Percutaneous cardiopulmonary bypass support in high-risk patients undergoing percutaneous transluminal coronary angioplasty

Percutaneous cardiopulmonary support-supported percutaneous coronary intervention: a single center experience

Background and Objectives

Percutaneous cardiopulmonary support (PCPS) has proven to be a valuable technique in high-risk coronary patients undergoing percutaneous coronary intervention (PCI). However, there have been few studies on PCI associated with PCPS in Korea. We summarized our experience with PCPS-supported PCI.

Subjects and Methods

We retrospectively reviewed 19 patients with PCPS-supported PCI between August 2005 and June 2009. PCPS was used as an elective procedure for 10 patients with at least two of the following conditions: left-ventricular ejection fraction <35%, target vessel(s) supplying more than 50% of the viable myocardium, high risk surgical patients, and patients who refused coronary bypass surgery. In the remaining 9 patients PCPS was used as an emergency procedure, to stabilize and even resuscitate patients with acute myocardial infarction and cardiogenic shock, in order to attempt urgent PCI.

Results

Among the 19 patients who were treated with PCPS-supported PCI, 11 (57.9%) survived and 8 (42.1%) patients did not. ST elevation myocardial infarction with cardiogenic shock was more prevalent in the non-survivors than in the survivors (75% vs. 27.3%, p=0.04). The elective PCPS-supported PCI was practiced more frequently in the survivors than in the non-survivors (72.7% vs. 25%, p=0.04). In the analysis of the event-free survival curve between elective and emergency procedures, there was a significant difference in the survival rate (p=0.025). Among the survivors there were more patients with multi-vessel disease, but a lower Thrombolysis in Myocardial Infarction grade in the culprit lesions was detected in the non-survivors, before PCI. Although we studied high-risk patients, there was no procedure-related mortality.

Conclusion

Our experience suggests that PCPS may be helpful in high risk patients treated with PCI, especially in elective cases. More aggressive and larger scale studies of PCPS should follow.

Earlier application of percutaneous cardiopulmonary support rescues patients from severe cardiopulmonary failure using the APACHE III scoring system

Percutaneous cardiopulmonary support (PCPS) is a widely accepted treatment for severe cardiopulmonary failure. This system, which uses a percutaneous approach and autopriming devices, can be rapidly applied in emergency situations. We sought to identify the risk factors that could help predict in-hospital mortality, and to assess its outcomes in survivors. During a 2-yr period, 50 patients underwent PCPS for the treatment of severe cardiopulmonary failure, and of those, 22 (44%) were classified as survivors and 28 (56%) as non-survivors. We compared the 2 groups for risk factors of in-hospital mortality and to establish proper PCPS timing. Twenty patients underwent PCPS for acute myocardial infarction, 20 for severe cardiopulmonary failure after cardiac surgery, 7 for acute respiratory distress syndrome, and 3 for acute myocarditis. Multivariate analysis showed that an acute physiology, age, and chronic health evaluation (APACHE) III score >or=50 prior to PCPS was the only significant predictor of in-hospital mortality (P=0.001). Overall 18-month survival was 42.2%. Cox analysis showed patients with APACHE III scores >or=50 had a poor prognosis (P=0.001). Earlier application of PCPS, and other preemptive strategies designed to optimize high-risk patients, may improve patient outcomes. Identifying patients with high APACHE scores at the beginning of PCPS may predict in-hospital mortality. Survivors, particularly those with higher APACHE scores, may require more frequent follow-up to improve overall survival.

Successful resuscitation of an elderly man with deep accidental hypothermia using portable extracorporeal circulation in the emergency department: a case report

INTRODUCTION

Deep accidental hypothermia (body temperature below 28 degrees C) is rare and has a high mortality rate. Successful resuscitation usually occurs in the young, but a prompt intervention using a portable extracorporeal cardiopulmonary circulation device can also provide a good outcome for older persons.

CASE PRESENTATION

We report the successful resuscitation of an 82-year-old male from deep accidental hypothermia using portable extracorporeal circulation in the emergency department.

CONCLUSION

This successful resuscitation of an 82-year-old patient demonstrates that a prompt intervention by a medical team that trains together, using a mobile cardiopulmonary bypass device via a percutaneous approach, can potentially provide good outcomes for all victims of deep accidental hypothermia, both in the operating suites and the emergency department.

Factors for Weaning From a Percutaneous Cardiopulmonary Support System (PCPS) in Patients With Severe Cardiac Failure A Comparative Study in Weaned and Nonweaned Patients

The percutaneous cardiopulmonary support system (PCPS) has been widely accepted for the treatment of patients with severe cardiac failure. This system, which uses Seldinger's method through a percutaneous approach, enables rapid application in emergency situations. However, the indication for deployment and discontinuation of PCPS has not yet been established. We evaluated the results of PCPS use for the treatment of patients with severe cardiac failure and investigated factors that would predict successful weaning from PCPS. A total of 32 patients (23 men and 9 women) who had PCPS for the treatment of severe cardiac failure between January 1997 and October 2004 were retrospectively reviewed. The mean age of the patients was 57 +/- 17 years (range, 14 to 78 years). PCPS was necessary for severe cardiac failure after cardiac surgery in 15 patients, pulmonary infarction in 4, acute myocardial infarction in 3, acute myocarditis in 3, and other causes in 7. The mean duration of PCPS support in all 32 patients was 134 +/- 117 hours (range, 8 to 532). Twelve patients (38%) could be weaned from PCPS (group A), while the remaining 20 patients (62%) could not (group B). The incidence of cardiac arrest prior to PCPS use (n = 10, 31%) was significantly (P < 0.05) lower in group A (1/12, 8%) than in group B (9/20, 45%). There were significant differences in the APACHE II scores, urine output, serum lactate levels, and epinephrine and dopamine dose received from PCPS induction to 72 hours after PCPS use between the 2 groups (P < 0.05). Multivariate logistic regression analysis showed that an episode of cardiac arrest prior to PCPS induction was the only significant predictor for the unsuitability for discontinuation of PCPS. This retrospective study showed the limitation of PCPS therapy for patients with an episode of cardiac arrest who did not show improvement in their APACHE II score, urine output, serum lactate levels, and catecholamine dose received within 72 hours after PCPS induction. These results may help formulate criteria for indication and discontinuation of PCPS for patients with severe cardiac failure.

Clinical introduction of the Tandemheart, a percutaneous left ventricular assist device, for circulatory support during high-risk percutaneous coronary intervention

BACKGROUND

In patients with poor left ventricular function and high-risk coronary lesions, prolonged ischemia during percutaneous coronary intervention (PCI) may have major hemodynamic consequences. The Tandemheart is a percutaneous left ventricular assist device intended for short-term circulatory support.

METHODS AND RESULTS

The Tandem-heart incorporates 9-17 F. arterial cannulae and a unique 21 F. transseptal cannula and centrifugal bloodpump. Operating at 7500 rpm, the pump withdraws oxygenated blood from the left atrium and delivers up to 4 liters/min to the arterial circulation. As of May 2001, the Tandem-heart was electively employed in three male patients (ages 52, 54 and 56) scheduled for high-risk PCI. The mean time to initial circulatory support was less than 30 minutes. Systemic hemodynamics significantly improved prior to PCI in two patients. Pump flow after one hour ranged from 2.43 to 3.8 liters/min (mean 3.17 liters/min) and duration of support from 23 to 49 hours (mean 33 hours). Procedural success was 100%, with no significant hemolysis or bleeding. Successful weaning was completed in all patients, who have remained free of major cardiac events up to seven months post-PCI.

CONCLUSIONS

In this first clinical experience of elective use of Tandem-heart for circulatory support during high-risk PCI, the device was easily inserted and preserved hemodynamic stability, regardless of the intrinsic cardiac function, creating optimism for more widespread use for this and other indications.

Therapeutic strategy of perioperative use of percutaneous cardiopulmonary bypass support (PCPS) for adult cardiac surgery

SUBJECT AND METHOD

Percutaneous cardiopulmonary bypass support is beneficial for patients with circulatory collapse. However, therapeutic strategies of percutaneous cardiopulmonary bypass support for post-cardiotomy LOS have not been determined. We reviewed 9 patients undergoing cardiac surgery and treated with percutaneous cardiopulmonary bypass support to determine an adequate strategy for perioperative use of percutaneous cardiopulmonary bypass support. Patients included 8 males and 1 female with a mean age of 56.4 +/- 3.9 years. Six patients with IHD underwent CABG for 5 and CABG + MVR for 1 patient and 3 patients with valvular disease underwent AVR, AVR + MVR, and Ross operation respectively. Indication for percutaneous cardiopulmonary bypass support was post-cardiotomy LOS in 7 and preoperative cardiogenic shock in 2 patients. All patients underwent IABP associated with percutaneous cardiopulmonary bypass support. Systemic blood pressure was regulated to 100-120 mmHg by percutaneous cardiopulmonary bypass support flow and with minimum inotropic supports.

RESULTS

Six of 9 patients (66.7%) were weaned from percutaneous cardiopulmonary bypass support and 5 patients were discharged. Five of 6 patients (83.3%) with IHD were weaned from percutaneous cardiopulmonary bypass support compared to 1 of 3 patients (33.3%) (p = 0.134) with valvular disease. Hemodynamic conditions in patients weaned from percutaneous cardiopulmonary bypass support were markedly improved within 40 hours of the introduction of percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 23.9 +/- 5.5 hrs). In contrast, those unable to be weaned from percutaneous cardiopulmonary bypass support (mean percutaneous cardiopulmonary bypass support running time: 84.3 +/- 6.3 hrs) showed no improvement and developed major complications such as cerebral damage or multiorgan failure.

CONCLUSIONS

Perioperative use of percutaneous cardiopulmonary bypass support may be more effective for patients undergoing coronary artery surgery. Limited use of percutaneous cardiopulmonary bypass support within 48 hours may be applicable for post-cardiotomy patients.

Comparison of acute results of prophylactic intraaortic balloon pumping with cardiopulmonary support for percutaneous transluminal coronary angioplasty (PCTA)

High-risk patients not eligible for coronary artery bypass grafting (CABG) are being considered for percutaneous coronary interventions, using cardiopulmonary support (CPS) or intraaortic balloon pump (IABP). However, few data are available regarding case selection and outcome with various support devices. Over a 4-yr period, 149 patients underwent high-risk coronary angioplasty, using elective placement of support devices. Based on physician preference, 58 patients underwent CPS and 91 underwent IABP support prior to the angioplasty. Patients selected for CPS-assisted angioplasty were more likely to be males, and to have a history of chronic angina, congestive heart failure, and lower ejection fraction (26+/-13% vs. 32+/-14%, P = 0.01). Multivessel disease was present in 95% of CPS patients and 89% of IABP patients (P = 0.35). Multivessel angioplasty was performed more frequently in the CPS group (40% vs. 20%, P = 0.01), and angioplasty success was higher in the CPS groups (99% vs. 87%, P = 0.005). Major cardiac events such as myocardial infarction, bypass surgery, stroke, and death did not differ between the groups. Peripheral vascular complications such as hematomas (36% vs. 24%, P = 0.16), vascular repair (14% vs. 3%, P = 0.03), and transfusions (60% vs. 27%, P = 0.0001) were higher in the CPS group. In conclusion, despite a higher risk profile, CPS allowed longer balloon inflations and higher PTCA success rates compared to IABP. However, peripheral vascular complications were higher in the CPS group, and major cardiac events were similar to those in IABP-treated patients. These data suggest that either method of support may be acceptable during high-risk PTCA.

Evaluation of an active coronary perfusion balloon device using Doppler flow wire during PTCA

The aim of this study was to assess whether active coronary perfusion catheters (APC) can provide a sufficient coronary flow in large caliber vessels during balloon inflation. To prevent myocardial ischemia during PTCA, these APC may be employed. However, it is as yet unknown whether the active flow rate of these devices approaches the flow rate prior to PTCA during balloon inflation. Therefore, we measured the efficacy of the APC during balloon inflation in vessels supplying a large amount of myocardium. In 12 patients (1 female, 11 males, 53 +/- 12.6 yr) with stenosed vessels (average diameter 3.4 +/- 0.26 mm), the coronary flow velocity was measured using a 0.014" Doppler guidewire, which was placed distally bypassing the balloon of the APC. The active perfusion balloon catheter was advanced through a 7F guiding catheter along a 0.014" guidewire. After removal of the guidewire, arterial blood being withdrawn from the side port of the femoral angioplasty sheath was pumped through the catheter to the distal coronary vessel. The perfusion volumes of the pump were set to different levels between 30 to 60 ml/min. Intracoronary flow rate was calculated by the angiographically assessed vessel luminal area [symbol: see text] average peak velocity [symbol: see text] 0.5. The mean coronary flow rate prior to PTCA was 43 +/- 17.7 ml/min. Maximum flow during PTCA was 55 +/- 19.6 ml/min. We found a good correlation between the preset external pump rate and the coronary flow in situ (r = 0.92). Pre-PTCA flow rates were achieved in 11 of 12 patients (92%) during balloon inflation. No relevant decrease in the arterial pressure occurred during dilation times of 4.6 +/- 1.63 min. Only two patients showed significant ECG changes during these balloon inflations. After an average follow-up period of 13 +/- 6.3 mo, only one patient (8%) had a significant re-stenosis requiring the implantation of a stent. The combination of intravascular Doppler velocity measurements with quantitative coronary angiography offers the opportunity of exact online flow registration during angioplasty. Using APC, It is possible to maintain a sufficient coronary flow in the distal vessel during balloon inflation even in large vessels. Therefore, as compared with mechanical circulatory assist devices, coronary assist by APC is a little invasive, but according to our measurements it might be a sufficient tool for performing PTCA also in high-risk patients.

Maintenance of hemostasis after invasive cardiac procedures: implications for outpatient catheterization

OBJECTIVES

This study investigated the efficacy of four different methods of arterial puncture site management during recovery from invasive cardiac procedures. The primary goals were less patient discomfort and improved clinical outcome.

BACKGROUND

The increasing use of outpatient catheterization, large interventional devices and potent periprocedural anticoagulation regimens has made the reduction of groin complications a high priority. Despite these trends, there are no randomized trials comparing commonly used techniques in treating the catheter entry site for the first few hours after the procedure.

METHODS

Four-hundred consecutive patients undergoing catheterization laboratory procedures were randomly assigned to one of four dressing techniques applied after achieving hemostasis: a sandbag placed over the site; a pressure dressing constructed from surgical gauze and elastic tape; a commercially available compression device; and no use of compressive dressing. Of these 400 patients, 171 would have been eligible for outpatient procedures in the absence of geographic constraints. The dressings were removed, and ambulation was encouraged 5 h after sheath removal. Uniform initial compression times, patient instructions, nursing follow-up and a structured interview and physical examination at 24 h were used.

RESULTS

The level of patient discomfort before and after dressing removal, as well as site tenderness at 24-h follow-up, was statistically similar in all four groups. Hematomas (typically small) and areas of ecchymosis were observed in 58 and 122 patients, respectively, but both their frequency and size were equally represented in each group. Important adverse events were confined to bleeding, rated as mild in 5.8%, moderate in 0.8% and severe in 0.6% of patients. Again, all four groups were statistically similar. Comparable findings were observed in the subgroup of patients eligible for outpatient procedures.

CONCLUSIONS

Despite an increase in inconvenience and expense, none of the three compression techniques that were investigated improved patient satisfaction or outcome. Therefore, the routine use of compression dressings after invasive cardiac procedures cannot be recommended.

PTCA with the use of cardiac assist devices: risk stratification, short- and long-term results

Percutaneous cardiopulmonary assist devices (PCPS) have become available in interventional cardiology within recent years. These tools offer the opportunity of performing percutaneous transluminal coronary angioplasty (PTCA) in high-risk patients characterized by significant stenoses of several coronary arteries and a poor left ventricular function. It is unclear for which patients PCPS are necessary and which patients will profit by PTCA as compared to coronary artery bypass grafting (CABG). Therefore, the anticipated risk of CABG and of PTCA without assist devices was calculated according to risk scores and compared with our results of assisted PTCA. In addition the long-term survival rate was investigated. In 35 patients (mean 65.5 years of age, 12 females, 23 males), we performed PTCA concomitant with the use of cardiac assist devices. The indications for the use of a cardiac assist device were severely impaired LV function (EF 30% +/- 8.9%) in combination with significant coronary artery disease (2.7 +/- 0.3 vessels) and a significant supply area of the vessel to be dilated. In 6 patients, PCPS was started before coronary angioplasty because of hemodynamic instability. In 21 cases, PCPS was on a standby basis without being connected to the patient's circulation. In 8 patients, a left heart assist device, the 14F-Hemopump, was inserted percutaneously. The patients were analyzed using risk scores of angioplasty and of coronary bypass graft surgery. The calculated risk of hemodynamic compromise during PTCA according to the risk scores was more than 50%. The anticipated risk of a fatal outcome following CABG would have been 19.8%. PTCA was performed on an average of 2.0 coronary arteries per patient and was successful in 85%. We observed a decline in angina pectoris classification (CCS) from 3.5 to 1.6. An average reduction of 1.1 NYHA class was achieved. The in-hospital mortality was 8.6% (3 patients: 1 x sepsis, 1 x early reocclusion, 1 x cerebral embolism). At 24 months follow-up, a re-PTCA was necessary in four cases because of restenosis. In the remainder, NYHA and CCS class were stable during the follow-up period. An additional five patients died during the first year and two patients in the second year. We conclude that PTCA with the use of a cardiac assist device shows favorable short-term results in a subset of patients with extended coronary artery disease and severely impaired LV function who are not suitable for nonsupported PTCA or CABG due to their risk profile. However, the long term results are not satisfying and stress the need for complete revascularisation with CABG once the patient's condition is stabilized by means of supported PTCA.

Percutaneous cardiopulmonary bypass-supported coronary angioplasty in patients with unstable angina pectoris or myocardial infarction and a left ventricular ejection fraction < or = 25%

The objective of this study was to determine the acute and long-term results of percutaneous cardiopulmonary bypass-supported angioplasty in treating high-risk patients with unstable presentations and severely depressed left ventricular (LV) function (ejection fraction [EF] < or = 25%). One hundred seven consecutive patients with a mean LVEF of 19 +/- 3% were studied. Seventy-four patients (69%) had unstable angina, 60 (56%) had New York Heart Association class III or IV symptoms, 74 (69%) had recent (< 15 days) documented acute myocardial infarction, 103 (96%) had 3-vessel disease, and 58 (54%) had only 1 remaining patent artery. A total of 50 patients (47%) were deemed unsuitable for bypass surgery. Of 196 severe narrowings attempted in 166 coronary arteries, 193 (98%) were successfully dilated in 105 patients (98%), and there was no procedure-related mortality, Q-wave myocardial infarction, or urgent requirement for coronary bypass surgery. There were 5 in-hospital deaths (4.7%) and the remaining 102 patients have been followed for 24.5 +/- 1.3 (mean +/- SE) months. Twenty-three patients (21%) died between 1 and 23 months after the procedure. One- and 2-year survival free of cardiac death was 83% and 77%, respectively. Of the 79 surviving patients, 65 have survived event free of myocardial infarction and revascularization; event-free survival for 1 and 2 years was 76% and 69.5%, respectively. In the 64 patients in whom LV function was measured before and after the procedure, global EF increased from 20.6% to 29.3% (p < 0.001). Patients who remained event free had a greater improvement in LVEF than those who had a cardiac event during follow-up (p < 0.05). Thus, this study demonstrates the safety and efficacy of percutaneous cardiopulmonary bypass-supported angioplasty in the immediate treatment of high-risk unstable patients with multivessel coronary artery disease and severely depressed LV function.

Strategies for the palliation of severe unprotected left main coronary artery disease: use of newer technologies

Angioplasty of unprotected left main coronary artery lesions is associated with high procedural and late mortalities. We describe the successful use of rotational coronary atherectomy with prophylactic supportive measures in the management of a heavily calcified unprotected left main lesion. This report demonstrates that high-risk lesions, previously regarded as unapproachable, may be safety treated with newer technologies.

Coronary angioplasty in high risk patients: comparison of elective intraaortic balloon pump and percutaneous cardiopulmonary bypass support--a randomized study

Forty patients undergoing percutaneous transluminal coronary angioplasty (PTCA) with severely impaired left ventricular ejection fraction (LVEF) < 30% were randomized between prophylactic intraaortic balloon pump (IABP) support (N = 20) and percutaneous cardiopulmonary bypass (PCPB) support (N = 20). The indications for both groups were left ventricular (LV) dysfunction and a large area of myocardium (> 50%) being perfused by the target vessel. The IABP and PCPB supported groups were comparable in LVEF (20% +/- 6.4% vs 22.8% +/- 8.1%), mean pulmonary artery pressure (46.5 +/- 10.5 mmHg vs 42.6 +/- 12.6 mmHg), average number of vessels dilated (1.4 vs 1.3), mean inflation time (2.8 +/- 0.3 min vs 3.1 +/- 0.5 min), and hospital stay after PTCA (5.6 +/- 1.2 days vs 5.2 +/- 1.4 days). The primary success rate (95% vs 95%) and hospital mortality (5% vs 5%) were also similar in the two groups. Two patients required surgical exploration of the femoral artery and eight patients required blood transfusion in the PCPB group. IABP patients had no vascular complications and did not require blood transfusion. High risk PTCA is equally effective whether using prophylactic IABP or PCPB support. PCPB support, however, has a higher rate of vascular complications and need for blood transfusions. IABP has the additional advantage of ease of insertion and the support can be used for a longer period after PTCA, if required.

An in vitro evaluation of venous cannula in a simulated partial (femoro-femoral) cardiopulmonary bypass circuit

We designed a study to evaluate three factors (siphon gradient [PH], the right atrial pressure [RAP], and the inferior vena caval flow [IVCF]) to be optimized to maximize the venous drainage flow (DF) during partial cardiopulmonary bypass using eight venous cannulas of three different types and an original model circuit. The relationship between venous DF and the three factors is indicated by the multiple regression equation DF2 = alpha PH + beta RAP + gamma IVCF2 + C, where alpha, beta, and gamma are regression estimates and C is a constant. Multiple regression analysis results showed that DF was positively correlated with PH and RAP and negatively correlated with IVCF. A long cannula with 12 side holes and 60 cm long was considered to be useful to yield the optimal venous drainage flow under the condition of maintenance of the flow balance (DF and ICVF) and the pressure balance (RAP and IVCP) at the zero point. Moreover, this model may allow extensive research in flow dynamics of venous cannula without involving human subjects.

Reversible coronary artery kinking caused by cardiopulmonary support

Cardiopulmonary support is utilized to provide optimal hemodynamic stability in high risk patients undergoing percutaneous transluminal coronary angioplasty. This report describes a patient undergoing supported angioplasty in whom multiple new severe stenoses were noted following coronary dilation and that were completely reversed by discontinuing cardiopulmonary support.

Emergency cardiopulmonary bypass support in patients with cardiac arrest caused by myocardial infarction

Emergency percutaneous cardiopulmonary bypass support (PCPS) was instituted in 3 patients with acute myocardial infarction in cardiac arrest refractory to conventional resuscitation measures. All had severe double or triple vessel disease. Percutaneous transluminal coronary angioplasty (PTCA) was performed in 1 patient and PTCA and directional coronary atherectomy (DCA) were performed in the other 2 patients on combined intraaortic balloon pumping (IABP) and PCPS. Flow rates of 2 to 5 L/min were achieved, with restoration of mean arterial pressure to more than 60 mm Hg during PCPS. The status of all patients was improved hemodynamically with PCPS. One patient died of hemorrhage during PCPS. DCA was successfully performed in the other 2 patients, and PCPS and IABP was discontinued. Time on PCPS ranged from 10 h to 8 days. Time on IABP ranged from 10 days to 2 weeks. These 2 patients died of pneumonia or multiorgan failure after 1.5 months. In conclusion, emergency PCPS is a powerful resuscitative tool that may stabilize the condition of patients in cardiac arrest to allow for definitive intervention.

Extracorporeal circulation in the management of severe tricyclic antidepressant overdose

Extracorporeal circulation is a technique that provides precise control of circulation, oxygenation, temperature, and blood composition in patients suffering from cardiopulmonary failure. The investigators present the case of a near fatal tricyclic antidepressant overdose that failed to respond to standard therapy but was resuscitated using extracorporeal circulation.

Emergent percutaneous cardiopulmonary bypass in patients having cardiovascular collapse in the cardiac catheterization laboratory

Percutaneous cardiopulmonary bypass (PCB) was instituted in 30 initially stable patients who developed either cardiac arrest refractory to resuscitation (n = 7) or cardiogenic shock (mean arterial blood pressure < 50 mm Hg unresponsive to fluid resuscitation or vasopressors) (n = 23) after a catheterization laboratory complication. Events leading to collapse included abrupt closure during percutaneous transluminal coronary angioplasty (PTCA) (n = 22), complications from diagnostic cardiac catheterization (n = 6), left ventricular perforation during mitral valvuloplasty (n = 1), and right ventricular perforation during pericardiocentesis (n = 1). PCB was initiated within 20 minutes of cardiovascular collapse in 83% of patients (arrest: 21 +/- 13 minutes [range 10 to 50]; and shock: 17 +/- 6 minutes [range 10 to 30]). Mean arterial blood pressure increased on PCB from 0 to 56 mm Hg in patients with cardiac arrest and from 37 to 63 mm Hg in those with cardiogenic shock at mean PCB flow rates of 2.5 to 5.0 liters/min. Subsequent therapy on PCB included emergent cardiac surgery (n = 14), PTCA (n = 13) and medical therapy (n = 3). Six patients (20%) survived to hospital discharge (3 with cardiac surgery, 2 with PTCA, and 1 with medical therapy). All 7 patients with refractory cardiac arrest died despite further interventions on PCB, whereas 6 of 23 (26%) with cardiogenic shock survived to hospital discharge. Thus, in response to cardiovascular collapse in the catheterization laboratory, PCB does not salvage patients who do not regain a stable cardiac rhythm. PCB can stabilize patients who develop cardiogenic shock for further interventions which are lifesaving in only a minority of patients.

Percutaneous transluminal angioplasty of saphenous vein grafts for medically refractory unstable angina

OBJECTIVES

We attempted to answer the question, Is balloon angioplasty a reasonable alternative to repeat coronary artery bypass graft surgery in patients with previous coronary bypass graft surgery, medically refractory unstable angina and vein graft lesions?

BACKGROUND

Patients with medically refractory unstable angina need revascularization. Patients with previous coronary artery bypass graft surgery and medically refractory angina are at "high risk" for adverse outcomes with repeat coronary bypass graft surgery. Conversely, patients with angioplasty of old vein grafts are also at "high risk" for adverse outcomes.

METHODS

Balloon angioplasty of 89 lesions in saphenous vein grafts was performed in 75 consecutive patients with medically refractory unstable angina. Of these 75 patients, 24 (32%) had myocardial infarct within 30 days, 23 (31%) had left ventricular ejection fraction < 0.35, and 50 (67%) had major comorbidity. Patients underwent standard balloon angioplasty with aggressive use of intravenous and intracoronary heparin, urokinase, nitroglycerin, oral aspirin, calcium channel blocking agents and coumadin.

RESULTS

Angiographic success (reduction of stenosis < or = 50% without major complication) was seen in 84 of 89 lesions. Clinical success (angiographic success plus hospital discharge without major complication) was seen in 70 of 75 patients. During index hospitalization, two patients (3%) died, two (3%) had nonfatal infarcts, and one (1%) had emergency reoperation (coronary bypass graft surgery). In late follow up (3 to 66 months), 14 (20%) patients were lost to follow-up, 17 (23%) had repeat percutaneous transluminal coronary angioplasty, 2 (3%) had late bypass graft reoperation, 18 (25%) had late death, and 1 (< 1%) had a heart transplant. Of the 41 patients alive after one or more angioplasties, 25 have little or no angina, and 16 have occasional or more angina. We compared long-term survival rate in these 75 patients with a cohort of patients with high risk, unstable angina from the Veterans Affairs Surgical Registry (2,570 patients). The 30-day survival rate was better in patients with coronary angioplasty (97% vs. 92%, p < 0.05), but by 6 months there was no difference, and by 5 years a trend toward a higher survival rate with coronary artery bypass graft surgery was seen.

CONCLUSIONS

Balloon angioplasty of saphenous vein grafts with aggressive adjunctive pharmacotherapy is a reasonable alternative to repeat coronary bypass graft surgery in patients with medically refractory unstable angina, previous coronary bypass graft surgery and saphenous vein narrowing.

Percutaneous Cardiopulmonary Bypass for Cardiogenic Shock

Percutaneous cardiopulmonary bypass was performed in 9 patients who developed cardiogenic shock. Of these patients, 5 were postoperative patients who developed cardiogenic shock on the day of operation. In 3 of these patients, intraaortic balloon pump was used in addition to percutaneous cardiopulmonary bypass. Two patients required percutaneous cardiopulmonary bypass in the cardiac catheterization laboratory for cardiogenic shock during angioplasty, and 2 other patients developed cardiogenic shock secondary to acute anterior wall myocardial infarction. Cardiopulmonary bypass was initiated with 18F femoral arterial and venous cannulae. Flow rates between 2.5 and 4.5 l/min and a mean blood pressure equal to or greater than 60mmHg were achieved. Of 5 postoperative patients, 3 survived and 2 died. Two patients who crashed during angioplasty were managed with emergency coronary artery bypass grafting, and both survived. Of 2 patients who developed cardiogenic shock following acute anterior wall myocardial infarction, 1 survived and 1 died. The surviving 6 patients were followed up for a mean period of 8 months. Five patients were in New York Heart Association Functional Class I, and 1 patient was in Class II.

Left main coronary angioplasty in a 10-year-old boy with homozygous familial hypercholesterolemia

Homozygous familial hypercholesterolemia is a rare cause of premature coronary artery disease. A young boy with this disorder who underwent successful coronary angioplasty for left main stem stenosis is presented.

Long-term outcome of patients with depressed left ventricular function undergoing percutaneous transluminal coronary angioplasty. The NHLBI PTCA Registry

BACKGROUND

Coronary revascularization with bypass has been shown to improve survival in patients with coronary artery disease and left ventricular dysfunction. In these patients, use of nonsurgical revascularization with percutaneous transluminal coronary angioplasty (PTCA) is increasing, although their long-term outcome has not been well delineated. The purpose of this investigation was to characterize the outcome of angioplasty in patients with decreased left ventricular function and contrast it with the results in patients with normal left ventricular function.

METHODS AND RESULTS

In the 1985-1986 National Heart, Lung, and Blood Institute's PTCA Registry, of 1,802 patients undergoing PTCA, 244 patients (13.5%) had an ejection fraction of < or = 45% (mean, 39.6 +/- 6.8%). These patients had a higher incidence of prior infarction, a longer and worse history of manifestations of coronary disease, and more extensive coronary artery disease than patients with well-preserved function; 88% and 91%, respectively, had successful dilation of at least one lesion (nonsignificant difference). However, patients with decreased left ventricular function had a decreased frequency of successful dilation of all lesions in which PTCA was attempted (76% versus 84%, p < 0.01). There were no statistically significant differences in in-hospital complications--death occurred in 0.8% and 0.7%, nonfatal myocardial infarction occurred in 4.9% and 4.5%, and emergency surgical revascularization was performed in 4.5% and 3.2%, respectively. Patients were followed for a mean of 4.1 years; during this time, patients with decreased left ventricular function had significantly worse survival and combined event-free survival. Despite this, at 4 years, 87% of the patients with a mean ejection fraction of 39.6% remained alive, and 77% were alive and had not experienced infarction or required bypass.

CONCLUSIONS

PTCA is effective in selected patients with depressed left ventricular function. Initial outcome and risk-benefit ratio are excellent. Successful dilation of at least one vessel was achieved in 88% of patients with depressed left ventricular function and in 91% of patients with more normal left ventricular function. The former group, however, had a decreased incidence of successful dilation in all lesions in which dilation was attempted (76% versus 84%, p < 0.01). There was no significant difference in in-hospital complications between the two groups. During follow-up, patients with decreased left ventricular function had worse event-free survival, although 77% were alive without infarction or bypass grafting at 4 years.

Salvage angioplasty: an alternative to high risk surgery for unstable angina?

This prospective, Human Subjects Committee and Ethics Committee approved investigation was performed to determine if coronary angioplasty (PTCA) might be a reasonable alternative revascularization method for unstable angina patients thought to be at high risk for operative (CABG) mortality. Between March 1990 and October 1991, thirty-four consecutive patients with medically refractory rest angina were deamed to have high risk of surgical mortality and underwent PTCA without surgical backup. Predicted operative mortality was calculated for each patient based upon the VA Surgical Risk Assessment model. Angioplasty of 52 vessels was attempted. Reduction in lumenal narrowing to < 50% and improved angiographic flow was obtained in 47 vessels. There were four complicating infarctions. One death occurred in the lab, and three patients with unsuccessful angioplasty died within 30 days of pump failure. Relief of angina occurred in 30/34. Thirty patients were discharged home. In follow-up from 1 to 12 months, there have been 2 late sudden deaths at 4 months and 9 months, 1 death from lung cancer; 4 patients have stable exertional angina; 2 are awaiting heart transplant but are pain free, and one patient who had PTCA during cardiogenic shock from acute myocardial infarction had elective coronary artery bypass surgery. There have been no late myocardial infarctions. The observed angioplasty 30-day mortality of 11.8% (95% confidence limit 1% to 22.6%) compares favorably with the predicted operative mortality of 23.8% for this group. This prospective but non-randomized series supports the concept that balloon angioplasty may be a reasonable alternative to surgical intervention in some patients with unstable angina and high risk for surgery. A prospective randomized trial is warranted.

Percutaneous introduction of left atrial cannula for left heart bypass: utility of biplane transesophageal echocardiographic guidance for transseptal puncture

For introduction of a left atrial (LA) cannula by the transseptal puncture technique, we examined the feasibility of using biplane transesophageal echocardiography (B-TEE). A transseptal puncture was performed on 15 patients (3 male; 12 female; mean age, 48.9 +/- 11.2 years) by B-TEE guide during percutaneous transvenous mitral comissurotomy (PTMC). The entire Brocken-brough needle and the position of its tip were clearly observed in the right atrium by a longitudinal image of B-TEE in all patients (100%), and in 2 (13%) of them also by the transverse image of B-TEE. The puncture was about 1 cm caudal from the center of the fossa ovalis to avoid any large residual atrial septal defect. After transseptal puncture, a Mullin's sheath (7 Fr) and a dilator (14 Fr) were inserted into the left atrium in order, and then an Inoue's balloon catheter (12 Fr) was introduced without difficulty into the left atrium in all patients. With contrast injection, the position of the sheaths's tip was clearly confirmed by B-TEE. Left heart bypass support (left atrial-femoral artery bypass or AAB) was performed on 2 patients after percutaneous introduction of the LA cannula using this technique, and both were successfully supported and survived. With B-TEE guidance, the Brockenbrough atrial septal puncture and introduction of the LA cannula into left atrium can be performed easily. Thus, percutaneous left heart bypass can be set up quickly and safely even in an intensive care unit or outpatient emergency room without radiographic guidance.

Safety and efficacy of percutaneous transluminal coronary angioplasty in patients with left ventricular dysfunction

The risks and long-term outcome after 845 elective percutaneous transluminal coronary angioplasties (PTCA) in patients with left ventricular (LV) dysfunction (ejection fraction less than or equal to 40%) were examined. Procedural results were compared with 8,117 consecutive procedures in patients with ejection fractions greater than 40%. The patients with LV dysfunction were older (63 vs 60 years, p less than 0.01), had a greater incidence of prior myocardial infarction (84 vs 45%, p less than 0.001), prior bypass surgery (39 vs 21%, p less than 0.001), 3-vessel disease (62 vs 33%, p less than 0.001), and class IV angina (48 vs 41%, p less than 0.01) than the control group. Angiographic success was lower (93 vs 95%, p less than 0.01), and overall procedural mortality was increased ( 4 vs 1%, p less than 0.001) in the study group. Emergency surgery rates were identical (2%). No significant difference was found in rates of nonfatal Q-wave myocardial infarction (2 vs 1%). At mean follow-up of 33.5 months, 15% of the patients with LV dysfunction required late bypass surgery, 27% underwent repeat PTCA, and 59% were angina free. Actuarial survival at 1 and 4 years was 87 and 69%, respectively. Cox regression analysis identified 3-vessel disease, age greater than or equal to 70 years, class IV angina and incomplete revascularization as correlates of long-term mortality. These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with LV dysfunction.

Effect of peripheral cardiopulmonary bypass on left ventricular size, afterload and myocardial function during elective supported coronary angioplasty

Although cardiopulmonary bypass support has been increasingly used for high risk coronary angioplasty, few data exist regarding its effects on left ventricular function. Accordingly, in 20 patients changes in left ventricular size, afterload and myocardial function were assessed by continuous hemodynamic monitoring and simultaneous two-dimensional echocardiography during cardiopulmonary bypass-supported high risk angioplasty. The cross-sectional left ventricular area during bypass support remained unchanged during diastole, whereas during systole it decreased (from 29.6 +/- 11.4 to 27.6 +/- 10.4 cm2, p less than 0.05). Global left ventricular function expressed as fractional area change remained unchanged from baseline to bypass support but decreased during balloon inflation (from 0.27 +/- 0.11 to 0.17 +/- 0.09, p less than 0.001). The end-systolic meridional wall stress decreased during bypass support (from 141 +/- 75 to 110 +/- 58 x 10(3) dynes/cm2, p less than 0.02). Regional myocardial function was assessed by a wall motion score (0 = normal, 1 = hypokinesia, 2 = akinesia and 3 = dyskinesia). Regions supplied by a stenotic (greater than or equal to 50% diameter) vessel deteriorated during bypass support (score from 0.9 +/- 0.8 to 1.06 +/- 0.8, p less than 0.01), whereas regions supplied by a nonstenotic vessel did not. Regions supplied by the target vessel deteriorated further during balloon inflation (score from 0.7 +/- 0.6 to 1.7 +/- 0.75, p less than 0.001). Thus, although left ventricular size and global function remain unchanged and afterload decreases during bypass support, myocardial dysfunction in regions supplied by a stenotic vessel may occur. Furthermore, regional and global left ventricular dysfunction still occur with angioplasty balloon inflation during cardiopulmonary bypass support.

Percutaneous support devices for high risk or complicated coronary angioplasty

Indications for coronary angioplasty have expanded to include patients with unstable acute ischemic syndromes, severe multivessel coronary artery disease and impaired left ventricular function. Several mechanical approaches have been developed as adjuncts to high risk coronary angioplasty to improve patient tolerance of coronary balloon occlusion and maintain hemodynamic stability in the event of complications. These percutaneous techniques include intraaortic balloon counterpulsation, anterograde transcatheter coronary perfusion, coronary sinus retroperfusion, cardiopulmonary bypass, Hemopump left ventricular assistance and partial left heart bypass. The intraaortic balloon pump provides hemodynamic support and ameliorates ischemia by decreasing myocardial work; it may be inserted for periprocedural complications or before angioplasty in patients with ischemia or hypotension. Anterograde distal coronary artery perfusion may be accomplished passively through an autoperfusion catheter or by active pumping of oxygenated blood or fluorocarbons through the central lumen of an angioplasty catheter. Synchronized coronary sinus retroperfusion produces pulsatile blood flow via the cardiac veins to the coronary bed distal to a stenosis. Both perfusion techniques limit development of ischemic chest pain and myocardial dysfunction in patients undergoing prolonged balloon inflations. Percutaneous cardiopulmonary bypass provides complete systemic hemodynamic support which is independent of intrinsic cardiac function or rhythm and has been employed prophylactically in very high risk patients before coronary angioplasty or emergently for abrupt closure. These and newer support devices, while associated with significant complications, may ultimately improve the safety of coronary angioplasty and allow its application to those who would otherwise not be candidates for revascularization.

Left ventricular rupture complicating percutaneous mitral commissurotomy: salvage using percutaneous cardiopulmonary bypass support

Left ventricular rupture resulting in death has been reported to be a complication of percutaneous mitral commissurotomy. We report a 71-year-old man in whom a left ventricular rupture occurred during percutaneous mitral commissurotomy and resulted in hemodynamic collapse due to acute cardiac tamponade. The patient was stabilized using percutaneously instituted cardiopulmonary bypass support with subsequent repair of the left ventricle and successful mitral valve replacement. Three months later this patient remains in New York Heart Class I.

Percutaneous cardiopulmonary bypass support in the catheterization laboratory: technique and complications

A safe and easily applied technique of percutaneous cardiopulmonary bypass support has been developed for use in the cardiac catheterization laboratory. The importance of this technique lies in its ability to maintain hemodynamic stability during high risk interventional procedures regardless of intrinsic cardiac function. Venous and arterial cannulas (18F) are inserted percutaneously over a stiff guide wire after sequential dilatation with 12F and 14F dilators. Bypass flow rates of up to 5 L/min can be achieved. This technique can be applied to support patients with cardiac arrest, hemodynamic collapse after abrupt closure during coronary angioplasty, and cardiogenic shock, as well as those undergoing high-risk elective coronary angioplasty. This form of support also permits transport of the patient to the operating room in a stable condition after an unsuccessful angioplasty. The complications are mostly related to cannula removal and can be minimized by the use of a proper technique. Although the ultimate role of this new technique remains to be completely defined, it appears that it will expand the patient population for whom coronary interventions can be applied.