Effective surgical management of high-risk coronary patients using preoperative intra-aortic balloon counterpulsation therapy.
The proportion of high-risk coronary patients submitted to surgical myocardial revascularization (CABG) is steadily increasing. High-risk patients utilize more hospital resources and have a higher procedural cost than low-moderate risk CABG patients. An efficient management is essential to improve outcome and reduce costs. This report entails three study periods. In an initial retrospective study coronary high-risk criteria were established. At least two of the following factors were required: redo CABG, unstable angina, left main stem stenosis greater than 70%, preoperative left ventricular ejection fraction < 0.30 and diffuse coronary artery disease. Poor preoperative cardiac performance was the major contributing factor for poor outcome. Intra-aortic balloon counterpulsation therapy (IABP) was introduced as preoperative therapy. During a second study period prospective randomized studies found preoperative IABP-therapy efficient, significantly improving both preoperative cardiac index (P < 0.0001), decreasing postoperative mortality (P < 0.0001) and morbidity, shorten intensive care unit stay as well as total hospital stay (P < 0.0001). Drug consumption was significantly reduced (P < 0.0001). Optimal timing was found to be 2 h prior to aortic cross-clamping and the therapy was found highly cost-beneficial with an average 36% reduction of the total procedural cost. During a third study period, well beyond any study protocol period, preoperative IABP therapy was again found highly effective with a close to 100% utilization rate in high-risk patients and continuous efficacy with excellent outcome, despite acceptance of sicker patients. During this post-study evaluation period 1/3 of the high-risk patients presented with 4 of the established risk factors. The use of preoperative IABP therapy is therefore highly recommended for high-risk coronary patients undergoing CABG.
Christenson
J T
JT
Clinic for Cardiovascular Surgery, University Hospital, CH-1211 14, Geneva, Switzerland. jtchristenson@hotmail.com
Schmuziger
M
M
Simonet
F
F
D000328:Adult; D000368:Aged; D000789:Angina, Unstable / Q000401:mortality / Q000601:surgery*; D003327:Coronary Disease / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007423:Intra-Aortic Balloon Pumping; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000601:surgery*; D011182:Postoperative Care; D011183:Postoperative Complications / Q000401:mortality*; D011300:Preoperative Care; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D012307:Risk Factors; D015996:Survival Rate