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, (C) 2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd. All rights reserved.