Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting

Background. The use of the intraaortic balloon pump (IABP) in patients unde rgoing coronary artery bypass grafting has been traditionally associated wi th a high complication rate and adverse outcomes. However, recent reports s how that many of these catastrophic outcomes can be avoided by preoperative ly placing the IABP in high-risk patients. To further validate these report s, we defined a set of liberal criteria for preoperative IABP insertion and applied them to a series of elderly patients (70 years or older) undergoin g isolated coronary artery bypass grafting. Methods, Two hundred six consecutive patients who underwent isolated corona ry artery bypass grafting with cardiopulmonary bypass were retrospectively reviewed. A rapid recovery protocol emphasizing reduced cardiopulmonary byp ass Lime, an anesthetic protocol for early extubation, perioperative admini stration of corticosteroids and thyroid hormone, and aggressive diuresis tv as applied to all patients. Patients who required an urgent operation becau se of failed percutaneous transluminal coronary angioplasty, a critical lef t main stenosis (70% or greater), pronounced left ventricular dysfunction ( left ventricular ejection fraction 40% or less), or unstable angina refract ory to medical therapy or who required an emergency reoperation received pr eoperative IABP support. Results. The 30-day mortality rate for the entire group was 4.4%. There wer e 97 patients (47%) who received a preoperative IABP (group II) in comparis on with 109 patients (53%) who did not fulfill the preoperative insertion c riteria (group I). patients in group II had a lower left ventricular ejecti on fraction (mean, 46% versus 59%, p < 0.001) and a higher incidence of con gestive heart failure (35% versus 17%, p < 0.01) and acute myocardial infar ction (37% versus 17%, p < 0.01) than patients in group I. The average post operative hospital length of stay for patients in group II was slightly lon ger than for those in group I (9.0 +/- 10.5 versus 6.0 +/- 3.7 days, p < 0. 01). However, there were no statistically significant differences in compli cation or mortality rates between the two groups. Only 2 patients (2.2%) ha d complications related to IABP insertion. Lower extremity ischemia occurre d in both patients, and both were treated successfully with thromboembolect omy. Conclusions. Liberal preoperative insertion of the IABP can be performed sa fely in high-risk elderly patients undergoing coronary artery bypass grafti ng, with results comparable to those in lower risk patients. (Ann Thorac Su rg 1994;67:610-3) (C) 1999 by The Society of Thoracic Surgeons.