Does the timing of treatment with intraaortic balloon pump in cardiac surgery affect survival?

Amin Bagheri; Behrooz Banivaheb; Matineh Heidari; Jamshid Bagheri

doi:10.4103/rcm.rcm_71_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 11 | Issue : 2 | Page : 43-48

Does the timing of treatment with intraaortic balloon pump in cardiac surgery affect survival?

Amin Bagheri¹, Behrooz Banivaheb², Matineh Heidari³, Jamshid Bagheri¹
¹ Cardiac Surgery and Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
² Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
³ Department of Firoozgar Neurology, Iran University of Medical Science, Tehran, Iran

Date of Submission	31-Dec-2021
Date of Acceptance	28-Jan-2022
Date of Web Publication	27-Jul-2022

Correspondence Address:
Prof. Jamshid Bagheri
Cardiac Surgery and Transplantation Research Center, Tehran University of Medical Sciences, 13185-1678, Tehran
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_71_21

Abstract

Background: The intraaortic balloon pump (IABP) is the most common mechanical assist device used as an adjunctive therapy for patients with low cardiac output among cardiac surgery. However, controversy still exists about the optimal time for IABP insertion. The study evaluated the association between timing of IABP insertion and outcome in cardiac surgical patients. Patients and Methods: Patients who underwent cardiac surgery between August 2007 and June 2014 were included. 273 of 3480 patients (7.84%) required perioperative IABP support. Of whom 21 (7.7%) received a preoperative IABP, 180 (65.9%) received an intraoperative IABP and 72 (26.4%) received a postoperative IABP. Predictors of early mortality were measured in stepwise multivariate logistic regression analyses. Results: The overall mortality rate for all patients requiring IABP was 29.3%. The incidence of mortality in patients who underwent pre-, intra- and postoperative IABP insertion was 19.0%, 22.8%, and 48.6%, respectively. The independent predictors of early mortality were age, cross clamp time, and postoperative IABP. However, either pre or intraoperative IABP insertion was not associated with increase in early mortality. Conclusions: IABP treatment in patients undergoing cardiac surgery was relatively safe accompanied by few complications. Timing of IABP insertion appears to be associated with survival as early insertion results are much more desirable compared to postoperative insertion.

Keywords: Cardiac surgery, early outcome, intraaortic balloon pump, mortality

How to cite this article:
Bagheri A, Banivaheb B, Heidari M, Bagheri J. Does the timing of treatment with intraaortic balloon pump in cardiac surgery affect survival?. Res Cardiovasc Med 2022;11:43-8

How to cite this URL:
Bagheri A, Banivaheb B, Heidari M, Bagheri J. Does the timing of treatment with intraaortic balloon pump in cardiac surgery affect survival?. Res Cardiovasc Med [serial online] 2022 [cited 2023 Feb 6];11:43-8. Available from: https://www.rcvmonline.com/text.asp?2022/11/2/43/352501

Introduction

The intraaortic balloon pump (IABP) is the most common mechanical assist device used as an adjunctive therapy for patients with low cardiac output during cardiac surgery. The balloon pump enhances myocardial oxygen supply by increasing aortic diastolic pressure and decreasing left ventricular afterload.^[1] Todays, this assist device being most popular due to its easy deployment, cost effectiveness, and low rate of related complications.^[2],[3],[4] Although the most benefit of IABP was seen in hemodynamically unstable patients because of myocardial ischemia, the overall in-hospital mortality remains high (ranging from 26% to 50%) in these patients receiving IABP.^[5],[6],[7] However, underlying cardiac problems such as low cardiac output, as the main indication for IABP use, is itself a reason for death in cardiac surgical patients.^[8]

Controversy still exists about the optimal time for IABP insertion. The incidence of mortality for preoperative insertion is about 20% while the intra- and postoperative insertion is associated with 30% and 40% mortalities, respectively.^[9] Although these findings may suggest the preoperative prophylactic IABP use in high risk patients, there is still debate due to its complication such as limb ischemia and bleeding.^[2]

The aim of this study was to present the timing of IABP use and its outcome during the perioperative period in cardiac surgical patients. We also determined the predictors of early mortality in patients undergoing IABP insertion among cardiac surgery.

Patients and Methods

Patient selection

This retrospective study was conducted between August 2007 and June 2014. All consecutive patients who underwent cardiac surgery in our department were selected for the analysis using Shariati Hospital Cardiac Surgery Database. Of 3480 patients, 273 (7.84%) required perioperative IABP support. The surgical procedures were included isolated coronary artery bypass grafting (CABG), cardiac valve surgery and combined CABG with valve repair or replacement, left ventricular aneurysm repair, carotid intervention or posterior pericardiotomy.

Patients were classified depending on the timing of IABP insertion. All patients who received IABP before surgical skin incision were classified as preoperative group. Patients requiring IABP during any phase of operation constituted the intraoperative group. Finally, the postoperative group included patients receiving IABP in the intensive care unit. IABP placements were mostly made percutaneously through the femoral artery. The indications for IABP support were cardiogenic shock, fail revascularization or as a bridge to surgery for the preoperative group. Intraoperative and postoperative IABP insertions were mainly owing to difficulty of weaning from cardiopulmonary bypass (CPB) despite maximal inotropic support and hemodynamic instability refractory to intravenous inotropic medications respectively.

The preoperative data such as gender, age, body surface area (BSA), diabetes mellitus (DM), hypertension, left ventricular ejection fraction (LVEF), and renal failure (elevated serum creatinine level more than 120 mmol/L) in addition to intraoperative findings including CPB time and aortic cross-clamp time were measured.

Clinical outcomes

The primary outcome was defined as mortality that occurred within 30 days of operation, whereas secondary outcomes were morbidities occurring during hospitalization. Significant postoperative morbidity was defined as need for reoperation for bleeding, leg infection, deep sternal infection, septicemia, vascular complications including acute limb ischemia and iliac or femoral dissection, pulmonary complications such as pleural effusion, pneumothorax or prolonged ventilation, cardiac arrest and other major morbidities. Moreover, patients who had suffered from stroke, those who had experienced a transient ischemic attack and patients who were in a coma made up the category of neurological complications. In addition to measuring supraventricular arrhythmia such as atrial flutter, fibrillation and paroxysmal atrial tachycardia, ventricular arrhythmia including ventricular tachycardia, fibrillation, and premature ventricular contraction were also evaluated postoperatively.

Statistical analysis

All statistical analyses were done with the SPSS software version 16.0 program (SPSS Inc, Chicago, IL, USA). Quantitative and categorical variables were reported as mean ± standard deviation and percentages, respectively. T-test was performed on continuous variables, whereas Chi-square test (or Fisher's exact test, if required) was used to compare for categorical variables. P < 0.05 was considered statistical significance.

To identify the potential confounding effects of the risk factors on surgical outcomes, univariate analyses were performed. Then, all variables with a P < 0.2 were selected into stepwise backward selection and finally assessed by multivariable logistic regression.

Results

Of 3480 cardiac surgery patients, 273 (107 females; mean age 58.1 ± 11.4) who required perioperative IABP support were enrolled in our study. The patients' baseline characteristics are presented in [Table 1]. Among these patients, 21 patients (7.7%) received IABP preoperatively, 180 patients (65.9%) intraoperatively, and 72 patients (26.4%) postoperatively.

Table 1: Patients` baseline characteristics

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The majority of 273 patients underwent isolated CABG (63.7%) while valve procedure with and without CABG contained lower number of IABP patients (18.7% and 10.3% respectively). Two hundred and twenty-six patients (83.1%) underwent on-pump cardiac surgery and the incidence of CABG patients was 78.2%. The mean CPB and cross-clamp times were 130.5 ± 70.3 and 54.4 ± 49.7 min, respectively.

The incidence of postoperative complications in IABP patients is shown in [Table 2]. Out of 273 patients, 25 (9.2%) required reoperation owing to bleeding. Leg infections and acute limb ischemia occurred in 4 (1.5%) and 3 (1.1%) patients, respectively. However, there were no patients that experienced iliac or femoral dissection.

Table 2: Postoperative outcomes

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The overall mortality rate for all patients requiring IABP was 29.3%. The incidence of mortality in patients who underwent pre, intra, and postoperative IABP insertion was 19.0%, 22.8% and 48.6%, respectively.

Univariate analyses of patients' baseline characteristics and operative data as predictors of mortality are presented in [Table 3] and [Table 4], respectively. Age, female, canadian cardiovascular society angina class III and IV, New York heart association class III and IV, postoperative IABP insertion, and prolonged CBP time and cross-clamp time increase the risk of mortality in IABP patients. However, increased BSA and LVEF less than 30% had protective effect on mortality rate in these patients. The comparison of basic characteristics based on patient's ejection fraction is presented in [Table 5]. The mean age, the incidence of female and postoperative IABP insertion in patients with left ventricle (LV) dysfunction (LVEF ≤ 30%) were significantly less than the patients with normal LV function. Moreover, other risk factors including DM, hypercholesterolemia, hypertriglyceridemia, renal failure, and hypertension were lower in patients with LV dysfunction [Table 5].

Table 3: Univariate analysis of patients` baseline characteristics for predictors of mortality

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Table 4: Univariate analysis of patients` operative data for predictors of mortality

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Table 5: Comparison of basic characteristics based on patient's ejection fraction

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Multivariable logistic regression analyses identified that the independent predictors of early mortality were age, cross-clamp time, and postoperative IABP [Table 6]. However, either pre or intraoperative IABP insertion was not associated with increase in early mortality.

Table 6: Multivariate analysis for predictors of mortality

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Discussion

The present study illustrated the early outcomes of 273 consecutive cardiac surgical patients who underwent IABP insertion at a single center. The results identified the postoperative IABP as one of the independent predictors of early mortality (P = 0.045); however, either pre or intraoperative IABP insertion was not associated with increase in early mortality.

IABP is the most common left ventricular assist device for the treatment of low cardiac output in cardiac surgical patients since its development in the 1960s.^[10] By diastolic inflation and rapid systolic deflation, the balloon pump improves myocardial oxygen supply decreasing oxygen demand.^[11]

The rate of the IABP insertion among patients undergoing cardiac surgery has increased recently as a result of increased high risk surgical population (such as older patients with poor LVEF and more complex cardiac pathologies).^[12] Despite advances in surgical technique and improvements in perioperative care of these high risk patients, the perioperative IABP mortality is still high (up to 50%).^[5],[6],[7]

The optimal time of IABP insertion is still controversial. On the other hand, it is hard to predict who will require IABP insertion or who can be managed without this device. By reviewing the literature, the incidence of mortality for preoperative IABP insertion is less than 20%. However, the overall hospital mortalities of intra and postoperative IABP insertions are much higher (about 30% and 40%, respectively).^[9] Parissis et al. revealed that the mortality rates according to IABP timing were 18.2%, 33.3%, and 58.3% for pre, intra and postoperative insertion, respectively, by reviewing 136 patients undergoing cardiac surgery.^[13] Furthermore, Ranucci et al. showed mortality rates with intra and postoperative IABP insertion as 41.5% and 64.45%, respectively.^[14] Many previous studies revealed that preoperative IABP insertion was associated with reduction early mortality.^{[12],[15],[16],[17],[18],[19]}

However, there is still concerns about the increase use of preoperative IABP owing to its life-threatening complications including major bleeding, limb ischemia, stroke, infections and vascular complications.^[2] On the other hand, some recent studies showed that the preoperative IABP use did not represent an early postoperative survival benefit.^{[20],[21],[22]} Moreover, a recent randomized controlled trial (n = 181) and a meta-analysis of 11 randomized controlled trial found that preoperative IABP use did not reduce the occurrence of 30-day mortality and adverse outcomes in high risk patients undergoing cardiac surgery.^[23]

In accordance with literature, the overall hospital mortality of cardiac surgical patients who received IABP treatment was 29.3% in our study. Postoperative IABP insertion had highest mortality (48.6%) and was an independent predictor of early mortality. However, pre and intraoperative balloon pump use was associated with lower mortality (19.0% and 22.8%, respectively). Postoperative IABP indication was mainly due to hemodynamic instability resistant to intravenous inotropic medications that reflects patient's critical situation and explain this high mortality rate. A review article evaluated the perioperative IABP use in patients undergoing cardiac surgery and reported overall mortality ranging from 21% to 73%.^[24] A retrospective study was conducted in Cleveland Clinic and the authors reported that the overall mortality for cardiac surgical patients with pre, intra, and postoperative IABP insertion was 12.6%, 17.5%, and 47.7%, respectively.^[25] Kucuker et al. showed an overall mortality rate of 27.3% in 121 (5.4%) patients requiring IABP insertion among 2196 cardiac surgical patients. The mortality as per time of IABP insertion was reported as preoperative 33.3%, intraoperative 19.7%, and postoperative 41.7% in their study.^[26]

The results of univariate analysis indicated lower rate of mortality in IABP patients with LV dysfunction. To explain it, we compared the basic characteristics based on patients EF and concluded that patients with LV dysfunction had a better profile than who had not LV dysfunction [Table 5]. However, LVEF was not associated with mortality in multivariate analysis.

Predictors of mortality in patients receiving IABP vary among different studies depending on the study population and on the methods used. Arafa et al. indicated that preoperative serum creatinine and myocardial infarction, LVEF, indication for operation and timing of IABP use were the independent predictors of mortality.^[15] Age, history of cardiac surgery, and critical preoperative state were found as independent predictors of early mortality in another retrospective study.^[27] Kucuker et al. found female gender, low LVEF, complex surgery, and postoperative IABP insertion as predictors for mortality.^[26] In this study, age, aortic cross clamp time, and postoperative IABP was identified as independent predictors of early mortality. Although we previously reported intraoperative IABP as a predictor of mortality in isolated CABG patient,^[28] both pre and intraoperative IABP was not significantly associated with increase in early mortality in the present study.

The retrospective nature of present study is one of the study limitations. Moreover, the small number of patients may have affected study power, although the number of patients undergoing IABP in the present study is greater in comparison with the previous study.^{[13],[16],[26],[27]} However, we offset any confounding effects by applying a stepwise multivariate logistic regression model.

Conclusions

IABP treatment in cardiac surgical patients was relatively safe accompanied by few complications. Timing of IABP insertion appears to be associated with survival as early insertion results are much more desirable in comparison with postoperative insertion.

Ethical clearance

This study was approved by the Tehran University of Medical Sciences ethical committee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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