International Society For Minimally Invasive Cardiothoracic Surgery

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Pre-operative Iabp In Refractory Ischaemia Is An Important Bridge To Offpump Cabg
Virendar Sarwal.
Ojas Superspeciality Hospital, Panchkula, India, Panchkula, India.

Background: Coronary artery disease with Triple Vessel Disease having ongoing chest pain with significant ST changes in ECG, having arrhythmias, haemodynamic instability , high Troponin I levels refractory to medical treatment, acute onset of LV dysfunction pose a significant challenge to OPCAB in emergency situations and often need to be converted to On pump surgery.Methods and Results: We did a randomized controlled study targeting 100 such patients where electively IABP was instituted in such patients preoperatively to stabilize them for a sufficient period of 24 to 72 hours and then take them for OPCAB. Parameters observed were ECG, requirement of inotropes, Clinical symptoms, serial Troponin I levels, Cardiac output and PA pressures intra-operatively. all patients were given Thermodilution or Continuous Cardiac output Catheter for intraoperative monitoring, Heart lung machine was always standby.Results: This is the early report of 48 such patients. The protocol was to coo; off these patients with high Trop I levels to below 5 ng/ml if hemodynamics remain stable and no fresh arrhythmias or ST changes were there. When taken for surgery Swan Ganz was introduced in all patients, Dry pump assembly and standby done in high PA pressure and low Cardiac output situations. Standard Mid sternotomy and Grafts harvested with atleast one IMA if patient remained stable. One deep pericardial stay only to avoid lifting of the heart too much. LIMA was anastomosed to LAD with Octopuss and intra-arterial shunt in all situations to avoid further ischemia or arrhythmias. PA pressures were monitored during positioning of heart and anastomosis closely. If there was rise in PA pressure beyond 45mmHg with fall in systemic pressure to less than 100mmhg the heart was lowered and rested. Cardiac output was monitored in an effort to maintain an index of 2.0 litres/sq meter of BSA. If need be Milrinone was added as an inodilator. In 45 patients PA pressure was in normal range at induction . In 3 patients it was still on higher side so Dobutrex infusion was incresed to 10ug/kg/mt which is used in all patients and in one patient Milirinone was added. CO was monitored closely. after grafting of each vessel a rest of 3 to 5 minutes was given to the heart to ward off the effect of reperfusion oedema. No patient had to converted to on pump CABG. Tee was done in all patients and was helpful to monitor the LV function after each grafting. Ejection fraction improved by atleast 20 to 40% in all patients. 30 patients need to be put on Nor Epi infusion, 38 patients required mild inotropic support and 7 patients required high inotropic support. There were no Ventricular fibrillations, 8 patients required Xylocard infusion along with cordarone which was started electively in all patients. Al patients tolerated the positioning of heart nicely. Average number of grafts was 3.8/patient. in 44 patients IABP was removed after 72hrs of surgery and 4 patients required it for 7 days. Conclusion: Pre operative IABP in acute situations in CAD is a good options to stabilize such patients and then take them to OPCAB. It reduces the pertinent risk to life in preoperative period and gives comfort to perform OPCAB smoothly intraoperatively. It helps avoiding crashes to pump during CABG. Thermodilution and TEE are important adjunct to IABP therapy.

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