Status 2 upgrade indication impacts posttransplant mortality in patients bridged with intraaortic balloon pump in the new heart allocation system.

To evaluate outcomes of patients undergoing heart transplants (HTs) using an intra-aortic balloon pump (IABP) under exception status. Adult patients supported by an IABP who underwent HT between November 18, 2018, and December 31, 2020, as documented in the United Network for Organ Sharing, were included. Patients were stratified according to requests for exception status. Kaplan-Meier methodology was used to look for differences in survival between groups. A total of 1284 patients were included; 492 (38.3%) were transplanted with an IABP under exception status. Exception status patients had higher body mass index, were more likely to be Black, and had longer waitlist times. Exception status patients received organs from younger donors, had a shorter ischemic time, and had a higher frequency of sex mismatch. The 1-year posttransplant survival was 93% for the nonexception and 88% for the exception IABP patients (hazard ratio: 1.85 [95% confidence interval: 1.12-2.86, P = .006]). The most common reason for requesting an exception status was inability to meet blood pressure criteria for extension (37% of patients). The most common reason for an extension request for an exception status was right ventricular dysfunction (24%). IABP patients transplanted under exception status have an increased 1-year mortality rate posttransplant compared with those without exception status.

Vascular complications associated with intraaortic balloon pump supported percutaneous coronary intervention (PCI) and clinical outcomes from the British Cardiovascular Intervention Society National PCI Database.

INTRODUCTION: The impact of a vascular complication (VC) in the setting of intraaortic balloon pump (IABP) supported PCI on clinical outcomes is unclear. METHODS: Using data from the BCIS National PCI Database, multivariate logistic regression was used to identify independent predictors of a VC. Propensity scoring was used to quantify the association between a VC and outcomes. RESULTS: Between 2007 and 2014, 9,970 PCIs in England and Wales were supported by IABP (1.6% of total PCI), with 224 femoral VCs (2.3%). Annualized rates of a VC reduced as the use of radial access for PCI increased. The independent predictors of a VC included a procedural complication (odds ratio [OR] 2.9, p < .001), female sex (OR 2.3, p < .001), PCI for stable angina (OR 3.47, p = .028), and use of a glycoprotein inhibitor (OR 1.46 [1.1:2.5], p = .04), with a lower likelihood of a VC when radial access was used for PCI (OR 0.48, p = .008). A VC was associated with a higher likelihood of transfusion (OR 5.7 [3.5:9.2], p < .0001), acute kidney injury (OR 2.6 [1.2:6.1], p = .027), and periprocedural MI (OR 3.2 [1.5:6.7], p = .002) but not with adjusted mortality at discharge (OR 1.2 [0.8:1.7], p = .394) or 12-months (OR 1.1 [0.76:1.56], p = .639). In sensitivity analyses, there was a trend towards higher mortality in patients experiencing a VC who underwent PCI for stable angina (OR 4.1 [1.0:16.4], p value for interaction .069). Discussion and Conclusions Although in-hospital morbidity was observed to be adversely affected by occurrence of a VC during IABP-supported PCI, in-hospital and 1-year survival were similar between groups.

The science of safety: complications associated with the use of mechanical circulatory support in cardiogenic shock and best practices to maximize safety.

Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use. Multiple devices exist across a spectrum from modest to complete support, and each is associated with unique risks. In this review, we summarize existing data on complications associated with the three most widely used acute MCS platforms: the intra-aortic balloon pump (IABP), Impella systems, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We review evidence from available randomized trials and highlight challenges comparing complication rates from case series and comparative observational studies where a lack of granular data precludes appropriate matching of patients by CS severity. We further offer a series of best practices to help shock practitioners minimize the risk of MCS-associated complications and ensure the best possible outcomes for patients.

Outcome analysis for prediction of intraaortic balloon pump support failure and long-term survival in high-risk patients undergoing mitral valve surgery.

The outcome predictors of intra-aortic balloon pump (IABP) in patients who undergo mitral valve surgery remain unknown. This study aimed to retrospectively review valvular surgery in patients who received an IABP to identify the predictors of failure of IABP support and anticipate the necessary therapy. This retrospective observational study recruited a total of 157 consecutive patients who underwent open-heart mitral valve surgery with IABP implantation intraoperatively or postoperatively. Univariate and multivariate logistic regression analyses were performed to identify the risk factors attributed to 30-day mortality. Follow-up data of survivors were collected to investigate the effect of IABP support to evaluate long-term outcomes. The overall 30-day mortality was 35.7% (56 patients). The following factors that contributed to 30-day mortality included sepsis (P < .001, OR: 5.627, 95%CI: 2.422-11.683); IABP implantation postoperatively rather than intraoperatively (P = .001, OR: 6.395, 95%CI: 2.085-19.511); right heart failure (P = .042, OR: 3.419, 95%CI: 1.225-12.257); and lack of subvalvular apparatus preservation (P = .033, OR: 3.710, 95%CI: 1.094-13.167). Furthermore, follow-up data of these patients showed an estimation of 5-year and 10-year survival rates of 58.9% and 35.7%, respectively. Patients with intraoperative IABP demonstrated better long-term survival outcomes when compared to those with postoperative IABP (χ2  = 4.291, P = .038). In summary, this study distinguished the preoperative predictors of 30-day mortality of IABP-support in mitral valve surgery patients. These results indicated that early intervention with IABP should be taken into consideration in case of hemodynamic instability in critically ill patients undergoing mitral valve surgery.

Mechanical Circulatory Support for Cardiogenic Shock in the Critically Ill.

Patients requiring mechanical circulatory support (MCS) constitute a heterogeneous group whose needs have guided the development of a broad range of MCS devices. Appropriate patient and device selection are important for maximizing the potential benefit of these therapies. Currently available devices can be deployed percutaneously or surgically implanted. They can also be configured for left, right, or biventricular support and remain in place for hours to years, offering varying levels of flow. In the critical care setting, patients with the highest acuity have the worst outcomes when receiving an implantable long-term ventricular assist device (VAD); therefore, shorter-term devices should be considered for stabilization and optimization prior to implantation of a long-term device. In this focused review for the critical care clinician, we discuss important considerations for identifying VAD candidates, identifying the range of devices available to support them, bridging strategies that may improve outcomes for patients who are critically ill, and identifying areas of ongoing research.

Cardiogenic Shock Due to Aluminum Phosphide Poisoning Treated with Intra-aortic Balloon Pump: A Report of Two Cases.

The mortality rate from aluminum phosphide (AlP) poisoning is as high as 70-100%, with refractory hypotension and severe metabolic acidosis being the two most common presentations in this poisoning. As this poisoning has no specific antidote, treatments revolve around supportive care. Cardiogenic shock created by toxic myocarditis is considered the main cause of mortality in these patients. Meanwhile, the intra-aortic balloon pump (IABP) has been suggested for the treatment of cardiogenic shock. This article reports the successful treatment of cardiogenic shock caused by AlP poisoning in a 17-year-old man and a 21-year-old woman using the IABP procedure.

Deployment of acute mechanical circulatory support devices via the axillary artery.

Introduction: Use of acute mechanical circulatory support (MCS) devices for high-risk cardiac intervention, cardiogenic shock, and advanced heart failure is growing. Alternate vascular access options for these devices remains a clinical challenge. Building on experience from trans-aortic valve replacement procedures, the axillary artery is becoming a common access route for acute MCS and represents an important advance in the development of acute MCS technologies. Areas covered: Authors review the clinical data and technical aspect of acute MCS deployment via the axillary artery. Axillary access is particularly useful for patients: 1) with severe peripheral vascular disease, 2) with hostile femoral access due to infection, indwelling endovascular devices, or obesity, and 3) to provide early mobility and ambulation. In this review, we discuss the deployment, technical issues and hemostasis regarding the use of intraaortic balloon pump, specifically, axillary intraaortic balloon pumps, trans-valvular left ventricular Impella pumps and arterial outflow of VA-ECMO. Expert opinion: Vascular comorbidities or device design may limit the traditional iliofemoral access route for acute mechanical circulatory support devices. Large bore access for the deployment of these devices through the axillary artery is feasible and safe when appropriate vascular access and closure techniques are used.

Evaluation of heparin induced thrombocytopenia using probability scores in a mechanical circulatory support population.

Patients on mechanical circulatory support (MCS) devices carry a high risk for thrombocytopenia and due to the routine use of heparin, heparin induced thrombocytopenia (HIT) is frequently suspected. HIT Expert Panel (HEP) and 4T scoring tools have been validated in the general medicine population to assess the probability of HIT diagnosis, however, these tests have not been validated for use in patients requiring MCS support. The objective of this study was to assess the association of 4T and HEP scores to available assess HIT diagnostic tests in patients requiring MCS. We conducted a retrospective review of patients requiring MCS who had heparin PF4 antibody optical density and/or serotonin release assay results reported. A 4T and HEP score at the time of heparin antibody ordering was calculated. Utilizing previously described ranges for HIT diagnostic tests, patients were categorized into two HIT probability categories: probable and not probable. Descriptive statistics were used for the 4T and HEP scores in both HIT probability categories and t-test and receiver operating characteristic (ROC) analysis were used to determine the association and agreement between each scoring tool and HIT probability. Eighty-five patients were identified who had HIT diagnostic tests ordered while on MCS; 7 patients were classified as HIT probable and 78 patients were classified as HIT not probable. Based on ROC analysis, 4T score and HEP score had an AUC of 0.88 (± 0.06) and 0.96 (± 0.02), respectively demonstrating high predictability of HIT. Utilizing sensitivity and specificity analysis through ROC curves, a cut off score of 3 for 4T score and 1 for HEP score was established. Based on our analysis, both 4T and HEP scores have high predictability of HIT in the mechanical circulatory support population.

N-terminal of the prohormone brain natriuretic peptide is a predictor of hemodynamic instability in valve disease.

Aim: The usefulness of N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) as a predictor of perioperative hemodynamic instability is not fully elucidated. Methods: This prospective study was conducted on a group of 455 patients undergoing elective heart valve surgery. The primary end point at the 30-day follow-up was postoperative hemodynamic instability. The secondary end point was death from all causes in patients with postoperative hemodynamic instability. Results: The postoperative hemodynamic instability occurred in 85 patients. At multivariate analysis NT-proBNP, New York Heart Association classes and glomerular filtration rate remained independent predictors of the primary end point. Age and NT-proBNP were associated with an increased risk of death. Conclusion: The preoperative NT-proBNP can be used to predict a postoperative hemodynamic instability as well as death in the group of patients with postoperative hemodynamic instability.

A Targeted Management Approach to Cardiogenic Shock.

Cardiogenic shock is a clinical syndrome characterized by low cardiac output and sustained tissue hypoperfusion resulting in end-organ dysfunction and death. In-hospital mortality rates range from 50% to 60%. Urgent diagnosis, timely transfer to a tertiary or quaternary medical facility with critical care management capabilities and multidisciplinary shock teams is a must to increase survival. Aggressive, hemodynamically guided medical management with careful monitoring of clinical and hemodynamic parameters with timely use of appropriate mechanical circulatory support devices is often necessary. As treatment options evolve, prospective randomized controlled trials are needed to define best practices that define superior clinical outcomes.

Pharmacologic Considerations in the Management of Patients Receiving Left Ventricular Percutaneous Mechanical Circulatory Support.

Percutaneous mechanical circulatory support (MCS) devices, including the intraaortic balloon pump, Impella, and TandemHeart, are often used for hemodynamic support in the setting of refractory cardiogenic shock. The thrombotic and bleeding complications associated with these devices is well recognized, and the Impella and TandemHeart devices have unique anticoagulation considerations that may influence patient outcomes. Both devices typically require use of a heparinized purge solution in combination with intravenous unfractionated heparin, thereby providing multiple sources of heparin exposure. Each device also has specific monitoring requirements and goal ranges. This review provides an overview of percutaneous MCS devices commonly used in the acute management of left ventricular failure, with an emphasis on pharmacologic considerations. We review recent evidence and guidelines and provide recommendations for appropriate use of anticoagulation during device support. Approaches to managing heparinized purge solutions, monitoring, and the utility of nonheparin anticoagulants are also provided because high-quality evidence in the literature is limited.

Mechanical Circulatory Support in Acute Decompensated Heart Failure and Shock.

An array of interventional therapeutics is available in the modern era, with uses depending on acute or chronic situations. This article focuses on support in acute decompensated heart failure and cardiogenic shock, including intra-aortic balloon pumps, continuous aortic flow augmentation, and extra-corporeal membrane oxygenation.

Influence of Cannulation Site on Carotid Perfusion During Extracorporeal Membrane Oxygenation in a Compliant Human Aortic Model.

Blood oxygenized by veno-arterial extracorporeal membrane oxygenation (ECMO) can be returned to the aorta (central cannulation) or to peripheral arteries (axillar, femoral). Hemodynamic effects of these cannulation types were analyzed in a mock loop with an aortic model representative of normal anatomy and compliance under physiological pressures and flow rates. Pressures, flow rates, and contribution of ECMO flow to total flow as a measure of oxygen supply were monitored in the carotids. Steady or pulsatile ECMO flow, residual or no cardiac output, and intraaortic balloon pump counterpulsation were tested as independent factors. With residual heart function, central cannulation provided the best oxygenated flow and pressure to the carotid arteries (CA). Axillar cannulation preferentially perfused the right CA at the expense of the left CA. Femoral cannulation provided only lower amounts of oxygenated blood to both CA. Pulsation increased the surplus hemodynamic energy. Counterpulsation reduced flow with femoral cannulation but improved flow and pressure with axillar cannulation. Femoral cannulation failed to provide oxygenated blood to coronary and supraaortic arteries with residual heart function. Central cannulation provided the best hemodynamics and oxygen supply to the brain. With a resting heart but not with an ejecting heart, pulsatile ECMO flow enhanced CA hemodynamics.

Balón de contrapulsación e inotrópicos no catecolamínicos en el manejo del shock cardiogénico secundario a cardiopatía de Takotsubo: Una serie de casos / Intraaortic balloon pump and non-catecholamine inotropic drugs in the management of cardiogenic shock due toTakotsubo cardiomyopathy: A series of cases / Balão de contra-pulsação intra-aórtico e drogas inotrópicas não catecolamínicas no manejo de choque cardiogênico por cardiomiopatia de Takotsubo: Uma série de casos

Introducción. La cardiopatía por estrés o síndrome de Takotsubo suele complicarse con el desarrollo de shock cardiogénico, pudiendo requerir de apoyo inotrópico. En dicha situación la utilización de fármacos derivados de catecolaminas ha sido cuestionada, planteándose la utilidad del balón de contrapulsación e inotrópicos no catecolamínicos. Material y métodos. Fueron incluidos pacientes con cardiopatía de Takotsubo y desarrollo de shock cardiogénico tratados con balón de contrapulsación e inotrópicos no catecolamínicos, en dos hospitales universitarios. Resultados. Entre el 1º de Enero de 2010 y el 1º de Enero de 2014 fueron incluidas 6 pacientes de sexo femenino con un promedio de edad de 54 años, con criterios hemodinámicos de shock cardiogénico. En todas se implantó balón de contrapulsación, recibiendo además tres de ellas tratamiento con milrinona y tres con levosimendan. La evolución hemodinámica fue favorable, desarrollando una paciente fibrilación auricular y otra paciente pérdida de pulso en el miembro del balón. Conclusiones. En una serie de pacientes con cardiopatía de Takotsubo y desarrollo de shock cardiogénico, el manejo con balón de contrapulsación e inotrópicos no derivados de catecolaminas resultó efectivo y seguro. Estudios con un número apropiado de pacientes determinarán la utilidad de dicha terapéutica.

Introduction. Stress cardiomyopathy or Takotsubo's syndrome could be complicated with development of cardiogenic shock requiring inotropic support. In that situation the use of catecholamines drugs has been questioned, being proposed the utilization of intraaortic balloon pump and non-catecholamines inotropic drugs. Materials and methods. There were included patients with Takotsubo's cardiomyopathy and development of cardiogenic shock who were treated with intraaortic balloon pump and non-catecholamines inotropic drugs, in two university hospitals. Results. Between January 1 of 2010 and January 1 of 2014 there were admitted 6 female patients with an average age of 54 years, showing hemodynamic criteria of cardiogenic shock. All of them received an intraaortic balloon pump and were also treated with milrinone, in 3 cases, and levosimendan, the other 3 patients. The hemodynamic evolution was favorable presenting, as complications, an atrial fibrillation, in one case, and loosing pulse in the balloon`s limb in another case. Conclusions. In a series of patients with Takotsubo`s cardiomyopathy developing cardiogenic shock the treatment with intraaortic balloon pump and non-catecholamine inotropic drugs was effective and safe. Studies with an appropriate number of patients will determine the utility of this approach.

Introdução. A cardiomiopatia do estresse ou síndrome de Tako-tsubo poderia ser complicada com o desenvolvimento de choque cardiogênico, necessitando de suporte inotrópico. Nessa situação, o uso de drogas catecolamínicas tem sido questionado, sendo proposta a utilização de balão de contra-pulsação intra-aórtico e drogas inotrópicas não catecolamínicas. Materiais e métodos. Foram incluídos pacientes com cardiomiopatia de Tako-tsubo e desenvolvimento de choque cardiogênico que foram tratados com balão de contra-pulsação intra-aórtico e drogas inotrópicas não catecolamínicas, em dois hospitais universitários. Resultados. Entre 1 de Janeiro de 2010 e 1 de Janeiro de 2014 foram internadas 6 pacientes do sexo feminino, com uma média idade de 54 anos, mostrando critérios hemodinâmicos de choque cardiogênico. Todos eles receberam um balão de contra-pulsação intra-aórtico e também foram tratados com milrinona, em 3 casos, e levosimendan, os outras 3 pacientes. A evolução hemodinâmica foi favorável, desenvolvendo uma paciente fibrilação atrial e outra perda de pulso A evolução hemodinâmica estava apresentando favorável, como complicações, uma fibrilação atrial, em um caso, e perdendo impulso no membro do balão de contra-pulsação em outro caso. Conclusões. Em uma série de pacientes com cardiomiopatia Tako-tsubo e desenvolvimento de choque cardiogênico, o tratamento com balão de contra-pulsação intra-aórtico e drogas inotrópicas não catecolamínicas foi eficaz e segura. Estudos com um número apropriado de pacientes irão determinar a utilidade desta terapia.

Cardiopulmonary bypass and intra-aortic balloon pump use is associated with higher short and long term mortality after transcatheter aortic valve replacement: a PARTNER trial substudy.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) with the balloon-expandable Sapien transcatheter heart valve improves survival compared to standard therapy in patients with severe aortic stenosis (AS) and is noninferior to surgical aortic valve replacement (AVR) in patients at high operative risk. Nonetheless, a significant proportion of patients may require pre-emptive or emergent support with cardiopulmonary bypass (CPB) and/or intra-aortic balloon pump (IABP) during TAVR due to pre-existing comorbid conditions or as a result of procedural complications. OBJECTIVES: We hypothesized that patients who required CPB or IABP would have increased periprocedural complications and reduced long-term survival. In addition, we sought to determine whether preprocedural variables could predict the need for CPB and IABP. METHODS: The study population included 2,525 patients in the PARTNER Trial (Cohort A and B) and the continuing access registry (CAR). Patients that received CPB or IABP were compared to patients that did not receive either, and then further divided into those that received support pre-TAVR and those that were placed on support emergently. RESULTS: One-hundred sixty-three patients (6.5%) were placed on CPB and/or IABP. The use of CPB or IABP was associated with higher 1 year mortality (49.1% vs. 21.6%, P < 0.001). In multivariable analysis, utilization of CPB or IABP was an independent predictor of 30 day (HR 6.95) and 1-year (HR 2.56) mortality. Although mortality was highest in emergent cases, mortality was also greater in planned CPB and IABP cases compared with non-CPB/IABP cases (53.3% and 40.3% vs. 21.6%, P < 0.001). CONCLUSIONS: These findings indicate that CPB and IABP use in TAVR portends a poor prognosis and its utilization, particularly in the setting of pre-emptive use, needs reconsideration.

Single-centre experience with perioperative use of intraaortic balloon pump in cardiac surgery.

BACKGROUND: Intraaortic balloon pump (IABP) is frequently used in cardiac surgery in order to prevent or treat low cardiac output syndrome. Although being widely used and forming the first line therapy in these haemodynamically unstable patients despite maximal medication, optimal timing for IABP insertion is still discussed. This retrospective study evaluates hospital outcomes of patients receiving IABP at preoperative, intraoperative and postoperative periods during cardiac surgery. MATERIALS AND METHODS: Between 2006 and 2012, 2196 patients underwent open cardiac surgery in our centre. IABP was used in 121 (5.4%) patients. Nine patients had preoperative IABP insertion, 76 patients (62.8%) had intraoperative insertion to ease weaning from cardiopulmonary bypass, and 36 patients (29.8%) had postoperative insertion in the intensive care unit mainly due to refractory haemodynamic instability. Hospital outcomes of these 121 patients were analysed retrospectively. RESULTS: The majority of the patients were male (men 89, 73.6% and women 32, 26.4%; mean age was 65.9±11.5 years). Among the cohort 87 (71.9%) underwent isolated coronary artery bypass surgery (CABG) and the rest (34 patients, 28.1%) were operated for valve disease with/without CABG or for CABG with carotid endarterectomy, left ventricular aneurysm repair, post myocardial infarction ventricular septal defect or pathologies involving ascending aorta. The overall hospital mortality of the whole cohort was 27.3%. Mortality rates according to IABP timing were 33.3%, 19.7% and 41.7% for pre, intra and postoperative insertion, respectively. Logistic regression analysis identified female gender, low ejection fraction (<30%), complex surgery and postoperative insertion as risk factors for mortality. CONCLUSION: IABP insertion timing in cardiac surgery is crucial and many reports advocate early insertion since patient outcomes are poor for late insertions. This single centre study also confirms that the least favourable results are among patients with postoperative IABP insertion.

Association between obesity and postoperative atrial fibrillation in patients undergoing cardiac operations: a systematic review and meta-analysis.

In a systematic review and random-effects meta-analysis, we evaluated whether obesity is associated with postoperative atrial fibrillation (POAF) in patients undergoing cardiac operations. We selected 18 observational studies until December 2011 that excluded patients with preoperative AF (n=36,147). Obese patients had a modest higher risk of POAF compared with nonobese (odds ratio, 1.12; 95% confidence interval, 1.04 to 1.21; p=0.002). The association between obesity and POAF did not vary substantially by type of cardiac operation, study design, or year of publication. POAF was significantly associated with a higher risk of stroke, respiratory failure, and operative death.

Risks associated with the transfusion of various blood products in aortic valve replacement.

BACKGROUND: Patients undergoing cardiac operations often require transfusions of red blood cells, plasma, and platelets. From a statistical point of view, there is a significant collinearity between the components, but they differ in indications for use and composition. This study explores the relationship between the transfusion of different blood components and long-term mortality in patients undergoing aortic valve replacement alone or combined with revascularization. METHODS: A retrospective single-center study was performed including 1,311 patients undergoing aortic valve replacement. Patients who received more than 7 units of red blood cells, those who died early (7 days), and emergency cases were excluded. Patients were monitored for up to 9.5 years. A broad selection of potential risk factors were analyzed using Cox proportional hazards regression, where transfusion of red blood cells, plasma, and platelets were forced to remain in the model. RESULTS: The transfusion of red blood cells was not associated with decreased long-term survival (hazard ratio [HR], 1.01; p = 0.520) nor was the transfusion of platelets (HR, 0.946; p = 0.124); however, the transfusion of plasma was (HR, 1.041; p < 0.001). All HRs are per unit of blood product transfused. No increased risk was found for patients undergoing a combined procedure. CONCLUSIONS: No significant risk for long-term mortality was associated with transfusion of red blood cells during the study period. However, the transfusion of plasma was associated with increased mortality.

Prophylactic intraaortic balloon counterpulsation in high-risk cardiac surgery: a survey of opinion and current practice.

INTRODUCTION: Patients undergoing cardiac surgery increasingly have greater comorbidities and subsequently are at higher risk of adverse postoperative outcomes. Despite some evidence suggests that prophylactic intraaortic balloon counterpulsation reduces mortality in selected high-risk patients, its use remains low. The aim of this study was to investigate reported management strategies of high-risk patients and attitudes towards further research in this area. METHODS: A 22-question survey was developed and distributed electronically to all practicing cardiothoracic fellows through the email list of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons. RESULTS: The response rate was 28% (n=31). Reported use of prophylactic intraaortic balloon counterpulsation varied depending on the specified preoperative indication. Prophylactic intraaortic balloon counterpulsation was used occasionally or never by the majority of respondents for their patients with characteristics similar to those of previous trials. The most frequent reason given for not using prophylactic intraaortic balloon counterpulsation was lack of data (42.9%), with a willingness to consider participation in an randomised controlled trial of prophylactic intraaortic balloon counterpulsation by a large majority of respondents (79.3%). CONCLUSIONS: The majority of surgeons who responded to this survey do not routinely use prophylactic intraaortic balloon counterpulsation for high-risk patients. Further prospective data is warranted to ascertain whether potential barriers to a randomised control trial of prophylactic intraaortic balloon counterpulsation, such as adequate patient numbers and clear selection criteria, can be overcome.

Coronary revascularization in diabetic patients: off-pump versus on-pump surgery.

BACKGROUND: Coronary artery bypass grafting (CABG) is a well-established procedure for treating diabetic patients with multivessel disease, but extracorporeal circulation and cardioplegia-induced cardiac arrest introduce a severe burden to these patients. The present study investigated if off-pump CABG decreases 30-day mortality and mid-term mortality in diabetic patients in comparison with conventional CABG. METHODS: From February 2009 through October 2011, data from 355 consecutive adult diabetic patients undergoing off-pump CABG and 502 patients undergoing on-pump CABG were prospectively recorded. Data analysis was performed by propensity score (PS)-adjusted logistic regression analysis and PS-adjusted Cox regression analysis. The primary endpoint was 30-day mortality. Secondary endpoints were major complications and mortality on follow-up. RESULTS: Off-pump CABG was associated with a significantly lower 30-day mortality rate (0.3% vs 4.2%; adjusted odds ratio [OR] = 0.09 [95% confidence interval (CI):0.01 to 0.70] p = 0.021) than on-pump CABG. Results coincided with a lower rate of postoperative neurologic complications in patients undergoing off-pump CABG (1.7% vs 5.4%; adjusted OR = 0.31 [95% CI: 0.12 to 0.77] p = 0.012) and a less frequent need for hemofiltration in these patients (3.4% vs 10.4%; adjusted OR = 0.30 [95% CI: 0.14 to 0.64] p = 0.002). The off-pump technique decreased the 6-month mortality rate (2.3% vs 8.8%; adjusted hazard ratio = 0.27 [95% CI: 0.12 to 0.61] p = 0.002) and also the 1-year mortality rate (4.0% vs 10.6%; adjusted hazard ratio = 0.40 [95% CI: 0.22 to 0.75] p = 0.004) significantly. CONCLUSIONS: Our data indicate that in terms of postoperative complications and early and mid-term survival, off-pump CABG is superior to the on-pump technique in diabetic patients.