. In the most recent 38 patients, the on-pump beating-heart procedure was used without cardioplegic arrest. A significant reduction occurred in the observed mortality between the conventional and on-pump beating groups (21.7% vs 2.6%, P = .04), despite a higher predicted mortality risk calculated by using EuroSCORE (9.0 +/- 1.6 vs 9.6 +/- 1.6, P = .048) and a greater use of a preoperative intra-aortic balloon pump (43.5% vs 78.9%, P = .005). On-pump beating-heart patients received fewer bypass grafts than conventional patients (2.0 vs 2.9, P = .001), but the internal thoracic artery was used more often in on-pump beating-heart patients (P = .014). Three patients in the conventional coronary artery bypass grafting group required new insertion of an intra-aortic balloon pump, whereas no patients required this in the on-pump beating-heart group (P = .220). Postoperative renal failure requiring hemodialysis occurred in 2 patients in the conventional coronary artery bypass grafting group but in no patients in the on-pump beating-heart group (P = .138). On-pump beating-heart coronary artery bypass grafting is the preferred method of emergency myocardial revascularization for patients with acute myocardial infarction who might tolerate cardioplegic arrest poorly. It has lower postoperative mortality and morbidity than conventional coronary artery bypass grafting.