41. Use of Perioperative Mechanical Circulatory Support in Patients with Ischemic Cardiomyopathy Undergoing Surgical Revascularization
Presented During: Complex Issues in Coronary Surgery*
University of Virginia
Charlottesville, VA
United States - Contact Me
Leora Yarboro is an associate professor of surgery at the University of Virginia. She is the surgical director of heart transplantation and mechanical circulatory support. She is certified by both the American Board of Thoracic Surgery and the American Board of Surgery.
Columbia University
New York City, NY
United States - Contact Me
Alice Vinogradsky is a 4th year medical student at Columbia University's Vagelos College of Physicians and Surgeons and an incoming cardiothoracic surgery PGY-1 at Columbia. She conducts clinical outcomes research in heart failure under the mentorship of Dr. Koji Takeda and in pediatric and congenital cardiac surgery with Dr. Andrew B. Goldstone.
Saturday, May 6, 2023: 11:00 AM - 11:15 AM
15 Minutes
Los Angeles Convention Center
Room: 515A
Abstract
Objective: We aimed to explore optimal patient selection and perioperative mechanical circulatory support (MCS) in patients with reduced ejection fraction (EF) who undergo surgical revascularization.
Methods: Patients with reduced EF (<35%) undergoing isolated coronary artery bypass grafting (CABG) from 2015-2021 were identified. Requirement of preoperative MCS (pre-MCS) and postoperative MCS (post-MCS) were noted, defined as use of intra-aortic balloon pump (IABP), ECMO, or Impella. Primary outcomes of interest were in-hospital mortality and long-term survival. Logistic regression was used to identify risk factors for MCS requirement.
Results: A total of 378 patients were included. Median STS predicted risk of mortality was 2.4% (IQR 1.3-4.4%). Sixty-five percent (n=246) of patients had previous myocardial infarction, of which 75% were within 21 days of CABG. Twenty-one patients (5.5%) presented in cardiogenic shock, of which 15 were in shock at the time of CABG. Thirty-nine patients (10.3%) required pre-MCS; compared to patients that did not require pre-MCS, those that did had lower pulmonary artery saturation (57.8% vs 63%, p=0.01) and cardiac index (2.0 vs 2.5, p=0.01) on preop catheterization and lower LV end diastolic diameter (50mm vs 55mm, p=0.01) on echo. Of patients that required pre-MCS, 8 (20.5%) required post-MCS (2 IABP, 4 ECMO, 1 Impella, 1 Centrimag). Of patients that did not require pre-MCS, 22 (6.4%) required post-MCS (14 IABP, 5 ECMO, 3 Impella). Independent risk factors for requiring post-MCS were low preop EF (OR 0.91, 95%CI 0.85-0.99, p=0.02), presence of mild MR compared to no MR preop (OR 3.37, 95%CI 1.17-9.73, p=0.03), and cross-clamp time (OR 1.02, 95%CI 1.01-1.04, p=0.02). Overall, in-hospital mortality was 2.9% and 3-year survival was 95.2%. Compared to those who did not require perioperative MCS, those that required pre-MCS had similar in-hospital mortality (3.2% vs 1.6%, p=.50) and 3-year survival (96.8% vs 96.8%, p=.98). However, patients who required post-MCS had significantly worse in-hospital mortality and 3-year survival (16.7% and 76.7% respectively, p <0.001).
Conclusion: In a large series of patients with reduced EF who underwent surgical revascularization, we report favorable outcomes with selective use of MCS. Despite worse severity of illness, patients requiring pre-MCS have similar outcomes to those that do not require perioperative MCS, while patients requiring post-MCS have worse short- and long-term survival.
Methods: Patients with reduced EF (<35%) undergoing isolated coronary artery bypass grafting (CABG) from 2015-2021 were identified. Requirement of preoperative MCS (pre-MCS) and postoperative MCS (post-MCS) were noted, defined as use of intra-aortic balloon pump (IABP), ECMO, or Impella. Primary outcomes of interest were in-hospital mortality and long-term survival. Logistic regression was used to identify risk factors for MCS requirement.
Results: A total of 378 patients were included. Median STS predicted risk of mortality was 2.4% (IQR 1.3-4.4%). Sixty-five percent (n=246) of patients had previous myocardial infarction, of which 75% were within 21 days of CABG. Twenty-one patients (5.5%) presented in cardiogenic shock, of which 15 were in shock at the time of CABG. Thirty-nine patients (10.3%) required pre-MCS; compared to patients that did not require pre-MCS, those that did had lower pulmonary artery saturation (57.8% vs 63%, p=0.01) and cardiac index (2.0 vs 2.5, p=0.01) on preop catheterization and lower LV end diastolic diameter (50mm vs 55mm, p=0.01) on echo. Of patients that required pre-MCS, 8 (20.5%) required post-MCS (2 IABP, 4 ECMO, 1 Impella, 1 Centrimag). Of patients that did not require pre-MCS, 22 (6.4%) required post-MCS (14 IABP, 5 ECMO, 3 Impella). Independent risk factors for requiring post-MCS were low preop EF (OR 0.91, 95%CI 0.85-0.99, p=0.02), presence of mild MR compared to no MR preop (OR 3.37, 95%CI 1.17-9.73, p=0.03), and cross-clamp time (OR 1.02, 95%CI 1.01-1.04, p=0.02). Overall, in-hospital mortality was 2.9% and 3-year survival was 95.2%. Compared to those who did not require perioperative MCS, those that required pre-MCS had similar in-hospital mortality (3.2% vs 1.6%, p=.50) and 3-year survival (96.8% vs 96.8%, p=.98). However, patients who required post-MCS had significantly worse in-hospital mortality and 3-year survival (16.7% and 76.7% respectively, p <0.001).
Conclusion: In a large series of patients with reduced EF who underwent surgical revascularization, we report favorable outcomes with selective use of MCS. Despite worse severity of illness, patients requiring pre-MCS have similar outcomes to those that do not require perioperative MCS, while patients requiring post-MCS have worse short- and long-term survival.
Presentation Duration
7 minute presentation; 7 minute discussion