Role of Intra-Aortic Balloon Pump in Off-Pump Coronary Artery Bypass <br/>—A Vettath Modification

Abstract

Objective: Hemodynamic deterioration during positioning of the heart has been the most critical complication of off-pump coronary artery bypass surgery. Pre-operative use of intra-aortic balloon pump has been shown to prevent this complication in high risk patients. The role of balloon pump in high risk patients has been questioned by our group. We modified the role of balloon pump in our patients, thus avoiding the conversion to cardiopulmonary bypass. Methods: 4063 off-pump coronary bypass surgeries were performed by a single surgeon in our center, over thirteen years. 130 intra-aortic balloons used between July 2002 and December 2015 were removed from the theater, once the distal anastomosis was performed. We studied this group of patients for-time and need for insertion, duration of balloon used, local insertion problems and survival. Results: Initially, we inserted intra-aortic balloons in high risk patients. We observed that, patients with low ejection fraction and patients with critical left main coronary artery disease were not the ones who actually needed balloon pump support. It was the patients who had ongoing ischemia, with preserved left ventricular function, and ST depression intra-operatively, who needed balloon pump support to perform complete anatomical revascularization. Conclusions: Intra-aortic balloon pump has helped us to position the heart without hemodynamic instability, thereby avoiding conversion to cardiopulmonary bypass. This enabled us to perform off-pump surgery in virtually all areas of the heart, thus maintaining perfect hemodynamics.

Off-Pump Coronary Artery Bypass Grafting Improves Early Clinical Outcomes Including Operative Mortality

“…Despite these limitations, our results have improved over the years. Previously, after auditing our results, we noticed that our learning curve for offpump CABG extended beyond the first 500 patients [Vettath 2016]. This can easily be confirmed when looking at Figure 2.…”

“…An additional 5 to 7% of patients are considered to have myocardial infarction, stroke, and renal failure requiring dialysis. Early initiation of IABP lead to an improvement in clinical outcome of our patients, with a significant reduction in conversion rate, perioperative MI and renal failure [Vettath 2016]. The standardization of the approach to a patient with ischemic heart disease and how we do off-pump CABG has consistently brought down the operative (30-day) mortality rate of our patients, lowering it to less than 1%, which is superior to 30-day results published in large randomized controlled trials to date [Diegeler 2013;Houlind 2012;Shroyer 2009].…”

“…As it is a single surgeon center, there are more technical constants than in a teaching hospital, where more surgeons operate. Previously, we published details regarding our off-pump technique and how we avoid conversions, and the role of the intra-aortic balloon pump (IABP) [Vettath 2016;Vettath 2013]. Although the safety and the efficacy in off-pump CABG have been reported to be comparable to on-pump CABG, off-pump CABG is a more of a skill based procedure.…”

Revascularisation Strategies in OPCAB (Off Pump Coronary Artery Bypass)

“…Because every patient who undergo OPCAB in our centre has two arterial lines, one in the Radial artery and another in the Femoral artery. The one in the femoral region is exchanged to an IABP using the Seldinger technique [8]. This has been a boon for us, as we are able to place the IABP immediately, and then go on with the grafting without going on the heart lung machine (HLM).…”

Development of SIMS (Simple Indigenous Metallic Stabilizer) for OPCAB

“…We have been performing the same for over two decades. As one of the pioneers of this technique, we have fabricated, developed, innovated and re-engineered this technique to perform OPCAB in all patients needing CABG (coronary artery bypass grafting) [1]- [7]. We herewith present our recent innovation-A simple indigenous metallic stabilizer (SIMS) which we have used for the past three years.…”