ABSTRACT: High-risk cardiac patients, especially those with severe coronary artery disease, are prone to ischemic, arrhythmic and heart failure complications during urgent or emergent noncardiac surgery. The American and European guidelines endorse selective revascularization by either coronary artery bypass grafting or percutaneous coronary intervention in symptomatic ischemic patients prior to major elective surgery. However, conventional revascularization may not be suitable for certain patients requiring emergent or urgent surgery. Reported are two representative cases in which severely ischemic patients were bridged uneventfully through moderate-risk surgery by using prophylactic intra-aortic balloon pump (IABP). Prophylactic IABP should be considered for the support of ischemic patients who are severely symptomatic or hemodynamically unstable undergoing moderate-high risk surgery, who are not suitable for preoperative revascularization. This therapeutic option should be acknowledged in the relevant guidelines.
Certain high-risk cardiac patients, especially those with severely symptomatic coronary artery disease (CAD), are particularly prone to ischemic, arrhythmic and heart failure complications during urgent or emergent moderate-high risk noncardiac surgery.1,2 Most of these patients can be managed with medical therapy. However, for patients with unstable or post-infarction angina, severe chronic angina refractory to medical therapy, electrical or hemodynamic instability, who are designated to undergo moderate-high risk surgery, coronary revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) should be contemplated.
Revascularization, however, is not suitable for many of these patients in view of: a) the urgent nature of the noncardiac surgery and potential risk or harm that any revascularization-related delay may impose; b) the requirement of dual antiplatelet therapy (DAPT) post-stenting (4 and 52 weeks for bare-metal and drug-eluting stents, respectively) that is contraindicated in certain types of surgery and increases the risk of bleeding in others; c) suboptimal target lesions and coronary anatomy may yield suboptimal revascularization results; d) excessive co-morbidities, poorly defined or unfavorable prognosis and life expectancy; and e) relative contraindications for revascularization by either PCI or CABG.
We report our experience with 2 high-risk patients who received IABP prior to urgent noncardiac surgery. These cases illustrate the potential benefit of prophylactic IABP in severely ischemic high-risk cardiac patients requiring urgent or emergent moderate-high risk noncardiac surgery.
Case Report. Patient #1. An 81-year-old female was admitted due to left hip prosthesis failure. Her past medical history was remarkable for severe arthritis, hypertension, and stage IV breast cancer with metastases to the proximal left femur which was treated with bilateral mastectomy and adjuvant chemotherapy. Her left hip prosthesis was initially placed in 1997 and revised in 2007 secondary to post-radiation necrosis. On the current admission, an X-ray of her left femur revealed diffuse osseous metastases, a fractured prosthetic stem, and degenerative arthritis of the right hip and left knee. She was scheduled for urgent resection and re-implantation of her left proximal femoral prosthesis. During her preoperative evaluation, she reported intermittent spontaneous chest discomfort worsening over the previous 2 months. She denied any previous cardiac history and her risk factors were limited to age and hypertension. Her rest transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction (LVEF) of 75%, moderate aortic regurgitation and trace tricuspid regurgitation. Systolic pulmonary artery pressure was estimated to be 35 mmHg. During a dobutamine stress echocardiogram, she developed 8/10 chest pain partially relieved by sublingual nitroglycerin administration. TTE revealed severe anterior ischemia. Coronary angiography revealed triple-vessel coronary artery disease, 98% stenosis of the first obtuse marginal ostium (OM1) and distal circumflex, 90% segmental stenosis of the mid-left anterior descending (LAD) artery and ostial stenosis of the first diagonal (D1) branch (Figure 1), and 70% stenosis of both posterior descending and posterior left ventricular branches. Given the urgency of her surgery, the suboptimal target vessels for PCI, concern related to DAPT and the uncertain prognosis, it was decided to support the patient through surgery with IABP. Under fluoroscopic guidance, a 7 French (Fr) sheathless intra-aortic balloon (Datascope, Fairfield, New Jersey) was inserted. Her preoperative medical therapy included metoprolol 25 mg every 6 hours, aspirin 325 mg and atorvastatin 40 mg daily. Intravenous nitroglycerin for blood pressure control was used during the procedure. Heparin was not given.
The surgery was uneventful with no cardiovascular complications and she was transferred to the Cardiac Care Unit for post-operative management. Prior to discharge to rehabilitation, the patient underwent elective complex PCI with successful stenting of the proximal LAD artery, the OM1 branch and the first diagonal branch. The patient tolerated the procedure without any complications and remained chest pain free throughout her rehabilitation and was later discharged home in stable condition.
Patient #2. A 63-year-old female was admitted to an outside hospital with hematemesis in the setting of supratherapeutic warfarin therapy (INR = 5.2). Her past medical history was notable for polycythemia vera associated with multiple events of deep venous thrombosis and portal vein thrombosis leading to portal hypertension and esophageal varices. She had been treated with coumadin and digoxin for paroxysmal atrial fibrillation (since 1997). Endoscopy showed grade 2–3 non-bleeding esophageal varices, a clean small ulcer in the distal antrum, and gastric varices with evidence of a recent bleed. She was transferred to University Hospital for management of her portal hypertension and recent variceal bleed. Upon admission, her initial vital signs were stable. Pertinent physical findings included diffuse abdominal discomfort on deep palpation. Her electrocardiogram showed normal sinus rhythm at 55 beats/minute, with left axis deviation and left ventricular hypertrophy. The patient was evaluated for a transjugular intrahepatic portosystemic shunt (TIPS), but was deemed not suitable due to complete portal vein thrombosis and was referred to surgery for gastric devascularization. Given a history of heart failure symptoms and substernal chest pain, Cardiology was consulted for preoperative evaluation and risk stratification. TTE revealed a severely reduced LVEF (25%), with global hypokinesis, apical akinesis, grade III diastolic dysfunction, moderate mitral valve insufficiency and mild pulmonary hypertension (40 mmHg). A dipyrimadole nuclear stress test revealed a large area of severe ischemia in the anterior wall and apex, which improved at rest, and a dilated left ventricle and a moderately sized fixed inferior wall defect with decreased wall motion suggesting an old infarct. Left coronary angiography showed a long (4 cm) coronary dissection extending from the ostium of the LAD to the mid-LAD and involving the origin of a large D1 branch (Figure 2) and a smaller D2. The flow to the distal LAD was limited (TIMI flow 2) with some collateral flow from the right coronary artery. A multiple disciplinary meeting was held to discuss treatment options and perioperative management. Given the relative contraindications for DAPT and the history of multiple complications and comorbidities, the consensus was to employ IABP (7 Fr sheathless) for hemodynamic support during her surgery. Her medical therapy included carvedilol 12.5 mg twice daily, digoxin 0.125 mg daily, enalapril 10 twice daily and atorvastatin 10 mg daily. Aspirin was avoided. Heparin (target PTT, 55–80) was started after IABP insertion and discontinued 4 hours prior to surgery. On the following day, IABP was initiated and the patient had her surgery. She tolerated the surgical procedure well and reported no chest pain after surgery. Her post-operative electrocardiogram was unchanged and labs showed no elevation of cardiac enzymes. A post-operative echocardiogram was performed and showed no significant changes. She was discharged home a few days later on appropriate medical therapy.
Discussion. Unstable angina, severely symptomatic chronic stable angina, critical stenotic valvular heart disease, electrical instability and decompensated heart failure are contraindications for elective surgery and pose a considerable risk for urgent or emergent surgery. The guidelines3,4 suggest that in the presence of these clinical conditions, elective surgery should be cancelled until corrective measures (optimizing medical therapy, PCI, CABG, valve replacement) have been taken to reduce the cardiovascular risk. In the face of time constraints of urgent or emergent surgery, execution of these corrective measures is not always possible and temporary bridging procedures to minimize cardiovascular complications should be considered.
The potential benefits of prophylactic IABP insertion stem from improved cardiac performance, which is related to increased coronary perfusion and afterload reduction, consequently increasing supply and reducing oxygen demand, respectively.5,6 Preoperative IABP for high-risk patients undergoing cardiac surgery has been a widely accepted and studied practice7 (albeit not in prospective randomized trials), with favorable outcome trends.8,9 The use of IABP for hemodynamic support of unstable cardiac patients undergoing noncardiac surgery is supported by only a handful of case reports demonstrating favorable outcomes (Table 1). One review suggested that patients at very high risk for perioperative complications may benefit most from prophylactic IABP prior to noncardiac surgery.10
Potential complications. Vascular complications, thrombo-embolism, bleeding and infection are all potential complications from IABP. The reported major complication rates during IABP vary greatly between 4–18%.11,12 However, these complication rates do not reflect the contemporary practice of 7 Fr sheathless insertion. The most important risk factors associated with ischemic complications include catheter diameter,13 duration of therapy,14 peripheral arterial disease, diabetes15 and female sex.16 Other issues related to complications include adequate anticoagulation and adequate physician and nursing expertise. It is therefore important to carefully weigh the risks and benefits of this procedure when deciding which patients are suitable candidates. Unfortunately, patients undergoing the highest risk surgery (major vascular surgery) cannot benefit from this therapy.
Adjunctive or alternative strategies. Revascularization and optimizing medical therapy may play a certain role in certain patient subsets as adjunctive or alternative strategies. These strategies, however, may require considerable time delay and patient selection in order to be effective, and are probably less applicable and effective in improving outcomes in emergent or urgent noncardiac surgery.
Medical therapy. An initial small, single-center study showed dramatic mortality reduction with the preoperative administration of the beta-blocker bisoprolol.17 Two other studies showed that perioperative beta-blockade significantly reduces the risk of ischemic events.18,19 However, three large-scale, multicenter randomized trials failed to demonstrate a favorable effect of beta-blockers on perioperative or post-operative mortality (POISE,20 MaVS,21 DIPOM22). The potential role of statins in perioperative risk reduction has been demonstrated by the DECREASE23,24 Investigators, but probably warrants large-scale randomized confirmation studies.
Revascularization. Although both CARP25 and DECREASE-V26 (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography) failed to demonstrate superiority of revascularization strategy over medical therapy in ischemic patients undergoing major vascular surgery, they did not reveal inferiority or harm. These studies are of limited utility due to methodology issues in both and lack of statistical power in the latter. The methodological issues with CARP range from the fact that only 42.8% of the patients who underwent angiography were enrolled in the study (among the excluded were patients with left main coronary stenosis). The methods of lesion assessment, treatment and adjunctive therapy reflect the state of practice in the United States from March, 1999 to February, 2003, but do not reflect modern PCI. There were incomplete cardiac isoenzyme drawings (88%), incomplete long-term follow-up (85% at 1 year), and the study reported a total mortality at 30 months instead of perioperative cardiovascular morbidity and mortality. The data emerging from FAME27 and DEFER28 seem to indicate that targeted revascularization of hemodynamically significant coronary lesions supplying territory with documented ischemia are likely to enhance both appropriateness and efficacy of these interventions, and may improve patient outcome. It is possible, although not proven, that with better lesion assessment, newer and better PCI devices, stents, and adjunctive pharmacotherapy, prophylactic albeit selective revascularization may have a second and stronger wind.29,30
Revascularization may impose considerable delay in planned surgery (especially in the case of CABG or when DAPT is contraindicated or likely to increase the complications of surgery). Moreover, coronary artery stenting, with the associated commitment for DAPT, carries its own morbidity31,32 from bleeding complications.
The efficacy and safety of presurgical revascularization remain unproven and controversial.33 Consequently, it should be applied selectively, bearing in mind the urgency and nature of the noncardiac surgery being planned along with the potential short- and long-term benefits, risks and limitations imposed by the various revascularization methods. Since the extent and nature of the revascularization decision reflect multifactorial considerations, it should probably be carefully individualized and not applied as an all-inclusive strategy.
Conclusion. The cases presented demonstrate the potential benefit of prophylactic IABP in high-risk cardiac patients with severely symptomatic CAD who are undergoing urgent noncardiac surgery, and are not suitable for conventional revascularization. This forgotten remedy, which can be executed with small diameter (7 Fr sheathless) IABP catheters, should be acknowledged in the preoperative guidelines and be subject to further investigation.
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From the *New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey and the §Division of Cardiology, Department of Medicine, University Hospital and New Jersey Medical School (UMDNJ), Newark, New Jersey. The authors report no conflicts of interest regarding the content herein. Manuscript submitted May 4, 2010, provisional acceptance given May 26, 2010, final version accepted June 10, 2010. Address for correspondence: Edo Kaluski, MD, FACC, FESC, FSCAI, Director of Invasive Cardiology and Cardiac Catheterization Laboratories, University Hospital, University of Medicine and Dentistry of New Jersey, 185 South Orange Ave., MSB I-538, Newark, NJ 07101. E-mail: firstname.lastname@example.org