Is Use of the Intraaortic Balloon Pump in Octogenarians Justified? Donato A. Sisto, FACS, Darryl M. Hoffman, FRCS, Sylvia Fernandes, MD, and Robert W. M. Frater, FRCS Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, Bronx, New York
Increasing numbers of octogenarians are seen in the operating room or critical care unit with circumstances for which intraaortic balloon pump (IABP) assistance is appropriate, but it has been suggested that the complication rate for IABP use in octogenarians is excessive. From 1980 to 1990, 25 octogenarians needed an IABP in our institution, as an adjunct to operation in 20 patients (1 had repair of a ventricular rupture and 19 underwent coronary grafting); 5 patients did not have operation. The indications for IABP use were unstable angina, 12 (48%); cardiogenic shock, 10 (40%); and difficulty weaning off cardiopulmonary bypass, 3 (12%)-these 3 were the only ones who had insertion through a femoral cut-down. No serious insertion difficulties were noticed with the percutaneous route in the other 22 patients. Without operation, 4 of 5 patients died in the hospital (SO%), and the 5th died 2 years 8 months after discharge. After operation, there were two hospital deaths (10%) and two late
deaths, neither from cardiac causes. A fatal outcome occurred in 6 of 9 patients with cardiogenic shock. Intraaortic balloon pumprelated complications were rare, minor, and unrelated to IABP assistance duration, which ranged from 24 to 146 hours (mean, 49.9 hours). No long-term vascular complications resulted. Hospital stay averaged 22.2 days. At follow-up from 9 to 81 months (mean, 51.8 months), of the 16 survivors, 12 (75%)were in New York Heart Association class 1/11 and 2 each were in classes I11 and IV. The Kaplan-Meier survival curve is the same as that for other octogenarians (n = 153) who had cardiac operations without an intraaortic balloon pump from 1981 to 1990. We concluded that IABP use has been safe and effective for circulatory support in octogenarians undergoing coronary operations.
B
is maintained, but a list of IABP insertions was available. We consulted the hospital records of all these patients. Survivors were followed up through correspondence with the patient, the patient’s family, or the local physician. The mean period of follow-up was 51.84 months (range, 8.9 to 81 months). Patient well-being was estimated based on daily activities, and Kaplan-Meier survival curves were constructed.
y the year 2000, it is projected that 6.2% of the United States population will be aged 80 years or more, and by the year 2010, the figure will be 6.5% [l].It has been estimated that 43% of deaths in men and 46% of deaths in women aged 80 years and over were caused by cardiovascular disease [2]. A variety of clinical conditions arise in patients with cardiovascular disease that cannot be treated successfully by medical therapy alone. The intraaortic balloon pump (IABP), introduced in 1968 by Kantrowitz and associates [3], has emerged as the single most effective and widely used circulatory assist device. Indications for its use have widened rapidly. This report describes our experience with patients aged 80 years or more, in whom the need for mechanical circulatory support arose as a part of the management of cardiac disease in conjunction with medical or surgical therapy.
Material and Methods Between the years 1980 and 1990, 25 consecutive patients aged 80 years or older (14 men and 11 women) required the use of an IABP for circulatory support at some time during their course in our institution (where all IABPs are inserted by the cardiothoracic service). No formal registry Accepted for publication Jan 27, 1992. Address reprint requests to Dr Sisto, Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461.
0 1992 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:507-11)
Results
Techniques A 10.5For 9.5F Percor DL or Percor Stat DL balloon pump catheter manufactured by the Datascope Corporation, Paramus, NJ, was used. The catheter was inserted through the right femoral artery in 17 patients and through the left femoral artery in 8. The transaortic route was not used. A percutaneous technique with a guidewire was employed in 22 patients, and cutdown was used in the 3 patients experiencing difficulty in separating from bypass. Difficulty in maneuvering the catheter was experienced in only a single patient who had an extremely tortuous aorta. The balloon was triggered by the electrocardiogram or arterial pulse wave. Anticoagulation in preoperative situations was achieved using heparin: after a loading dose of 5,000 units, a continuous infusion of 800 to 1,000 Uihour was adjusted to maintain a partial thromboplastin time twice 0003-4975/92/$5.00
508
SISTO ET AL BALLOON PUMPING IN OCTOGENARIANS
Ann Thorac Surg 1992;54507-11
Table 1. lndications for and Timing of lnsertion Group Ia Ib
I1 I11
IV
Timing of Insertion
Preoperative: coronary care unit Preoperative: operating room Postoperative: operating room Postoperative: coronary care unit Not operated on: coronary care unit
Total
Table 2. Preoperative Clinical State
No. of Unstable Cardiogenic Patients Angina Shock 15
12
3
1
...
1
3
...
3
1
...
1
5
...
5
25
12
13
Insertion
Variable
Preop
(Ia/Ib)
No. of patients
Old myocardial infarction Myocardial infarction (
Increasing numbers of octogenarians are seen in the operating room or critical care unit with circumstances for which intraaortic balloon pump (IABP) assistance is appropriate, but it has been suggested that the complication rate for IABP use in octogenarians is excessive. From 1980 to 1990, 25 octogenarians needed an IABP in our institution, as an adjunct to operation in 20 patients (1 had repair of a ventricular rupture and 19 underwent coronary grafting); 5 patients did not have operation. The indications for IABP use were unstable angina, 12 (48%); cardiogenic shock, 10 (40%); and difficulty weaning off cardiopulmonary bypass, 3 (12%)-these 3 were the only ones who had insertion through a femoral cut-down. No serious insertion difficulties were noticed with the percutaneous route in the other 22 patients. Without operation, 4 of 5 patients died in the hospital (SO%), and the 5th died 2 years 8 months after discharge. After operation, there were two hospital deaths (10%) and two late
deaths, neither from cardiac causes. A fatal outcome occurred in 6 of 9 patients with cardiogenic shock. Intraaortic balloon pumprelated complications were rare, minor, and unrelated to IABP assistance duration, which ranged from 24 to 146 hours (mean, 49.9 hours). No long-term vascular complications resulted. Hospital stay averaged 22.2 days. At follow-up from 9 to 81 months (mean, 51.8 months), of the 16 survivors, 12 (75%)were in New York Heart Association class 1/11 and 2 each were in classes I11 and IV. The Kaplan-Meier survival curve is the same as that for other octogenarians (n = 153) who had cardiac operations without an intraaortic balloon pump from 1981 to 1990. We concluded that IABP use has been safe and effective for circulatory support in octogenarians undergoing coronary operations.
B
is maintained, but a list of IABP insertions was available. We consulted the hospital records of all these patients. Survivors were followed up through correspondence with the patient, the patient’s family, or the local physician. The mean period of follow-up was 51.84 months (range, 8.9 to 81 months). Patient well-being was estimated based on daily activities, and Kaplan-Meier survival curves were constructed.
y the year 2000, it is projected that 6.2% of the United States population will be aged 80 years or more, and by the year 2010, the figure will be 6.5% [l].It has been estimated that 43% of deaths in men and 46% of deaths in women aged 80 years and over were caused by cardiovascular disease [2]. A variety of clinical conditions arise in patients with cardiovascular disease that cannot be treated successfully by medical therapy alone. The intraaortic balloon pump (IABP), introduced in 1968 by Kantrowitz and associates [3], has emerged as the single most effective and widely used circulatory assist device. Indications for its use have widened rapidly. This report describes our experience with patients aged 80 years or more, in whom the need for mechanical circulatory support arose as a part of the management of cardiac disease in conjunction with medical or surgical therapy.
Material and Methods Between the years 1980 and 1990, 25 consecutive patients aged 80 years or older (14 men and 11 women) required the use of an IABP for circulatory support at some time during their course in our institution (where all IABPs are inserted by the cardiothoracic service). No formal registry Accepted for publication Jan 27, 1992. Address reprint requests to Dr Sisto, Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, 1825 Eastchester Rd, Bronx, NY 10461.
0 1992 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:507-11)
Results
Techniques A 10.5For 9.5F Percor DL or Percor Stat DL balloon pump catheter manufactured by the Datascope Corporation, Paramus, NJ, was used. The catheter was inserted through the right femoral artery in 17 patients and through the left femoral artery in 8. The transaortic route was not used. A percutaneous technique with a guidewire was employed in 22 patients, and cutdown was used in the 3 patients experiencing difficulty in separating from bypass. Difficulty in maneuvering the catheter was experienced in only a single patient who had an extremely tortuous aorta. The balloon was triggered by the electrocardiogram or arterial pulse wave. Anticoagulation in preoperative situations was achieved using heparin: after a loading dose of 5,000 units, a continuous infusion of 800 to 1,000 Uihour was adjusted to maintain a partial thromboplastin time twice 0003-4975/92/$5.00
508
SISTO ET AL BALLOON PUMPING IN OCTOGENARIANS
Ann Thorac Surg 1992;54507-11
Table 1. lndications for and Timing of lnsertion Group Ia Ib
I1 I11
IV
Timing of Insertion
Preoperative: coronary care unit Preoperative: operating room Postoperative: operating room Postoperative: coronary care unit Not operated on: coronary care unit
Total
Table 2. Preoperative Clinical State
No. of Unstable Cardiogenic Patients Angina Shock 15
12
3
1
...
1
3
...
3
1
...
1
5
...
5
25
12
13
Insertion
Variable
Preop
(Ia/Ib)
No. of patients
Old myocardial infarction Myocardial infarction (
