Vascular complications of the intraaortic balloon pump in patients undergoing open heart operations: 15-year experience.

BACKGROUND: The beneficial effects of the intraaortic balloon pump (IABP) in providing circulatory support must be weighed against its complications, particularly its vascular trauma. METHODS: Five hundred nine patients who underwent open heart operations at our institution and who were treated with the IABP from January 1980 through December 1994 were studied retrospectively to assess IABP-related vascular complications and their independent preoperative predictors and the implications of IABP-related vascular complications on the patients' mortality, morbidity (clinical sepsis and organ failure), and long-term survival. RESULTS: Early vascular complications occurred in 56 patients (11%) and major complications occurred in 41 patients (8%). The latter consisted of aortic perforation in 1 patient, aortoiliac dissection in 2 patients, and limb ischemia in 38 patients. Logistic regression analysis identified concomitant peripheral vascular disease (p<0.001), elevated preoperative end-diastolic pressure, small body surface area, and large catheter size (p<0.05) as independent risk factors for IABP-related major vascular complications in patients who survived the day of operation. Late IABP-related sequelae occurred in 10 patients, 9 of whom had had early vascular complications. The presence of vascular complications per se was not a significant independent factor among other risk factors for mortality, morbidity, or long-term survival. CONCLUSIONS: Careful clinical assessment of the aortofemoral vascular tree is a cornerstone of early diagnosis and early intervention and usually prevents limb loss. The significant decrease in major vascular complications that has occurred over the last 5 years can be explained by the increased use of catheters with smaller diameters. The timing of IABP insertion in relation to operation and the duration of IABP use were the only device-related risk factors identified for morbidity and survival.

Intraaortic balloon pumping for predominantly right ventricular failure after heart transplantation.

BACKGROUND: Right ventricular failure from elevated pulmonary vascular resistance in the recipient is a main cause of early mortality after heart transplantation. When pharmacologic treatment is insufficient, mechanical circulatory assistance has been used to support the failing right ventricle. Considering right and left ventricular interdependence, we investigated whether intraaortic balloon counterpulsation (IABP) might also alleviate predominantly right ventricular dysfunction after heart transplantation. METHODS: Among 278 cardiac recipients, 12 adult patients underwent mechanical circulatory support for cardiac allograft dysfunction. Five patients were treated with percutaneous IABP for early postoperative low cardiac output syndrome characterized by predominantly right ventricular failure. Clinical data and hemodynamic variables were recorded before and during IABP treatment. RESULTS: Cardiac index (CI) and mean arterial pressure (MAP) increased (CI 1.7 +/- 0.1 to 2.5 +/- 0.2, MAP 53 +/- 12 to 71 +/- 7, p < 0.05) within 1 hour after IABP, whereas central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) decreased (CVP 21.6 +/- 1.7 to 13.8 +/- 3.1, p < .05; PAWP 14.8 +/- 4.9 to 12.4 +/- 3.7, nonsignificant). Within the next 12 hours, CI and mixed venous oxygen saturation increased (p < 0.05) and pulmonary artery pressure decreased (p < 0.05). All 5 patients were weaned successfully and 4 are long-term survivors with adequate cardiac performance at 1 year follow-up. CONCLUSIONS: Intraaortic balloon pumping is a minimally invasive circulatory assist device with proved efficiency in low cardiac output syndromes. This report shows that low output syndrome caused by predominantly right ventricular allograft failure may be an additional indication for IABP.

Intraaortic balloon pump in open heart operations: 10-year follow-up with risk analysis.

BACKGROUND: The intraaortic balloon pump (IABP) is the primary mechanical device used for perioperative cardiac failure. METHODS: We analyzed the prognostic predictors and long-term survival of 344 patients undergoing cardiac operations who required the perioperative use of an IABP at our institution from January 1980 to December 1989. Hospital survivors (163 patients) were followed up for a mean of 7.45 years (range, 1 month to 15.3 years); cumulative follow-up included 1,167 patient-years. RESULTS: The early mortality rate was 52.6% (181 patients). From parameters available at the time of IABP insertion, logistic regression analysis identified preoperative serum creatinine level, left ventricular ejection fraction, perioperative myocardial infarction, timing of IABP insertion, and indication for operation as independent predictors of early (30-day) death (p < 0.05). Cox regression analysis of hospital survivors identified timing of IABP insertion, perfusion time, and preoperative serum creatinine level as independent prognostic factors for late death (p < 0.05), whereas patient age was only marginally significant (p < 0.06). There was no association between IABP-related complications and death. Survival analysis demonstrated a 10-year actual survival rate of 22.04% +/- 0.023%, with 57 patients still at risk and significantly improved survival among those who received an IABP before operation (p < 0.02). CONCLUSIONS: The early mortality rate in patients who received an IABP was high. Hospital survivors had a relatively good long-term prognosis. The significantly better short- and long-term survival of patients who received an IABP before operation may justify more liberal preoperative use of the IABP in high-risk patients.

Transthoracic intra-aortic balloon pump in open heart operations: techniques and outcome.

OBJECTIVE: During open heart surgery, direct transthoracic insertion of the intra-aortic balloon pump (IABP) is an alternative to the routine transfemoral insertion especially in the presence of severe peripheral vascular disease. METHODS: Over 19 years (1980-1998), 646 patients were treated with IABP. In 24 of them, the balloon was inserted transthoracic (TIABP) due to failure of transfemoral insertion in 13 or extensive occlusive aorto-iliac disease in 11 cases. RESULTS: Early mortality was 58.3% in patients having TIABP compared to 46.1% in patients with transfemoral IABP insertion (p > 0.2). Of the 24 patients receiving IABP transthoracic, none suffered vascular injury (i.e. perforation or dissection). Complications which could be related to TIABP occurred in 10 patients: 3 balloon ruptures, 1 mediastinal haemorrhage, 3 cerebrovascular accidents, 1 post-operative mediastinitis, and 2 late graft infections. CONCLUSIONS: TIABP is a useful alternative when transfemoral insertion of IABP is not feasible or hazardous because of occluded or severely diseased ilio-femoral arteries. Being a second choice and a more invasive treatment, transthoracic IABP is associated with increased mortality.

Mortality and morbidity after coronary artery bypass surgery related to pre-operative left ventricular ejection fraction: a follow-up study.

OBJECTIVE: To study the pre-operative level of left ventricular ejection fraction that may be indicative of an increased risk of early and late mortality and of recurrent angina pectoris and late non-fatal myocardial infarction. MATERIAL AND METHODS: A total of 934 patients with known left ventricular ejection fraction, 80 women and 854 men, were submitted to coronary artery bypass grafting at the Cardiovascular Unit of Rikshospitalet, Oslo, between August 1982 and December 1986. The closing date was the 1st of January 1993, with a mean follow-up of time of 7.4 years. The patients were divided in to four subgroups according to their level of left ventricular ejection fraction: < or = 40%, 41-60%, 61-80% and > 80%. The left ventricular ejection fraction varied from 13-98%. A chi-square test of linear trend was used to calculate the relative risk between the different subgroups. Cumulative survival was determined using survival curves. RESULTS: Early mortality. Twenty-five patients (2.7%) died within 30 days of operation. Patients with left ventricular ejection fraction < or = 40% had a relative risk of 10.2 (1.9-17.2), for left ventricular ejection fraction 41-60% the relative risk was 0.9 (0.1-8.9) and for left ventricular ejection fraction 61-80% the relative risk was 2.8 (0.6-17.2). Left ventricular ejection fraction > 80% was defined as relative risk = 1. Late mortality. Altogether, 174 patients died in the late phase (18.6%). For patients with left ventricular ejection fraction < or = 40% the relative risk was 3.6 (2.8-10.9), for left ventricular ejection fraction 41-60% the relative risk was 1.8 (1.1-3.6), and for left ventricular ejection fraction 61-80% the relative risk was 1.5 (0.9-2.8). Recurrent angina pectoris. A total of 138 patients developed recurrent angina pectoris during the follow-up period, giving an incidence of 14.8%. Here, for left ventricular ejection fraction < or = 40% the relative risk was 0.5 (0.2-1.3), for left ventricular ejection fraction 41-60% the relative risk was 1.0 (0.5-1.8) and for left ventricular ejection fraction 61-80% the relative risk was 1.2 (0.7-2.0). Late non-fatal myocardial infarction. Altogether, 90 patients (9.6%) experienced non-fatal myocardial infarction in the late phase. For left ventricular ejection fraction < or = 40% the relative risk was 0.6 (1.2-1.8), for left ventricular ejection fraction 41-60% the relative risk was 1.0 (0.5-2.0) and for left ventricular ejection fraction 61-80% the relative risk was 0.7 (0.41-1.3). Cumulative survival. When pooled together, the cumulative survival for patients with left ventricular ejection fraction > 40% was 95.9, 91.9 and 79% after 1, 5 and 10 years, respectively. For the patients with left ventricular ejection fraction < or = 40% cumulative survival was 87.5, 73.1 and 55.2%, respectively. CONCLUSION: When the left ventricular ejection fraction was 40% or lower, there was a substantial increase in the risk of early mortality in patients submitted to coronary artery bypass grafting. As for the risk of late mortality, there was a practically linear increase in risk with falling values of left ventricular ejection fraction. We found no difference in risk of developing recurrent angina pectoris or of late non-fatal myocardial infarction related to values of left ventricular ejection fraction.

Viral safety of solvent/detergent-treated plasma.

BACKGROUND: Pooling of plasma donations increases the risk for blood-borne infections. In solvent/detergent (SD)-treated plasma, lipid-enveloped viruses are efficiently inactivated. This method, however, does not affect non-lipid-enveloped viruses. The current study investigated the viral safety of SD-treated plasma (Octaplas) and paid particular attention to the transmission of non-lipid-enveloped viruses. STUDY DESIGN AND METHODS: The study comprised 343 adults undergoing cardiac surgery. Follow-up was performed 6 to 12 months and 2 years after operation. The sera were tested for hepatitis B surface antigen and specific antibodies against hepatitis A, B, and C; cyto-megalovirus; HIV, human T-lymphotropic virus types I and II; and human parvovirus B19 (B19). A total of 25 batches of SD-treated plasma prepared from Norwegian plasma were used. All batches were tested for hepatitis A virus and B19 by nucleic acid amplification testing and investigated for neutralizing antibodies directed against these viruses. RESULTS: In patients who received SD-treated plasma, B19 seroconversion occurred at a rate similar to that in nontransfused patients. No other seroconversions could be ascribed to the transfusion of SD-treated plasma. All 25 SD-treated plasma batches contained neutralizing antibodies against hepatitis A virus and B19. In nucleic amplification testing, all SD-treated plasma batches tested positive for B19, while five demonstrated borderline reactions for hepatitis A virus. CONCLUSION: Transfusion of SD-treated plasma was found to be safe with regard to lipid-enveloped viruses. Immune antibodies neutralize viral particles in plasma and are of importance in avoiding clinical disease with the non-lipid-enveloped hepatitis A virus and B19.

[Mortality and morbidity after coronary bypass surgery in high-risk patients]. / Dødelighet og sykelighet etter koronar bypasskirurgi hos høyrisikopasienter.

A total of 113 women and 912 men were submitted to coronary artery bypass surgery at Surgical Department A, Rikshospitalet between August 1982 and December 1986 and followed till January 1993. We found no difference in early mortality, recurrent angina pectoris or non-fatal myocardial infarction in diabetic patients compared to nondiabetic patients. However, total mortality was 1.87 times higher in the diabetic group. For patients with ejection fraction < or = 40%, early mortality was 10.2 times higher than for the reference group. For total mortality we found a practically linear relationship between increased mortality and falling ejection fraction values. We found no relationship between ejection fraction and recurrent angina and non-fatal myocardial infarction, neither did we find any difference in mortality and morbidity between women and men. Although a somewhat higher mortality and morbidity rate must be expected for high-risk patients, they seem to profit to the same extent from the favourable effects of coronary bypass surgery as other patients.