Intra- aortic balloon pump support in high-risk CABG: Successful perioperative management in a patient with triple vessel disease and left ventricular dysfunction

Bharathi. P*, Jona Parc. R, Monisha. M

Department of Nursing, CTICU, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu

*Correspondence

Abstract

Coronary Artery Bypass Grafting (CABG) remains the gold standard surgical intervention for patients with complex multi vessel coronary artery disease. However, patients with poor left ventricular function and extensive coronary involvement present significant perioperative challenges. This case report describes a 66-year-old male with triple vessel disease, distal left main involvement, and moderately severe left ventricular dysfunction (EF 30-40%) who underwent off-pump CABG but required intraoperative conversion to on-pump support due to hemodynamic instability. The patient was successfully managed with Intra-Aortic Balloon Pump (IABP) support during the intraoperative and early postoperative period. This case highlights the critical role of IABP in providing mechanical circulatory support for high-risk patients undergoing revascularization procedures.

Key words: Coronary Artery Bypass Grafting (CABG); Intra-Aortic Balloon Pump (IABP)

Introduction

Coronary artery disease continues to be a leading cause of morbidity and mortality worldwide. For patients with complex multi vessel disease, particularly those with left main involvement and impaired left ventricular function, CABG offers superior outcomes compared to percutaneous coronary intervention. The presence of left ventricular dysfunction significantly increases surgical risk and demands careful perioperative planning. The Intra-Aortic Balloon Pump (IABP) has been a mainstay of mechanical circulatory support for over five decades. By inflating during diastole and deflating during systole, the IABP augments coronary perfusion while reducing left ventricular afterload, thereby improving myocardial oxygen supply-demand balance. Its role in high-risk cardiac surgery patients, both prophylactically and therapeutically, is well-established.

This case report presents the successful utilization of IABP support in a high-risk patient undergoing CABG, demonstrating its value in managing intraoperative hemodynamic instability and facilitating postoperative recovery.

Case presentation

A 66-year-old male patient was admitted to Kauvery Hospital, Vadapalani on 01/06/2026 for elective CABG. He was a known case of coronary artery disease with triple vessel disease and distal left main involvement.

The patient presented the history of exertional dyspnea for 2-3 months, which was associated with profuse sweating. His past medical history included:

Dyslipidemia
Systemic Hypertension
Type 2 Diabetes Mellitus

Preoperative Assessment

The patient underwent comprehensive preoperative evaluation:

Electrocardiogram: Showed features of Acute Coronary Syndrome with Anterior Wall Myocardial Infarction (STEMI pattern)
Treadmill Test: Positive for inducible ischemia
Echocardiography: Revealed moderate left ventricular dysfunction with an ejection fraction of 30-40%
Coronary Angiography (06/05/2026): Confirmed triple vessel disease with distal left main involvement.

Laboratory Investigations

HbA1c: 5.7% (well-controlled diabetes)
Routine blood investigations, Doppler studies, USG abdomen, and chest X-ray were performed

Preoperative Medications

Ecospirin 75 mg
Brilinta 90 mg
Telma 40 mg
Oxra 10 mg
Rosuvas 20 mg
- Silodal D

Final Diagnosis

Triple Vessel Coronary Artery Disease
Left Main Disease
Moderately Severe Left Ventricular Dysfunction (EF 30-40%)
Type II Diabetes Mellitus (HbA1c 5.7%)
Systemic Hypertension
Dyslipidemia
Class II – III Angina

Intraoperative management

The patient was taken up for Off-Pump CABG (OPCAB) with a planned 3-graft procedure under general anesthesia.

Anesthesia and Monitoring

The patient was sedated and intubated with an 8.0 size endotracheal tube. The following lines were established:

16 Fr Ryles tube
Right Internal Jugular Vein central line
Left radial arterial line
14 Fr Foley’s catheter
Right Swan-Ganz catheter 7.5 Fr
PA sheath 8.5 Fr

Surgical Procedure

Surgical antibiotic prophylaxis was administered with Inj. Cefuroxime 1.5 gm IV, and incision was made at 12:45 hours. Median sternotomy was performed. Left Internal Mammary Artery (LIMA) and Saphenous Vein Graft (SVG) were harvested from the right leg. Systemic heparinization was achieved, and the heart was stabilized with a myocardial stabilizer. Distal anastomosis of the LAD vein graft was performed onto the aorta. The heart was then positioned for PDA grafting, and distal anastomosis was completed with SVG to PDA.

Hemodynamic Instability and IABP Insertion

During positioning for PDA grafting, the heart could not tolerate the position, resulting in hemodynamic instability. The surgical team promptly inserted an IABP through the right femoral approach. Despite IABP support, the patient continued to have borderline hemodynamics, leading to the decision to initiate Cardiopulmonary Bypass (CPB).

CPB was established through Aorta – DSSVC cannulation. The heart was positioned for OM grafting, and distal anastomosis was completed with SVG to OM (sequential). The proximal anastomosis of the OM graft was performed onto the proximal end of SVG-LAD. Due to poor myocardial contraction, the patient was supported on CPB for 40 minutes. Total CPB time was 87 minutes.

Weaning and Transfer

The patient was rewarmed fully and gradually weaned off CPB with inotropic and IABP support. Protamine was administered, hemostasis was secured, and chest closure was performed with mediastinal and left pleural drain tubes. RA and RV pacing wires were placed in situ.

At the time of transfer to CTICU, the patient required:

Dopamine 7.5 mcg/kg/min
Adrenaline 0.1 mcg/kg/min
Noradrenaline 0.1 mcg/kg/min
Vasopressin 3 units/hr
IABP settings: Auto mode, ECG trigger, 1:1 frequency, Augmentation 100%

Postoperative course

Parameter	POD 0	POD 1	POD 2	POD 3	POD 4	POD 5
Ventilator Status	Mechanical ventilator (PRVC Mode, PEEP 5, Fio2 50%, RR 14)	Mechanical support continued	Extubated; face mask O2 @6L started	Nasal Prongs@ 2L	Room air/ Face mask	Off oxygen support
IABP Status	Active	Active	Active	Active	Removed at 11.05 hrs	Removed
Inotropes	High dose	Continued	Continued	Gradually tapering	Minimal Support	Tapered & stopped
Sedation	Sedated & Paralysed	Continued sedation	Weaning started	Off sedation	Awake & alert	Fully conscious
Lines in Situ	ET Tube, Nasogastric tube, CVP line, Arterial line, Continuous Bladder Drainage, Swan- Ganz, PA Sheath	All lines continued	All lines continued	All lines continued	Swan- Ganz and arterial line removed	Central line & PA Sheath removed
Medications	Heparin Infusion started	Heparin 150U/hr, Lasix 1mg/hr, Human Actrapid	Heparin 150u/hr, Amiodarone 36mg/hr. started	Amiodarone infusion stopped; Tab. Amiodarone 200mg BD started	Heparin stopped; Lasix stopped; Tab. Dytor 20mg BD started	All IV-medication tapered
Fluid Management	Intravenous Fluid Continued	Fluid restriction 2.5L/day, RTF Fresubin HP started	Negative balance 500ml; Restriction 1.8-2L/day	Restriction 2L/day	Restriction 1.4L/day	Restriction 1.4L/day
Investigations	Hb, Magnesium, Chest X-ray	Hb, Urea, creatinine Electrolytes, Mg, APTT, Chest X-ray	Hb, Urea, creatinine Electrolytes, APTT, Chest X-ray	Routine Monitoring	CBC, Urea, Creatinine, Electrolytes	Routine monitoring
Critical Lab Values	-	-	Platelet: 32,000	-	Platelet: 26,000; Hb: 7.4	Stable
Transfusion	-	-	-	-	1-unit PRPC + 2 Units of RDP	-
Mobilization	Bedridden	Bedridden	Bedridden	Spirometry, Active & assisted exercise	Spirometry exercise. Mobilized evening.	Mobilization & walking done.
Diet	NBM	NBM	NBM / sips of liquids	Semisolid Diet	Semisolid/ Soft	Adequate oral diet
Physical Exam	Chest: Bilateral air entry; Abdomen: soft; Skin: intact; Site: No oozing	Stable	Stable	Stable	Minimal Crepitations heard	Minimal Crepitations resolved
Nebulization	-	-	-	-	Saline + Neb. Mucyst 400mg	Adequate nebulization given.
Family Education	-	Daily counselling given	Counselling continued	Counselling continued	Counselling continued	Discharge Counselling
Urine Output	Foley’s Catheter in situ	Foley’s Catheter in situ	Foley’s Catheter in situ	Foley’s Catheter in situ	Foley’s Catheter in situ	Foley’s removed; voiding normal
Hemodynamics	Stable with support	Stable with support	Stable with support	Stable	Stable	Stable without inotropes
Pulse Monitoring	Lower limb pulse hourly	Lower limb pulse hourly	Lower limb pulse hourly	Lower limb pulse hourly	Monitored post-IABP removed	Normal
Patient Shift	Shifted from CTOT to CTICU	In CTICU	In CTICU	In CTICU	In CTICU	Shifted to Ward

Discussion

This case demonstrates the successful management of a high-risk patient undergoing CABG with significant preoperative left ventricular dysfunction and extensive coronary artery disease. Several important aspects of perioperative care deserve discussion.

High-Risk Patient Characteristics

The patient presented with multiple risk factors that increased the complexity of surgical management:

Triple vessel disease with distal left main involvement – This pattern of coronary disease is associated with higher mortality and requires complete revascularization.
Moderately severe left ventricular dysfunction (EF 30-40%) – Impaired ejection fraction is a well-established predictor of poor outcomes following cardiac surgery.
Comorbid conditions – Diabetes mellitus, hypertension, and dyslipidemia further increased the perioperative risk.

The combination of these factors placed this patient in a high-risk category, necessitating careful preoperative planning and intraoperative preparedness for mechanical circulatory support.

Intraoperative Challenges

The decision to perform off-pump CABG was initially appropriate given the patient’s comorbidities. Off-pump surgery offers theoretical advantages including reduced systemic inflammatory response, decreased risk of neurological complications, and avoidance of aortic cannulation-related complications. However, positioning the heart for grafting of posterior vessels can cause hemodynamic compromise, particularly in patients with pre-existing ventricular dysfunction.

In this case, the heart could not tolerate positioning for PDA grafting, leading to hemodynamic instability despite IABP insertion. This necessitated conversion to on-pump surgery, a decision that likely prevented further deterioration and potential catastrophic outcomes. The ability to recognize and respond to this complication is a testament to the surgical team’s expertise and preparedness.

Role of IABP

The IABP played a crucial role at multiple stages of this patient’s care:

Intraoperative Support: Following the development of hemodynamic instability, IABP was inserted to provide mechanical support. Although it was insufficient to allow continuation of off-pump surgery, its presence likely facilitated the transition to CPB and provided support during the subsequent procedure.
Postoperative Support: The patient continued to require IABP support for four days postoperatively. This allowed gradual recovery of myocardial function while reducing the workload on the heart. The ability to wean inotropes and IABP over time suggests successful myocardial recovery.
Facilitating Recovery: The IABP likely contributed to improved coronary perfusion and reduced afterload, allowing the heart to recover from the ischemic insult of surgery and the hemodynamic instability encountered during the procedure.

Postoperative Management

The structured postoperative management followed a stepwise approach:

Maintaining hemodynamic stability with inotropes and IABP support
Gradual weaning of mechanical ventilation (extubation on POD 2)
Aggressive management of fluid balance (maintaining negative balance)
Monitoring complications (platelet drop managed with transfusion)
Early mobilization and rehabilitation
Tapering of inotropic support with successful removal of IABP and lines

The drop in platelet count observed postoperatively is a known complication of IABP use and was managed appropriately with platelet transfusion. The management of coagulation parameters with heparin infusion and monitoring of APTT reflects careful attention to thrombotic and bleeding risks.

Importance of Multidisciplinary Care

This case highlights the importance of a collaborative approach involving cardiac surgeons, anesthesiologists, intensivists, perfusionists, nursing staff, and other healthcare professionals. Each member of the team contributed to the successful outcome:

Surgeons made critical decisions regarding the timing of CPB initiation, graft selection, and surgical technique.
Anesthesiologists managed hemodynamics, inotropes, and ventilator settings.
Intensivists coordinated postoperative care, medication management, and weaning protocols.
Nurses provided meticulous monitoring, medication administration, and patient mobilization.
Perfusionists managed the CPB machine and IABP.

Conclusion

This case report demonstrates the successful management of a high-risk patient with multivessel coronary artery disease and impaired left ventricular function undergoing CABG. The patient experienced intraoperative hemodynamic instability requiring conversion from off-pump to on-pump surgery, with IABP support playing a critical role in the perioperative period. The patient’s postoperative course was characterized by gradual recovery with IABP and inotropic support, weaning of mechanical ventilation, management of complications, and successful mobilization. By postoperative day 5, the patient was hemodynamically stable without inotropes, had IABP removed, and was transferred to the ward. This case reinforces the importance of IABP as a life-saving device in high-risk cardiac surgery patients. It also highlights the value of a multidisciplinary approach, careful peri-operative planning, and the ability to adapt to intraoperative challenges. With appropriate support and management, even high-risk patients can achieve favorable outcomes following coronary artery bypass grafting.

Intra- aortic balloon pump support in high-risk CABG: Successful perioperative management in a patient with triple vessel disease and left ventricular dysfunction

Intra- aortic balloon pump support in high-risk CABG: Successful perioperative management in a patient with triple vessel disease and left ventricular dysfunction

Bharathi. P*, Jona Parc. R, Monisha. M

Nightingale Journals