Interactive Cardiovascular and Thoracic Surgery 2:416-419(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
Which patients would benefit from an intra-aortic balloon pump prior to cardiac surgery?
Joel Dunning* and
Brian Prendergast
Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
* Corresponding author. Tel./fax: +44-780-154-8122
joeldunning{at}doctors.org.uk
Received August 11, 2003;
received in revised form August 12, 2003;
accepted August 13, 2003
 |
Abstract
|
|---|
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is a group of patients who would benefit from a prophylactic intra-aortic balloon pump prior to cardiac surgery. Altogether 110 papers were found using the reported search, of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is evidence to support preoperative intra-aortic balloon pump insertion in patients with two of left ventricular ejection factor <30 or 40%, left main stem disease, unstable angina or redo-operation.
Key Words: Intra-aortic balloon pumping; Preoperative care; Evidence-based medicine; Thoracic surgery
|
1. Clinical scenario
|
|---|
You are about to perform a coronary arterial bypass graft on a 70 year old lady who has left main stem disease and an ejection fraction of 30% on echocardiography. She was an urgent referral from the cardiologists after being admitted 3 weeks ago with unstable angina, but has been stable since admission. You realise that she is a high risk case and you wonder whether preoperatively inserting an intra-aortic balloon pump would be of benefit to her?
|
2. Three-part question
|
|---|
In [high risk patients undergoing coronary arterial surgery] does [prophylactic IABP insertion] improve [in-patient survival, or time to discharge].
|
3. Search strategy
|
|---|
Medline 1966-July 2003 using the OVID interface [exp coronary artery bypass/OR CABG.mp OR exp thoracic surgery/OR coronary art$ bypass.mp OR cardiopulmonary bypass.mp OR exp cardiovascular surgical procedures/OR exp thoracic surgical procedures/] AND [exp intra-aortic balloon pumping/OR intra-aortic balloon pump.mp OR IABP.mp] AND [exp preoperative care/OR pre-operative.mp OR prophylactic.mp].
|
4. Search outcome
|
|---|
One hundred ten papers were found of which seven were deemed to be relevant [1–7]. These are summarised in Table 1.
|
5. Results
|
|---|
The three papers by Christenson et al. provide evidence for the placement of an IABP in patients with two of the following: LVEF <30 or 40%, left main stem disease, unstable angina or redo-operation. Although their individual papers are on the margins of significance, if all patients recruited in these three papers are different then taken together there is a significant mortality reduction. The IABP mortality in the three studies was 3.4% and in the control group it was 14% thus giving a number needed to treat in this group of patients of 10.
The remaining papers are cohort studies. Dietl et al. shows a mortality reduction in patients with LVEF <25%, but the remaining studies show no mortality benefit in cohorts of patients that are lower risk than the groups studied by Christenson.
There is some evidence provided in these papers that in the highest risk patients the prophylactic placement of an IABP may be of benefit in terms of survival. However the exact groups that may benefit have not been fully established. In addition the clear survival benefit in these high risk groups have not been established.
Further randomised studies in this area are needed to establish the benefit of pre-operative IABP use. If a reduction in mortality from 10 to 3% were desired a Prospective Randomised Controlled Trial of 440 patients would be needed to have an 80% chance of uncovering this difference.
|
6. Clinical bottom line
|
|---|
There is evidence to support preoperative IABP insertion in patients with two of LVEF <30 or 40%, left main stem disease, unstable angina or redo-operation.
doi:10.1016/S1569-9293(03)00182-8
|
References
|
|---|
- Christenson JT, Simonet F, Badel P, Schmuziger M. Optimal timing of preoperative intra-aortic balloon pump support in high-risk coronary patients. Ann Thorac Surg. 1999;68:934–939[Abstract/Free Full Text]
- Christenson JT, Simonet F, Badel P, Schmuziger M. Evaluation of preoperative intra-aortic balloon pump support in high risk coronary patients. Eur J Cardiothorac Surg. 1997;11:1097–1103[Abstract]
- Dietl CA, Berkheimer MD, Woods EL, Gilbert CL, Pharr WF, Benoit CH. Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Ann Thorac Surg. 1996;62:401–408[Abstract/Free Full Text]
- Christenson JT, Badel P, Simonet F, Schmuziger M. Preoperative intraaortic balloon pump enhances cardiac performance and improves the outcome of redo CABG. Ann Thorac Surg. 1997;64:1237–1244[Abstract/Free Full Text]
- Holman WL, Li Q, Kiefe CI, McGiffin DC, Peterson ED, Allman RM, Nielsen VG, Pacifico AD. Prophylactic value of preincision intra-aortic balloon pump: analysis of a statewide experience. J Thorac Cardiovasc Surg. 2000;120:1112–1119[Abstract/Free Full Text]
- Gutfinger DE, Ott RA, Miller M, Selvan A, Codini MA, Alimadadian H, Tanner TM. Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting. Ann Thorac Surg. 1999;67:610–613[Abstract/Free Full Text]
- Fasseas P, Kopistansky C, Bowers B, McCormick DJ. Pre-operative intra-aortic balloon counter pulsation in stable patients with left main stem coronary disease. J Invasive Cardiol. 2001;13:679–683[Medline]
This article has been cited by other articles:
|
|
|
|
 
I. R. Ramnarine, A. D. Grayson, W. C. Dihmis, N. K. Mediratta, B. M. Fabri, and J. A.C. Chalmers
Timing of intra-aortic balloon pump support and 1-year survival
Eur. J. Cardiothorac. Surg.,
May 1, 2005;
27(5):
887 - 892.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Barnard, J. Dunning, G. Musleh, and N. Odom
Is there a role for the use of radical lymph node dissection in the surgical management of resectable non-small cell lung cancer?
Interactive CardioVascular and Thoracic Surgery,
June 1, 2004;
3(2):
294 - 299.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
Top
Abstract
1. Clinical scenario