Asian Cardiovasc Thorac Ann 2008;16:301-304
© 2008 Asia Publishing EXchange Ltd
Mortality in Open Heart Surgery with Intraaortic Balloon Pump Support
Abbasali Karimi, MD,
Namvar Movahedi, MD,
Abbas Salehiomran, MD,
Mehrab Marzban, MD,
Seyed Hesameddin Abbasi, MD1,
Parin Yazdanifard, MD1
Cardiothoracic Surgery Department
1 Clinical Research Department, Tehran Heart Center, Medical Sciences University of Tehran Tehran, Iran
For reprint information contact: Abbasali Karimi, MD, Tel: 98 21 8802 9256, Fax: 98 21 8802 9256, Email: abbasalikarimi2006{at}yahoo.com Tehran Heart Center, North Kargar Street, Tehran, Iran 1411713138.
 |
ABSTRACT
|
|---|
Mechanical circulatory assistance is frequently needed to support the failing heart. The aim of this study was to determine perioperative prognostic factors for hospital mortality in patients undergoing open heart surgery who required intraaortic balloon pump support. Between January 2002 and September 2006, 475 patients received an intraaortic balloon pump perioperatively. Hospital mortality was 21.89%. Risk factors for hospital death identified by multivariate logistic regression analysis were peripheral vascular disease, left main coronary artery disease, postoperative renal failure, postoperative cardiac arrest, and prolonged hospital stay. Minor and major intraaortic balloon pump-related complications were not significant in univariate and multivariate analysis; the incidence was 5.05%. It is suggested that the threshold for using balloon pump support is decreased in high-risk patients undergoing cardiac surgery.
|
INTRODUCTION
|
|---|
Mechanical circulatory assistance is frequently needed to support the failing heart. An intraaortic balloon pump (IABP) is usually the first choice of mechanical device for perioperative cardiac failure.1 It reduces ventricular afterload, improves diastolic coronary perfusion, and enhances subendocardial perfusion.2 The IABP has been in widespread clinical use for hemodynamic support since it was introduced in 1968.3,4 Several studies have focused on prognostic factors for death in patients treated with an IABP, and there is great variability in the results because of the diversity of indications for IABP and patient populations.5–8 This retrospective study was carried out to analyze the hospital outcome of patients who underwent open heart surgery with IABP support, and to determine the prognostic factors for hospital mortality.
|
PATIENTS AND METHODS
|
|---|
Of 12,736 patients who underwent open heart surgery over a 4-year period (January 2002 to September 2006), IABP support was required in 475 (3.7%). They comprised 307 (64.6%) men and 168 (35.4%) women, with a mean age of 60.36 ± 10.25 years and mean body mass index of 26.22 ± 4.19 kg·m–2. There were 200 (42%) patients in New York Heart Association functional class III and IV, and 251 (53%) had a history of myocardial infarction. Intraaortic balloon pump insertion was performed before the operation in 20 (4%) cases, during the operation in 380 (80%), and postoperatively in 75 (16%). The operations were for ischemic heart disease (coronary artery bypass grafting with or without another procedure on the atrium or ventricle) in 440 (93%) patients, for valvular heart disease in 119 (25%), and for both coronary artery bypass and valve surgery in 91 (19%). All medical records of these patients were retrieved from our hospital surgery databank, and variables that might influence the outcome were collected and grouped into pre-, intra-, and postoperative subsets. The patient record forms contained 214 variables (91 pre-, 73 intra-, and 50 postoperative variables). Definitions of all variables were according to the STS Adult Cardiac Database.9 The early major and minor complications related to IABP use were abdominal aortic perforation, reoperation for bleeding (including femoral bleeding), limb ischemia, and local leg infection. Femoral artery bleeding was only considered if it needed reoperation. Low cardiac output was treated initially with inotropic agents (adrenaline and dobutamine); noradrenaline was used in vasogenic syndrome states. If the patient did not respond to vasoactive drugs (blood pressure did not raise or pulmonary artery pressure remained high), an IABP was inserted. Patients with post-myocardial infarction ventricular septal defect who required open heart surgery were routinely supported by IABP.
Univariate analysis of continuous variables was carried out by Student’s t test. Univariate analysis of categorical variables was undertaken using Fisher’s exact test. A p value < 0.05 was considered significant. Variables with a p value < 0.05 and those with known clinical importance but failed to meet the 
level were included in logistic regression analysis.
|
RESULTS
|
|---|
Hospital death (within 30 days) occurred in 104 patients; the mortality rate was 21.89%. The overall incidence of minor and major IABP-related complications was 5.05%. The demographic and perioperative variables of the patients who died and the 371 who were discharged alive from the hospital were compared and analyzed by univariate and multivariate analyses (Tables 1
, 2, and 3). All variables that were significantly different between patients who died in hospital and those who survived to discharge were entered into logistic regression analysis. Multivariate logistic regression analyses revealed the following factors as predictors of hospital mortality in patients with IABP support: peripheral vascular disease, left main coronary artery disease, postoperative renal failure, prolonged hospital stay, and postoperative cardiac arrest (Table 4).
View this table:
[in this window]
[in a new window]
|
Table 1. Univariate Analysis of Perioperative Quantitative Variables in 475 Patients Requiring Balloon Pump Support
|
|
View this table:
[in this window]
[in a new window]
|
Table 2. Univariate Analysis of Preoperative Qualitative Variables in 475 Patients Requiring Balloon Pump Support
|
|
View this table:
[in this window]
[in a new window]
|
Table 3. Univariate Analysis of Operative and Postoperative Quantitative Variables in 475 Patients Requiring Balloon Pump Support
|
|
View this table:
[in this window]
[in a new window]
|
Table 4. Results of Multivariate Analysis of Factors Associated with Hospital Death in Patients Requiring Balloon Pump Support
|
|
|
DISCUSSION
|
|---|
Despite ongoing improvements in surgical care and myocardial protection, the early mortality rate in patients who are supported with an IABP remains high. The mortality rate of 21.89% found in our study is within the acceptable range, and less than some rates reported in other studies.1,3,7,8,10,11 Multivariate logistic regression analysis identified the factors associated with hospital mortality in these patients undergoing open heart surgery with IABP support. Some of these factors had been identified previously. As revealed in other studies, left main disease may affect the survival of patients who receive an IABP.6,8,12,13 Arafa and colleagues14 as well as Meharwal and Trehan15 determined peripheral vascular disease to be a risk factor for major IABP-related complications, some of which could be related to hospital mortality. We also found by multivariate logistic regression analysis that peripheral vascular disease was a prognostic factor for early mortality during IABP use in open heart surgery. Postoperative renal dysfunction has been shown previously to correlate with a poor outcome after cardiac operations, and our results are in agreement with this.16 In our study, there was a significant linear relationship between early death during IABP use and postoperative cardiac arrest as well as prolonged hospital stay. These factors have not been identified in previous studies.
The reported rate of morbidity associated with IABP insertion is within the range of 8.7%–29%, and varies widely from minor local infection to death.5,11,17 In our study, the incidence of early minor and major complications, including acute limb ischemia, local leg infection, abdominal aorta perforation, and reoperation for severe femoral bleeding was 5.05%, which is close to the morbidity rate reported by Tokmakoglu and colleagues.3 There was no association between IABP insertion-related complications and hospital mortality, as shown by other studies, and it supports a policy of more liberal use of the IABP in high-risk patients, as advised previously.1,5,18–20 Thus, in view of the adequate results of IABP insertion in this study, we think it is sensible to decrease the threshold for using an IABP in high-risk patients undergoing open heart surgery.
|
REFERENCES
|
|---|
- Naunheim KS, Swartz MT, Pennington DG, Fiore AC, McBride LR, Peigh PS, et al. Intraaortic balloon pumping in patients requiring cardiac operations. Risk analysis and long-term follow-up. J Thorac Cardiovasc Surg 1992;104:1654–61.[Abstract]
- Maccioli GA, Lucas WJ, Norfleet EA. The intra-aortic balloon pump: a review. J Cardiothorac Anesth 1988;2:365–73.[Medline]
- Tokmako lu H, Farsak B, Günaydin S, Kandemir O, Aydin H, Yorgancio lu C, et al. Effectiveness of intraaortic balloon pumping in patients who were not able to be weaned from cardiopulmonary bypass after coronary artery bypass surgery and mortality predictors in the perioperative and early postoperative period. Anadolu Kardiyol Derg 2003;3:124–8.[Medline]
- Brown BG, Gundel WD, McGinnis GE, Selinger SL, Topaz SR, Gott VL. Improved intraaortic balloon diastolic augmentation with a double-balloon catheter in the ascending and the descending thoracic aorta. Ann Thorac Surg 1968;6:127–36.[Medline]
- Arafa OE, Pedersen TH, Svennevig JL, Fosse E, Geiran OR. Intraaortic balloon pump in open heart operations: 10-year follow-up with risk analysis. Ann Thorac Surg 1998;65:741–7.[Abstract/Free Full Text]
- Creswell LL, Rosenbloom M, Cox JL, Ferguson TB Sr, Kouchoukos NT, Spray TL, et al. Intraaortic balloon counterpulsation: patterns of usage and outcome in cardiac surgery patients. Ann Thorac Surg 1992;54:11–20.[Abstract]
- Baldwin RT, Slogoff S, Noon GP, Sekela M, Frazier OH, Edelman SK, et al. A model to predict survival at time of postcardiotomy intraaortic balloon pump insertion. Ann Thorac Surg 1993;55:908–13.[Abstract]
- Christenson JT, Buswell L, Velebit V, Maurice J, Simonet F, Schmuziger M. The intraaortic balloon pump for postcardiotomy heart failure. Experience with 169 intraaortic balloon pumps. Thorac Cardiovasc Surg 1995;43:129–33.[Medline]
- STS Adult Cardiac Database. Definition of terms. Version 2.41. Society of Thoracic Surgeons. Available at: www.sts.org/file/CoreDef241Book.pdf. Accessed November 16, 2007.
- McEnany MT, Kay HR, Buckley MJ, Daggett WM, Erdmann AJ, Mundth ED, et al. Clinical experience with intraaortic balloon pump support in 728 patients. Circulation 1978;58:124–32.
- Di Lello F, Mullen DC, Flemma RJ, Anderson AJ, Kleinman LH, Werner PH. Results of intraaortic balloon pumping after cardiac surgery: experience with the Percor balloon catheter. Ann Thorac Surg 1988;46:442–6.[Abstract]
- Fiane AE, Saatvedt K, Svennevig JL, Geiran O, Nordstrand K, Frøysaker T. The CarboMedics valve: midterm follow-up with analysis of risk factors. Ann Thorac Surg 1995;60:1053–8.[Abstract/Free Full Text]
- Corral CH, Vaughn CC. Intraaortic balloon counterpulsation: an eleven-year review and analysis of determinants of survival. Tex Heart Inst J 1986;13:39–44.[Medline]
- Arafa OE, Pedersen TH, Svennevig JL, Fosse E, Geiran OR. Vascular complications of the intraaortic balloon pump in patients undergoing open heart operations: 15-year experience. Ann Thorac Surg 1999;67:645–51.[Abstract/Free Full Text]
- Meharwal ZS, Trehan N. Vascular complications of intra-aortic balloon insertion in patients undergoing coronary revascularization: analysis of 911 cases. Eur J Cardiothorac Surg 2002;21:741–7.[Abstract/Free Full Text]
- Downing TP, Miller DC, Stofer R, Shumway NE. Use of the intra-aortic balloon pump after valve replacement. Predictive indices, correlative parameters, and patient survival. J Thorac Cardiovasc Surg 1986;92:210–7.[Abstract]
- Mackenzie DJ, Wagner WH, Kulber DA, Treiman RL, Cossman DV, Foran RF, et al. Vascular complications of intra-aortic balloon pump. Am J Surg 1992;164:517–21.[Medline]
- Pennington DG, Swartz M, Codd JE, Merjavy JP, Kaiser GC. Intraaortic balloon pumping in cardiac surgical patients: a nine-year experience. Ann Thorac Surg 1983;36:125–31.[Medline]
- Bolooki H, Williams W, Thurer RJ, Vargas A, Kaiser GA, Mack F, et al. Clinical and hemodynamic criteria for use of the intra-aortic balloon pump in patients requiring cardiac surgery. J Thorac Cardiovasc Surg 1976;72:756–68.[Abstract]
- Downing TP, Miller DC, Stinson EB, Burton NA, Oyer PE, Reitz BA, et al. Therapeutic efficacy of intraaortic balloon pump counterpulsation. Analysis with concurrent "control" subjects. Circulation 1981;64(Suppl II):108–13.
TOP
ABSTRACT
INTRODUCTION
