Intra-Aortic Balloon Pump Implantation Does Not Affect Long-Term Survival after Isolated CABG in Patients with Acute Myocardial Infarction (Thorac Cardiov Surg 2011;59:406–410)

First of all, I would like to congratulate the authors for this interesting study in a large cohort of patients. There is still an ongoing discussion about it as when to place an IABP in patients after acute myocardial infarction, who need surgical revascularization. Joskowiak et al report ~472 such patients, who underwent emergency CABG in their institution.[1] Among them, 158 received an IABP, 57 preoperatively and 101 intraoperatively. The latter two groups have been compared in the study and this leaves some questions. The time interval between insertion of the IABP and surgery in the first group was 47 hours, whereas the mean time between infarction and CABG in the whole group was 9.5 hours, which means that patients in group 1 were stabilized for 2 days before surgery, whereas the other patients were treated immediately. Many former studies have shown that the risk of surgery differs significantly depending on these time intervals within the first 48 hours. If we further look at the data in detail, we will see that the patients in the first group have been significantly sicker concerning impaired ventricular function, cardiogenic shock etc., which was surely the reason for the immediate IABP insertion. However, their cardiac mortality was only half and this is also true for other parameters like perioperative MI and death over time. Although none of these parameters reached statistical significance, they show a clear trend and the question remains open, whether the patients from the second group might also have experienced a major benefit under early IABP support but without the other comorbidities like renal insufficiency or cardiogenic shock and its sequelae as major contributors to the higher noncardiac mortality in group 1. Finally, I am missing a word to the majority of patients, who neither received IABP support preoperatively nor intraoperatively. How was their course? The curtain falls with many questions open and the conclusion is not supported by the results. At least, title and conclusions should begin with “The time interval of...” and even then some doubts remain.

• Reference

• 1 Joskowiak D, Szlapka M, Kappert U, Matschke K, Tugtekin SM. Intra-aortic balloon pump implantation does not affect long-term survival after isolated CABG in patients with acute myocardial infarction. Thorac Cardiovasc Surg 2011; 59 (7) 406-410