DIGOXIN AS A RESCUE DRUG IN INTRA AORTIC BALLOON PUMP AND INOTROPE DEPENDENT PATIENTS

Shahab Naqvi, Iftikhar Ahmed, Rashad Siddiqi, Syed Aqeel Hussain

Abstract


Background: In absence of cardiac transplant program in our country, when patients with poor
left ventricular (LV) functions undergo coronary revascularisation surgery, they are on one or
more inotropic supports with intra aortic balloon pump (IABP) at the time of weaning off from
cardiopulmonary bypass (CPB). Post-operatively, due to the poor LV function, many of these
patients become dependent on inotropic supports and IABP and eventually have a poor outcome.
We used digoxin in these patients as a rescue drug, where more than one attempts to wean them
off IABP and inotropic support had failed. Objective of the study was to evaluate the efficacy of
digoxin as a rescue drug in intra-aortic balloon pump (IABP) and inotropic support-dependent,
post-CABG patients in terms of improvement in their left ventricular ejection fraction (LVEF),
serum lactate and mixed venous oxygen saturation. Methods: It is a descriptive case series
conducted at Department of Cardiac Anesthesia & Intensive Care, Armed Forces Institute of
Cardiology and National Institute of Heart Diseases, Rawalpindi, Pakistan, from 1 Nov 2002 to 31
Dec 2007. Thirty post-coronary re-vascularisation patients who were inotrope and IABP
dependant and could not be weaned off from supports were given a trial of digoxin to see any
improvement in the cardiac functions. Mixed venous oxygen saturation (SvO2), serum lactate
levels and left ventricular ejection fraction (LVEF) in the bed side echo were monitored at predigoxin stage and then at three intervals: at serum digoxin level of up to 0.5 ηg/ml; then up to 1.0
ηg/ml and then up to 1.5 ηg/ml. Paired sample t-test was applied and 2-tailed significance was
calculated. Results: Significant improvement was seen in the mean SvO2, serum lactate levels and
LVEF when patient’s serum digoxin level were around 1.5 ηg/dL. Clinically, 20 out of 30 patients
(66.67%) improved with digoxin administration and were ultimately weaned off from IABP and
inotropic supports. There was no significant correlation between patient’s improvement and
presence of diabetes mellitus or hypertension. However, pre-operative IABP placement had a
significant correlation as 6 out of 8 patients (75%) were successfully weaned off at digoxin levels
around 1.5 ηg/mL. Conclusion: Improvement in significant number of patients suggests that
digoxin can be used as a rescue drug in IABP and inotropic support dependent patients after
CABG surgery especially in countries where heart transplant program does not exist. However,
more clinical trials with larger sample size are recommended for further evaluation.
Keywords: Digoxin, CABG, IABP-dependent, Inotrope-dependent

Full Text:

PDF

References


John R, Rajasinghe HA, Chen JM, Weinberg AD, Sinha P,

Mancini DM, et al. Long-term outcomes after cardiac

transplantation: an experience based on different eras of

immunosuppressive therapy. Ann Thorac Surg 2001;72:440–9.

Zubiate P, Kay JH, Mendez AM. Myocardial

revascularization for the patient with drastic impairment of

function of the left ventricle. J Thorac Cardiovasc Surg

;73:84–6.

Passamani E, Davis KB, Gillespie MJ, Killip T. A

randomized trial of coronary artery bypass surgery. Survival

of patients with a low ejection fraction. N Engl J Med

;312:1665–71.

Christakis GT, Weisel RD, Fremes SE, Ivanov J, David TE,

Goldman BS, et al. Coronary artery bypass grafting in

patients with poor ventricular function. Cardiovascular

Surgeons of the University of Toronto. J Thorac Cardiovasc

Surg 1992;103:1083–91.

Breisblatt WM, Stein KL, Wolfe CJ, Follansbee

WP, Capozzi J, Armitage JM, et al. Acute myocardial

dysfunction and recovery: a common occurrence after

coronary bypass surgery. J Am Coll Cardiol 1990;15:1261–9.

Mangano DT. Alteration of ventricular function during

coronary artery surgery. Acta Chir Scand Suppl

;550:57–62.

Cox DR. Regression models and life tables. J R Stat Soc

;34:187–220.

Lemeshow S, Hosmer DW. A review of goodness of fit

statistics for use in the development of logistic regression

models. Am J Epidemiol 1982;115:92–106.

Carr JA, Haithcock BE, Paone G, Bernabei AF, Silverman

NA. Long-term outcome after coronary artery bypass

grafting in patients with severe left ventricular dysfunction.

Ann Thorac Surg 2002;74:1531–6.

Ascione R, Narayan P, Rogers CA, Lim KH, Capoun R,

Angelini GD. Early and midterm clinical outcome in patients

with severe left ventricular dysfunction undergoing coronary

artery surgery. Ann Thorac Surg 2003;76:793–9.

Topkara VK, Cheema FH, Kesavaramanujam S, Mercando

ML, Cheema AF, et al. Coronary Artery Bypass Grafting in

Patients With Low Ejection Fraction. Circulation 2005;112:I-

–I-350.

Islamoğlu F, Apaydin AZ, Ozbaran M, Yüksel M, Telli A,

Durmaz I. Predictors of outcome after coronary bypass

surgery in patients with left ventricular dysfunction. Anadolu

Kardiyol Derg 2002;2(1):26–34.

Bolooki H. Clinical application of Intra-Aortic Ballon Pump.

Mount Kisco, New York: Futura Publishing; 1984.

Sarnoff SJ, Braunwald E, Welch GH Jr, Case RB, Stainsby

WN, Macruz R. Hemodynamic determinants of oxygen

consumption of the heart with special reference to the tension

time index. Am J Physiol 1958;192:148–56.

Akyurekli Y, Taichmann JC, Keon WJ. Effectivness of intra

aortic balloon counteroulsation and systolic unloading. Can J

Surg 1980;23:122–6.

Packer M. How should physicians view heart failure? The

philosophical and physiological evolution of three conceptual

models of the disease. Am J Cardiol 1993;71:3C–11C.

Bristow MR. The adrenergic nervous system in heart failure.

[Editorial] N Engl J Med 1984;311:850–1.

Tan LB, Jalil JE, Pick R, Janicki JS, Weber KT. Cardiac

myocyte necrosis induced by angiotensin II. Circ Res

;69:1185–95.

Samad K, Khan FA. The role of prophylactic Intra-Aortic

Balloon Pump Counterpulsation (IABP) in emergency noncardiac surgery. J Pak Med Assoc 2006;56:42–3.

J Ayub Med Coll Abbottabad 2010;22(2)

http://www.ayubmed.edu.pk/JAMC/PAST/22-2/Shahab.pdf

Hochman JS, Sleeper LA, Webb JG, Sanborn TA, White

HD, Talley JD, et al. Early revascularization in acute

myocardial infarction complicated by cardiogenic shock.

SHOCK Investigators. Should We Emergently Revascularize

Occluded Coronaries for Cardiogenic Shock. N Engl J Med

;341:625–34.

Dietl CA, Berkeimer MD, Woods EL, Gilbert CL, Pharr

WF, Benoit CH. Efficacy and cost-effectiveness of

preoperative IABP in patients with ejection fraction of 0.25

or less. Ann Thorac Surg 1996;62:401–8.

Qureshi MRK, Waqas M, Saqlain MU, Shahbaz A, Khan J,

Sami W. Use of IABP during Intra or Postoperative Period of

Coronary Artery. J Fatima Jinnah Med Coll Lahore

;1(1–2):32–6.

Christenson JT, Simonet F, Badel P, Schmuziger M. Optimal

timing of preoperative intra-aortic balloon pump support in

high-risk coronary patients. Ann Thorac Surg 1999;68:934–9.

Christenson JT, Badel P, Simonet F, Schmuziger M.

Preoperative intraaortic balloon pump enhances cardiac

performance and improves the outcome of redo CABG. Ann

Thorac Surg 1997;64:1237–44.

Gutfinger DE, Ott RA, Miller M, Selvan A, Codini MA,

Alimadadian H, Tanner TM. Aggressive preoperative use of

intraaortic balloon pump in elderly patients undergoing

coronary artery bypass grafting. Ann Thorac Surg

;67:610–3.

Kapadia FN, Vadi S, Bajan K, Shukla U. A two years

outcome analysis of patients on intra-aortic balloon pump in

a tertiary care center. Indian J Crit Care Med [serial online]

[cited 2008 Jan 1];8:157-61. Available

from: http://www.ijccm.org/text.asp?2004/8/3/157/13928

Withering W. An account of the foxglove and some of its

medical uses, with practical remarks on dropsy and other

diseases. In: Willius FA, Keys TE, eds. Classics of

cardiology: a collection of classic works on the heart and

circulation with comprehensive biographic accounts of the

authors. Malabar, Fla: Krieger; 1983. 747–58.

The effect of digoxin on mortality and morbidity in patients

with heart failure. The Digitalis Investigation Group. N Engl

J Med 1997;336:525–33.

Uretsky BF, Young JB, Shahidi FE, Yellen LG, Harrison

MC, Jolly MK. Randomized study assessing the effect of

digoxin withdrawal in patients with mild to moderate chronic

congestive heart failure: results of the PROVED trial.

PROVED Investigative Group. J Am Coll Cardiol

;22:955–62.

Packer M, Gheorghiade M, Young JB, Costantini PJ, Adams

KF, Cody RJ, et al. Withdrawal of digoxin from patients with

chronic heart failure treated with angiotensin-convertingenzyme inhibitors. RADIANCE Study. N Engl J Med

;329:1–7.

Alicandri C, Fariello R, Boni E, Zaninelli A, Castellano M,

Beschi M, et al. Captopril versus digoxin in mild-moderate

chronic heart failure: a crossover study. J Cardiovasc

Pharmacol 1987;9(suppl 2):S61–7.

Gheorghiade M, Hall V, Lakier JB, Goldstein S.

Comparative hemodynamic and neurohormonal effects of

intravenous captopril and digoxin and their combinations in

patients with severe heart failure. J Am Coll Cardiol

;13:134–42.

van Veldhuisen DJ, Man in't Veld AJ, Dunselman PH, Lok

DJ, Dohmen HJ, Poortermans JC, et al. Double-blind

placebo-controlled study of ibopamine and digoxin in

patients with mild to moderate heart failure: results of the

Dutch Ibopamine Multicenter Trial (DIMT). J Am Coll

Cardiol 1993;22:1564–73.

Eichhorn EJ, Gheorghiade M. Digoxin. Prog Cardiovasc Dis

;44:251–66

Ahmed A. Digoxin and reduction in mortality and

hospitalization in geriatric heart failure: importance of low

doses and low serum concentrations. J Gerontol A Biol Sci

Med Sci 2007;62:323–9.

Hoppe UC, Erdmann E. Digitalis in heart failure! Still

applicable? Z Kardiol 2005;94:307–11.

Rathore SS, Curtis JP, Wang Y, Bristow MR, Krumholz HM.

Association of serum digoxin concentration and outcomes in

patients with heart failure. JAMA 2003;289:871–8.

Wang L, Song S. Digoxin may reduce the mortality rates in

patients with congestive heart failure. Med Hypotheses

;64(1):124–6.

Dec GW. Digoxin remains useful in the management of

chronic heart failure. Med Clin North Am 2003;87:317–37.

Riaz K, Forker AD. Digoxin use in congestive heart failure.

Current status. Drugs 1998;55:747–58.


Refbacks

  • There are currently no refbacks.


Contact Number: +92-992-382571

email: [jamc] [@] [ayubmed.edu.pk]