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


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

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