RAPID-STAGED STRATEGY FOR CONCOMITANT CRITICAL CAROTID AND LEFT MAIN CORONARY-DISEASE WITH LEFT-VENTRICULAR DYSFUNCTION - IABP USE

Background. Few reports address the high-risk patient population with concomitant critical carotid and left main coronary disease with left ventricular dysfunction. To decrease the risks involved with the simul taneous and traditional staged surgical approaches, we developed a rap id staging strategy using an intraaortic balloon pump. Methods. Betwee n 1992 and 1996, 20 patients presented with a high-risk ''triad'' defi ned by greater than 70% stenosis of the left main coronary artery, eje ction fraction less than 0.30, and greater than 90% stenosis of the in ternal carotid artery. An intraaortic balloon pump was placed immediat ely before carotid endarterectomy under angiographic guidance. Less th an 24 hours later (mean, 18 hours) coronary artery bypass grafting was performed, and the intraaortic balloon pump was removed the day of co ronary artery bypass grafting in all cases (total IABP duration, <36 h ours). Results. Eighteen patients (18/20) were extubated on the day of coronary artery bypass grafting (mean, 12 hours). Sixteen patients (1 6/20) were transferred from the intensive care unit within 48 hours, w ith total hospital stay ranging from 6 to 12 days (mean, 8 days). Ther e were no 30-day postoperative deaths, myocardial infarctions, or neur ologic, vascular, bleeding, or other major complications. At a mean 29 .4-month follow-up, there were two noncardiac deaths and no neurologic events. Six-month, 1-year and 2-year follow-up ultrasounds showed all operative carotid arteries remained patent. Conclusions. A rapid stag ed procedure with angiographically guided placement of the intraaortic balloon pump was safe and effective in this very high risk patient po pulation. It may be an option to decrease the risks involved with simu ltaneous operations and increase the efficiency and safety of ''tradit ional'' staged carotid and coronary artery bypass grafting procedures. (Ann Thorac Surg 1998;66:1230-5) (C) 1998 by The Society of Thoracic Surgeons.