Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting

Abstract

Introduction

Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined.

Methodology

A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates.

Results

Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028).

Conclusion

Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Keywords

intra-aortic balloon pump high risk CABG pre-operative IABP third-world countries

Introduction

The intra-aortic balloon pump (IABP) is one of the most commonly used mechanical circulatory assist devices in patients undergoing coronary artery bypass grafting (CABG) with high risk of peri-operative morbidity and mortality.¹ It improves coronary blood flow, reducing left ventricular load and improving oxygen supply to the myocardium.² It provides critical temporary support to the left ventricle and prevents ischemic heart failure.³ In addition to its positive impact on the cardiac tissue, IABP also possess some other technical advantages including ease of implantation, widespread availability, lower complications and greater cost-effectiveness as compared to other temporary mechanical circulatory support (TMCS) devices.⁴ The main indications for IABP insertion are cardiogenic shock (CS), low-output cardiac syndromes post-open heart surgery, medically refractory ischemia or angina, left main coronary stenosis and decreased left ventricular ejection fraction.⁵

Other TMCS devices to support compromised hemodynamics includes a pulsatile percutaneous ventricular assist device (the iVAC), veno-arterial extra-corporeal membrane oxygenation (ECMO), iVAC, Impella and Tandem Heart percutaneous ventricular assist device.⁶ However due to technical difficulties, unavailability of expertise and high cost of other mechanical circulatory assist devices, IABP is the only mechanical circulatory assist device available and that too in only a few centres across third world countries like Pakistan.⁷

Recent studies conducted in this regard showed improved surgical outcomes with peri-operative IABP insertion in patients undergoing CABG with both severe and mild left ventricular dysfunction.^3,8,9 However it is not considered as a gold standard as multiple studies have shown increased complications such as increased risk of bleeding, reoperation, prolonged ventilation and ICU stay.¹ A recent meta-analysis showed improved outcomes with reduced mortality and reduction in major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing CABG.¹⁰ A recent study showed 1.6% reduction in mortality with IABP in patients undergoing CABG.¹ The 2011 American Heart Association guidelines recommended the use of IABP in patients with left main coronary artery disease, a left ventricular EF of <35% or patients who are undergoing reoperation in addition to certain well-established indications.³ However the effect of use of IABP in the peri-operative period still remains controversial.^11,12

There is very scarce data available on peri-operative usage of IABP and its outcomes especially from Indo-Pak region.⁷ Two previous studies have been reported from our institute; one on the peri-operative usage of IABP in patients undergoing CABG with limited number of patients (n = 15)¹³ and other on the overall usage of IABP in CS undergoing percutaneous coronary intervention.⁷ Hence the importance of this study is to share our experience of IABP insertion from a low-middle income country and its overall impact on patients’ short-term peri-operative morbidity, mortality and post-operative outcomes and the how the timing of its insertion (pre-operative vs peri-operative) affected the overall patient outcome. It’s a first study of its kind from our region as none of the previous studies from our region have evaluated this aspect of IABP.

Materials and methods

This was a single center, retrospective study conducted at the Department of Cardiothoracic Surgery, Aga Khan University Hospital. Prior to this study, ERC exemption was sought. The confidentiality and anonymity of the participants was ensured and the data was coded. Researchers were responsible for the excellence and integrity of this project. All the patients undergoing CABG and IABP insertion in same hospital stay in last 5 years were included in the study from January 2015 till December 2019.

The approximate number of patients that had presented in our institute in last 5 years and had undergone CABG and had an IABP insertion were 130 patients but due to incomplete medical records 33 patients were excluded from the study. Non-probability consecutive sampling technique was used. Data was collected retrospectively by reviewing patient’s medical records and was recorded on pre-designed performa. Date and timing of IABP insertion and date of surgery and its complications were noted by reviewing patients Intensive Care Unit data sheets and daily progress notes and they were followed until the day of discharge or 30th post-operative day and if discharged from hospital, 30-day follow-up for complications was done through file review of clinic follow ups.

All the patients whose age was greater than 18 years, and all those who received IABP preoperatively, intra-operatively or post-operatively and underwent emergency or elective CABG with or without other open-heart procedures were included in the study, while those patients who received IABP and underwent percutaneous coronary intervention or those with incomplete medical records were excluded.

Statistical analysis

Retrospective, hospital-based chart review with two independent data collectors was done in order to ensure data accuracy. Cases were then stratified according to the timing of insertion and divided into two groups that is either pre-operative or peri-operative (intra-operative and post-operative) and analyzed according to surgical outcomes and complication rates. Statistical analysis was conducted using SPSS Version 23.0 and STATA Version 16.0; all statistical tests were two-tailed and p-value of <0.05 was taken to be significant. Student’s t test was used to compare means for parametric data, while Mann-Whitney U test was used for non-parametric data. Continuous variables were described with means, standard error, and 95% confidence intervals reported.

Results

A total of 130 patients were admitted from 2015 to 2019 to our institute requiring IABP insertion and CABG, but only 97 patients were included in the study. Out of 97 patients, 20.6%, (n = 20) were admitted electively while 79.4%, (n = 77) were admitted through the emergency room. Out of all these patients collectively, 84.5%, (n = 82) underwent preoperative IABP insertion while 15.5%, (n = 15) of patients received perioperative insertion. In regards to gender, 78.3%, (n = 76) of the patients were male while 21.6%, (n = 21) were female, out of which 85.5%, (n = 65) males and 81%, (n = 17) of females underwent preoperative insertion of IABP while 14.5%, (n = 11) males and 19%, (n = 4) females underwent perioperative insertion of IABP. Of all the patients included in this study, 37.1%, (n = 36) of the patients were diagnosed to have ST-elevation myocardial infarction (MI) while the other 62.9%, (n = 61) were diagnosed to have Non-ST elevation MI (Table 1).

Table 1.

Cohort characteristics comparing patients who underwent pre-operative and peri-operative IABP insertion.

			Mode of IABP insertion
			Pre-operative insertion	Peri-operative insertion	p-value
Gender	Male	Count	65	11	0.7330
	Male	In %	79.3%	73.3%
	Female	Count	17	4
	Female	In %	20.7%	26.7%
Mode of admission	Elective	Count	10	10	0.0001
	Elective	In %	12.1%	66.7%
	Emergency	Count	72	5
	Emergency	In %	87.9%	33.3%
Diagnosis	STEMI	Count	33	3	0.1590
	STEMI	In %	40.2%	20%
	NSTEMI	Count	49	12
	NSTEMI	In %	59.8%	80%
Comorbids	Comorbids	Count	78	12
	Comorbids	In %	95.1%	80%
	NKCM	Count	4	3
	NKCM	In %	4.9%	20%
CKD	No	Count	73	14	1.0000
	No	In %	89.0%	93.3%
	Yes	Count	9	1
	Yes	In %	11.0%	6.7%
Diabetes mellitus	No	Count	22	8	0.660
	No	In %	26.8	53.3
	Yes	Count	60	7
	Yes	In %	73.2	46.7
Smoker	No	Count	71	15	0.2050
	No	In %	86.6%	100%
	Yes	Count	11	0
	Yes	In %	13.4%	0.0%
PAD	No	Count	81	15	1.0000
	No	In %	98.8%	100%
	Yes	Count	1	0
	Yes	In %	1.2%	0.0%
IHD	No	Count	51	13	0.0800
	No	In %	62.2%	86.7%
	Yes	Count	31	2
	Yes	In %	37.8%	13.3%
BPH	No	Count	79	14	0.4950
	No	In %	93.6	93.3
	Yes	Count	3	1
	Yes	In %	3.5%	6.7%
Asthma	No	Count	80	15	1.0000
	No	In %	97.6%	100.0%
	Yes	Count	2	0
	Yes	In %	2.4%	0.0%
OA	No	Count	79	15	1.0000
	No	In %	96.3%	100%
	Yes	Count	3	0
	Yes	In %	3.7%	0.0%
COPD	No	Count	78	15	1.0000
	No	In %	95.1%	100.0%
	Yes	Count	4	0
	Yes	In %	4.9%	0.0%
Dyslipidemia	No	Count	78	15
	No	In %	95.1	100.0%
	Yes	Count	4	0
	Yes	In %	4.9%	0.0%
Hypertension	No	Count	10	6	0.0160
	No	In %	12.2%	40.0%
	Yes	Count	72	9
	Yes	In %	87.8	60.0%

The most common cause for the IABP insertion was CS, which accounted for 48.5%, (n = 47) of the patients (Table 2). Preoperative use of inotropic drugs was significantly less in patients as compared to postoperatively with 15.5%, (n = 15) receiving norepinephrine and 6.2%, (n = 6) receiving epinephrine preoperatively as compared to 54.6%, (n = 53) receiving norepinephrine, 93.8%, (n = 91) receiving epinephrine and 10.3%, (n = 10) receiving dobutamine as well. Post operatively perioperative IABP patients had significantly higher rates of arrhythmias (46.7%, n = 7, p = 0.042) (Table 3).

Table 2.

Reasons of IABP insertion.

Reason of insertion of IABP		Mode of IABP insertion		Total
Reason of insertion of IABP		Preoperative insertion	Perioperative insertion	Total
Cardiogenic shock	Count	40	7	47
Cardiogenic shock	% Within reason of insertion of IABP	85.1%	14.9%	100.0%
Ventricular fibrillation	Count	4	3	7
Ventricular fibrillation	% Within reason of insertion of IABP	57.1%	42.9%	100.0%
LAD perforation	Count	1	0	1
LAD perforation	% Within reason of insertion of IABP	100.0%	0.0%	100.0%
PCI failed	Count	3	0	3
PCI failed	% Within reason of insertion of IABP	100.0%	0.0%	100.0%
CHF/LV failure	Count	17	2	19
CHF/LV failure	% Within reason of insertion of IABP	89.5%	10.5%	100.0%
High risk CABG	Count	3	0	3
High risk CABG	% Within reason of insertion of IABP	100.0%	0.0%	100.0%
MI	Count	7	3	10
MI	% Within reason of insertion of IABP	70.0%	30.0%	100.0%
Total LAD occlusion	Count	7	0	7
Total LAD occlusion	% Within reason of insertion of IABP	100.0%	0.0%	100.0%
Total	Count	82	15	97
Total	% Within reason of insertion of IABP	84.5%	15.5%	100.0%

Table 3.

Use of inotropes.

			New mode of IABP insertion		Total
			Preoperative insertion	Perioperative insertion	Total
Were inotropes given post-operatively	No	Count	4	0	4
	No	% Within were inotropes given	100.0%	0.0%	100.0%
	Yes	Count	78	15	93
	Yes	% Within were inotropes given	83.9%	16.1%	100.0%
Number of ionotropes immediately after surgery	.0	Count	4	0	4
	.0	% Within number of i0tropes immediately after surgery	100.0%	0.0%	100.0%
	1.0	Count	29	5	34
	1.0	% Within number of i0tropes immediately after surgery	85.3%	14.7%	100.0%
	2.0	Count	46	9	55
	2.0	% Within number of i0tropes immediately after surgery	83.6%	16.4%	100.0%
	3.0	Count	3	1	4
	3.0	% Within number of i0tropes immediately after surgery	75.0%	25.0%	100.0%
Epinephrine post operatively	No	Count	5	1	6
	No	% Within Epi post operatively	83.3%	16.7%	100.0%
	Yes	Count	77	14	91
	Yes	% Within Epi post operatively	84.6%	15.4%	100.0%
Norepinephrine post operatively	No	Count	39	5	44
	No	% Within NorEpi post operatively	88.6%	11.4%	100.0%
	Yes	Count	43	10	53
	Yes	% Within NorEpi post operatively	81.1%	18.9%	100.0%
Dobutamine postoperatively	No	Count	73	14	87
	No	% Within dobutamine postoperatively	83.9%	16.1%	100.0%
	Yes	Count	9	1	10
	Yes	% Within dobutamine postoperatively	90.0%	10.0%	100.0%

Overall only 9.3%, (n = 9) of patients experienced complications related to IABP insertion, out of which 88.90%, (n = 8) of patients had underwent preoperative IABP insertion as compared to 11.10%, (n = 1) of patients that underwent perioperative insertion (Table 4).

Table 4.

Complications related to IABP.

			Mode of IABP insertion		Total
			Preoperative insertion	Perioperative insertion	Total
Complications related to IABP	No	Count	74	14	88
	No	% complications related to IABP	84.1%	15.9%	100.0%
	Yes	Count	8	1	9
	Yes	% within complications related to IABP	88.9%	11.1%	100.0%
Types of complications	Aneurysmal aorta	Count	1		1
	Aneurysmal aorta	% within types of complications	100.0%		100.0%
	Septicemia	Count	4	1	4
	Septicemia	% within types of complications	80%	20%	100.0%
	Limb ischemia	Count	2		2
	Limb ischemia	% within types of complications	100.0%		100.0%
	Aortic tear	Count	1		1
	Aortic tear	% within types of complications	100.0%		100.0%

However, there were no significant differences between 30-day readmission rates in the two groups (9.8%, n = 8 vs 6.7%, n = 1), (p = 1.000). Length of hospital stay was higher in patients who were alive with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107) (Figure 1).

Figure 1.

Comparison of outcomes showing difference between preoperative and peri-operative insertion of IABP.

In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003) and the most common cause of death was cardiopulmonary arrest which was seen in 63.2%, (n = 12) in which IABP was inserted preoperatively as compared to 36.8%, (n = 7) in which IABP was inserted peri-operatively. (Table 5) The univariate and multivariate logistic regression analysis was performed to identify the predictors of peri-operative IABP insertion within our cohort (Table 6).

Table 5.

Outcomes of patients relating to timing of IABP insertion.

			New mode of IABP insertion		Total
			Preoperative insertion	Perioperative insertion		p-value
Outcome of patient	Expired	Count	17	9	26	0.0030
	Expired	% within outcome of patient	65.4%	34.6%	100.0%
	Alive	Count	65	6	71
	Alive	% within outcome of patient	91.5%	8.5%	100.0%
Cause of death	Cardiopulmonary arrest	Count	12	7	19
	Cardiopulmonary arrest	% within cause of death	63.2%	36.8%	100.0%
	Septic shock	Count	2	0	2
	Septic shock	% within cause of death	100.0%	0.0%	100.0%
	Pulmonary embolism	Count	0	1	1
	Pulmonary embolism	% within cause of death	0.0%	100.0%	100.0%
	Cardiogenic shock	Count	3	1	4
	Cardiogenic shock	% within cause of death	75.0%	25.0%	100.0%
Post-operative bleeding	No	Count	6	2	8
	No	% within post operative bleeding	75.0%	25.0%	100.0%
	Yes	Count	76	13	89
	Yes	% within post operative bleeding	85.4%	14.6%	100.0%
Re-opening of patient	No	Count	74	10	84	0.0280
	No	% within Re-opening of patient	88.1%	11.9%	100.0%
	Yes	Count	8	5	13
	Yes	% within Re-opening of patient	61.5%	38.5%	100.0%
Post operative cerebrovascular accident	No	Count	80	14	94	0.3990
	No	% within post operative cerebrovascular accident	85.1%	14.9%	100.0%
	Yes	Count	2	1	3
	Yes	% within post operative cerebrovascular accident	66.7%	33.3%	100.0%
Post-op arrhythmia	No	Count	66	8	74	0.0420
	No	% within post-op arrhythmia	89.2%	10.8%	100.0%
	Yes	Count	16	7	23
	Yes	% within post-op arrhythmia	69.6%	30.4%	100.0%
Readmission of patient within 30 days of surgery	No	Count	74	14	88	1.0000
	No	% Within readmission of patient within 30 days of surgery	84.1%	15.9%	100.0%
	Yes	Count	8	1	9
	Yes	% Within readmission of patient within 30 days of surgery	88.9%	11.1%	100.0%

Table 6.

Univariate and multivariate logistic regression analysis.

Univariate analysis	Odds Ratio	Std. Err.	z	P>z	[95% Conf.Interval]
Emergency admission	0.07	0.04	−4.15	0.0001	0.0196799	0.245048
Hypertension	0.21	0.13	−2.51	0.012	0.0611011	0.7103438
Diabetes mellitus	0.32	0.18	−1.98	0.048	0.1040681	0.989103
Multivariable analysis	Adjusted Odds Ratio	Std. Err.	z	P>z	[95% Conf.Interval]
Age	1.25	0.12	2.39	0.017	1.041267	1.510984
Female	54.62	103.6	2.11	0.035	1.326522	2249.306
IHD	0.005	0.01	−2.25	0.025	0.0000572	0.5127374
NSTEMI	30.49	51.75	2.01	0.044	1.094972	849.0986
Ventricular fibrillation	113.94	256.6	2.1	0.036	1.378697	9415.562

Discussion

The use of IABP in patients undergoing CABG has been a matter of discussion with controversial results. Several studies have been carried out all over the globe, which highlight the advantages and disadvantages of IABP support. But very few studies have been done which emphasize on the timing of the placement of IABP support and its effect on postoperative outcomes of the patient.

In our retrospective study, we analyzed all the patients undergoing CABG with IABP placement within 5 years and concluded that out of total 97 patients, 77 of them underwent emergency CABG. Out of all the patients 84.5%, (n = 82) had preoperative insertion of IABP and 15.5%, (n = 15) had perioperative IABP insertion. In a study done by Brucu et al it was concluded that, early use of IABP in CS was associated with significant improvement in 30-day mortality regardless of the etiology of CS.⁴ It was noticed in our study, about 48.5%, (n = 47) of our patients had CS due to which IABP was placed. IABP therapy is still used in cardiac surgery despite recent evidence from the IABP Shock II trial that could not prove a survival benefit of IABP in CS following myocardial infarction.¹⁴

In terms of post-operative mortality, our study showed that the patients who had IABP inserted preoperatively had lower mortality rate as compared to those who had perioperative insertion of IABP. A 30-day mortality rate was assessed and mortality rate appeared to be higher in the perioperative group since 91.5%, (n = 65) patients with preoperative IABP insertion survived while only 8.5%, (n = 6) patients with perioperative IABP insertion survived. A recent meta-analysis by Dyub et al.¹⁵ showed lower mortality and hospital length of stay in the preoperative group. However, in our study, the length of hospital stay was increased in the preoperative group, while the rate of readmission within 30 days and length of ICU stay was the same in both groups similar to the literature available.

About 9.3%, (n = 9) patients in our study developed complications of IABP insertion, the most important complications were septicemia (50%, n = 4), limb ischemia (25%, n = 2), aortic aneurysm (12.5%, n = 1) and aortic tear (12.5%, n = 1). However, if patients who are at higher risk of developing postoperative complications related to IABP insertion are identified early on and proper postoperative care and strict monitoring is carried out, the chances to develop complications related to IABP may be decreased. A study done in 2018, showed that the overall incidence of vascular complications ranged from 0.94% to 31.1%.¹⁵

A recent meta-analysis reported that prophylactic IABP reduced mortality and MACCE in high-risk CABG patients.¹ MACCE noticed in our study included death due to cardio-cerebral events, cerebrovascular events (3.1%, n = 3, p = 0.399), and arrythmias (23.7%, n = 23, p = 0.042). Total mortality was 26.8%, (n = 26), out of which 73.1%, (n = 19), died due to cardiopulmonary arrest while 15.4%, (n = 4) died due to CS. In a study done in 2019, major adverse cardiac or cerebrovascular events (MACCE) occurred in 3.8% overall (including after discharge), with a 5.9% MACCE in the prophylactic IABP group.¹ Taking into consideration that the large number of patients included in our study presented with CS and more than half of patients required emergency CABG, with several comorbids, such as DM (69.1%, n = 67), HTN (83.5%, n = 81), CKD (10.3%, n = 10), IHD (34.0%, n = 33), dyslipidemia (4.1%, n = 4). Approximately, (11.4%, n = 11) were smokers, and 2.1%, (n = 2) had asthma, while 4.1%, (n = 4) had COPD. About (79.4%, n = 77) underwent emergency CABG, and about 37.1%, (n = 36) had STEMI, the expected MACCE and mortality was much higher than reported.

Reopening due to bleeding in CABG patients is one of the important post-operative complications. We noticed in our study, that about 92.7%, (n = 76) patients who had preoperative IABP insertion had only 9.8%, (n = 8) were reopened due to bleeding while in the group who had perioperative IABP insertion 86.7%, (n = 13 out of 15) were bleeding and 33.3%, (n = 5) were reopened. Although significant (p-value of 0.028), this could be due to the fact that patients who underwent emergent surgery received acute coronary syndrome protocol closer to time of surgery, than those who first underwent pre-operative IABP placement and had an urgent surgery. In a study conducted in 2019, the results showed that there were no significant differences in reoperation for bleeding in patients with IABP as compared to those without IABP.¹

Cardiac surgery patients often need inotropic support to establish hemodynamic stability and adequate oxygen supply.¹⁶ About 7.3%, (n = 7) patients in our study, required preoperative epinephrine while 18.3%, (n = 15) required preoperative norepinephrine. On the other hand, about 95.9%, (n = 93) patients required inotropes post-operatively from which, 56.7%, (n = 55) were on dual inotropes that is epinephrine and norepinephrine, 35.1%, (n = 34) were on single inotropic support and 4.1%, (n = 4) required triple inotropic support, (epinephrine, norepinephrine and dobutamine). According to the recent literature, it has been deduced that inotropic support, IABP and adequate volume management during surgery and post-surgery period in ICU has led to better and early hemodynamic stability.¹⁶

In regards to the aforementioned findings, our study has shed light upon the need of IABP insertion in patients undergoing CABG and its overall effect on decreasing the postoperative mortality and morbidity in high risk patients. Furthermore, prophylactic, preoperative IABP insertion in high-risk patients undergoing cardiac surgery as was preferred in our institute decreases mortality and morbidity further. Preoperative IABP insertion should be considered in high-risk patients undergoing CABG.¹⁷ as opposed to certain studies which were carried out. Yu et al reported that preoperative IABP before CABG surgery is associated with increased in-hospital morbidity and longer postoperative ICU stay as compared to patients without IABP support.¹⁷

Limitations

One of the major limitations of our study is a single center retrospective cohort analysis. All the patients that were selected had IABP inserted and no control group was added. Also there may be a selection bias effect as time from admission to time of surgery was not assessed as this could determine whether patients receiving IABP pre-operatively were more or less stable than the peri-operative group. The effect of IABP on postoperative morbidity and mortality was analyzed by using the use of inotropes, the postoperative complications, length of stay, reopening and the rate of readmissions, however, the timing of IABP insertion is still a questionable debate due to the fact that this retrospective study is based on a smaller scale. Hence, in order to adequately determine the effect of IABP on overall mortality and morbidity and precisely assess the timing of IABP placement in relation to outcomes, multi-centric studies need to be carried out with increased number of participants including control groups with greater follow up times.

Although half of the patients receiving IABP in the peri-operative group were electively admitted for surgery, the major limitation of this study was that we did not assessed the intra-operative complications or technical difficulties that may have led to IABP placement in the peri-operative group. This can lead to increase morbidity and mortality post-operatively in the peri-operative group.

Conclusion

Preoperative prophylactic use of IABP was related to a decline in overall short-term mortality and morbidity in high-risk patients undergoing CABG. Our study shows improved survival in patients with preoperatively inserted IABP. Complication rates were also higher in the perioperative group. This can be beneficial for high-risk patients undergoing CABG surgery in third world countries where iVACs are either unavailable or are not affordable. Expanding the use of IABP before CABG in resource-limited third world countries such as Pakistan may improve overall survival for patients. However further prospective. multi-center studies are required especially which determine the intra-operative complications that can lead to IABP insertion in the peri-operative group before it can be concluded that prophylactic IABP insertion in high risk patients have better outcomes.

Footnotes

Author contributions

Abdul Ahad Sohail: Original draft, critical review, literature search.

Areeba Samejo: Original draft, literature search, data collection.

Hamza Bajwa: Original draft, literature search, data collection.

Rida Wahab: Original draft, critical review, literature search. Narmeen Asif: Original draft, critical review, literature search.

Hina Inam: Original draft, critical review, literature search.

Syed Shahabuddin: Original draft, critical review, literature search.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The ethical committee of Aga Khan University Hospital has approved this study.

ORCID iD

Abdul Ahad Sohail

References

Nakamura

Hamasaki

Uchida

, et al. The use of prophylactic intra-aortic balloon pump in high-risk patients undergoing coronary artery bypass grafting. PLoS One 2019; 14(10): e0224273.

Iakobishvili

Behar

Boyko

, et al.

Does current treatment of cardiogenic shock complicating the acute coronary syndromes comply with guidelines?

Am Heart J 2005; 149(1): 98–103.

X-Y

Gao

C-Q

. Peri-operative application of intra-aortic balloon pumping reduced in-hospital mortality of patients with coronary artery disease and left ventricular dysfunction. Chin Med J 2019; 132(8): 935–942.

Gul

Bellumkonda

. Usefulness of intra-aortic balloon pump in patients with cardiogenic shock. Am J Cardiol 2019; 123(5): 750–756.

McCabe

Abel

Subramanian

, et al. Complications of intra-aortic balloon insertion and counterpulsation. Circulation 1978; 57(4): 769–773.

Jiritano

Coco

Matteucci

, et al. Temporary mechanical circulatory support in acute heart failure. Card Fail Rev 2020; 6: 1–7.

Jafary

Khan

Kumar

, et al. Survival of patients treated with intra-aortic balloon counterpulsation at a tertiary care center in Pakistan–patient characteristics and predictors of in-hospital mortality. BMC Cardiovasc Disord 2004; 4(1): 22.

Christenson

Licker

Kalangos

. The role of intra-aortic counterpulsation in high-risk OPCAB surgery: A prospective randomized study. J Card Surg 2003; 18(4): 286–294.

Theologou

Bashir

Rengarajan

, et al. Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting. Cochrane Database Syst Rev 2011; 2011(1): CD004472.

10.

Field

Rengarajan

Khan

, et al. Preoperative intra aortic balloon pumps in patients undergoing coronary artery bypass grafting. Cochrane Database Syst Rev 2007; (1): CD004472.

11.

Parissis

Graham

Lampridis

, et al. IABP: History-evolution-pathophysiology-indications: What we need to know. J Cardiothorac Surg 2016; 11(1): 122.

12.

Thiele

Zeymer

Neumann

F-J

Intraaortic Balloon Pump in cardiogenic shock II IABP-SHOCK II trial investigators , et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): Final 12 month results of a randomised, open-label trial. Lancet 2013; 382(9905): 1638–1645.

13.

Jafarey

Amanullah

Khan

, et al. The use of intra aortic baloon pump in patients undergoing coronary artery bypass grafting at the Aga Khan University Hospital, Karachi. J Pak Med Assoc 2000; 50(3): 3–7.

14.

Slottosch

Liakopoulos

Scherner

, et al. Preoperative intraaortic balloon pump before urgent coronary bypass grafting. Asian Cardiovasc Thorac Ann 2018; 26(5): 353–360. DOI: 10.1177/0218492318782066.

15.

Lavana

Fraser

Smith

, et al. Influence of timing of intraaortic balloon placement in cardiac surgical patients. J Thorac Cardiovasc Surg 2010; 140(1): 80–85. DOI: 10.1016/j.jtcvs.2009.09.033.

16.

Keranovic

Salihovic

Zrnanovic

, et al. Inotropic and mechanical support of critically ill patient after cardiac surgery. Med Arch 2020; 74(3): 236–239. DOI: 10.5455/medarh.2020.74.236-239.

17.

Deppe

Weber

Liakopoulos

, et al. Preoperative intra-aortic balloon pump use in high-risk patients prior to coronary artery bypass graft surgery decreases the risk for morbidity and mortality-A meta-analysis of 9,212 patients. J Card Surg 2017; 32(3): 177–185. DOI: 10.1111/jocs.13114.