Pre-Operative Inotropes: A Boon or a Bane Mr Syed Mohiyaddin1, Dr Nathan Tyson1, Dr Kevin Mohee2, Adnan Yousaf2 Prof. S Ashraf1 1Department of Cardiothoracic Surgery, Morriston Hospital 2Department of Cardiology, Morriston Hospital Background Results The use of inotropes, and to a lesser extent intra-aortic balloon pumps (IABP), are both employed frequently in adult cardiac surgery. Although a number of pharmacological agents may be used for this purpose, the use of noradrenaline is most prevalent. A sympathomimetic, noradrenaline acts by producing peripheral vasoconstriction, and is used to increase mean arterial pressure (MAP)1. IABP acts by inflating during diastole to improve myocardial perfusion via retrograde flow. Balloon pumps are employed in around 5% of cardiac patients post-operatively2. The use of IABP is therefore indicated in patients with ongoing chest pain prior to coronary artery bypass grafting or those with significant persistent hypotension, or in those patients with poor left ventricular function or cardiogenic shock. However, there are a number of associated complications3. Both therapies are frequently used post-operatively to improve end-organ perfusion in patients who have undergone cardiac surgery. This is due to the well-reported temporary reduction in ventricular function and cardiac output following surgery, combined with the vasodilatory effects of anaesthesia4. However, IABP and inotropes pre-operatively are often considered to be bridging therapies to surgery in unstable patients. Despite this, Hines suggested as far back as 1990 that pre-operative inotropes (including the newer phosphodiesterase inhibitors) may have a role in routine management in order to improve post-operative outcomes5. Despite this, there have only been a limited number of studies looking at pre-operative inotropes and IABP usage as a routine. Until further research is undertaken, these strategies are likely to be preserved for high risk patients. In a study group of 9619 patients underwent cardiothoracic surgery. Of these, 4997 (52.9%) underwent first time CABG. Of these patients, 70.7% were male. The mean age of the patient population was 68.2 ± 10.5 years. In our study, 103 patients received pre-operative inotropes for poor ventricular function. Of these patients who had pre-operative inotropes there were improvements in haemodynamic parameters, reduced post-operative inotropic requirements. More than 33% of patients in the overall cohort had diffuse three vessel coronary artery disease with more than 5% stenosis. 49% of all procedures were performed as elective cases. In this study, 69% of patient had established hypertension or more than one reading of 140/90 when measured pre-operatively. The Kaplan-Meier Survival curves for each group are shown below: Aim To evaluate the impact on survival and outcomes of the pre-operative used of inotropes and IABP, and to compare the outcomes of patients in each of these two groups. Mean post-operative survival across all patients undergoing cardiac surgery was 2861.7 ± 17.4 days. Means and Medians for Survival Time Grouping Mean Estimate Standard Error   Lower Bound Upper Bound No IABP, No Inotrope 2904.987 17.379 2870.923 2939.050 No IABP, Inotrope Used 2385.044 184.816 2022.805 2747.282 IABP Used, No Inotrope 2285.190 99.185 2090.787 2479.593 IABP Used, Inotrope Used 2075.380 204.100 1675.344 2475.416 Methods A total of 9619 patients who underwent cardiac surgery, a retrospective study which examined outcomes of patients undergoing surgery to a period of 12 years. All patients were eligible for inclusion in this study. A number of variables were recorded as listed below: Demographics – Age at the time of surgery, DOB and Gender was recorded for all patients. EuroScore and Logistic Euroscore was also recorded, as was cause of death where appropriate. Cardiovascular Health – Pre-operative angina and dyspnoea status was recorded, as was the existence of extracardiac arteriopathy. RV and LV function, smoking status, history of diabetes, previous ischaemic heart disease or cerebrovascular event Pre-Operative Management – Urgency of surgical invervention was recorded, in addition to the use of inotropic support or the use of IABP. The indication for inotropic and IABP support was also noted. Surgical variables – Urgency of treatment, surgery performed and the site of coronary grafting. Data was also collected on valve surgery. Post-Operative – Status (alive vs. deceased) at the censor date, overall survival time and the post-operative requirement for inotropes or IABP. The need for resternotomy was also recorded. Data was analysed using SPSS version 24. Survival was analysed using Kaplan-Meier survival analysis with post-hoc Mantel-Cox test. Mantel-Cox analysis shows that the post-operative survival in patients requiring IABP or inotropes (as shown above) differed significantly (χ2=63.314, P=0.000) Conclusions Unlike post-operative use of inotropes in patients undergoing cardiac surgery, pre-operative use of inotropes have shown to be a predictor of better outcomes in previous studies. However, a pre-operative requirement for inotropes has been associated with decreased survival pot-operatively in this study. Further work is needed to clarify these findings. Individual post-operative complications associated with inotrope and IABP usage wwere not evaluated in this study, but represent the focus of further future work. Additional, further clinical studies addressing the optimum choice, dose, timing and duration of selected inotropes could be further studied. It is hoped that a definitive protocol for the pre-operative use of inotropes and IABP may be developed in the near future. References Morimatsu, H., et al., Norepinephrine for hypotensive vasodilatation after cardiac surgery: impact on renal function. Intensive Care Med, 2003. 29(7): p. 1106-12. 2. Parissis, H., et al., The need for intra aortic balloon pump support following open heart surgery: risk analysis and outcome. J Cardiothorac Surg, 2010. 5: p. 20. 3. Parissis, H., A. Soo, and B. Al-Alao, Intra aortic balloon pump: literature review of risk factors related to complications of the intraaortic balloon pump. J Cardiothorac Surg, 2011. 6: p. 147. 4. Lomivorotov, V.V., et al., Low-Cardiac-Output Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth, 2017. 31(1): p. 291-308. 5. Hines, R., Preoperative and postoperative use of inotropes in cardiac surgery. Cardiothorac Vasc Anesth, 1990. 4(6): p 29-33