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PubMed1979

The importance of myocardial protection in combined aortic valve replacement and myocardial revascularization.

To determine the importance of different methods of myocardial protection for combined aortic valve replacement and coronary revascularization, we analyzed the records of 82 consecutive patients who underwent the combined procedure between 1973 and 1978. Sixty-three (77%) had angina and 63 (77%) were in New York Heart Association Functional Class III or IV. Moderate to severe left ventricular impairment was present in 59%, and the mean number of diseased vessels was 1.9 per patient. Group I consisted of 18 patients with intermittent ischemia, almost all of whom had operation between 1973 and 1976. Group IIa consisted of 24 patients operated on between 1973 and December, 1976, with coronary perfusion, and Group IIb had 18 patients in whom a similar technique was used in 1977 and 1978. Group III consisted of 22 patients operated on in 1977 and 1978 in whom cold chemical cardioplegia was used. The early mortality (less than 30 days) for Group I was 50% and for Group IIa 29%. There were no deaths in Group IIb and Group III. The incidence of perioperative myocardial infarction was 21% in Group I, 6% in Group IIa, 11% in Group IIb, and zero in Group III. The incidence of cardiogenic shock requiring prolonged inotropic support and intraaortic balloon counterpulsation was significantly less in Group III (9%) than in Group IIb (50%) (p less than 0.05). If other manifestations of myocardial injury, such as perioperative infarction and cardiogenic shock requiring intraaortic balloon counterpulsation or inotropic support, are taken into consideration, cold chemical cardioplegia appears to provide better myocardial protection than coronary perfusion of the fibrillating heart.

Adult↗
PubMed1979

Vascular evaluation for balloon pumping.

The effectiveness of intraaortic balloon counterpulsation is reduced frequently by arterial insufficiency following balloon insertion and occasionally by inability to pass the balloon centrally from a peripheral site. From a series of patients undergoing cardiac catheterization, a subgroup with increased likelihood of needing balloon counterpulsation can be selected. Patients so chosen have received one aortoiliac injection of contrast material at the time of cardiac catheterization. Impressive degrees of vessel irregularity and stenosis on an atherosclerotic basis and of tortuosity of normal lumen size have been noted. Such information, gathered at little additional risk or irradiation, is considered to be important in the subsequent choice of sides for transfemoral insertion and may rule out attempted passage of the balloon by this route, directing the surgeon to a deliberate, prompt, transabdominal or thoracic aortic insertion if necessary.

Aged↗
PubMed1976

Use of a left heart assist device after intracardiac surgery: technique and clinical experience.

A left heart assist device (LHAD) has been employed in 14 patients. All had advanced heart disease and were in low cardiac output after repair, such that they could not be separated from cardiopulmonary bypass despite prolonged support and adjuvant therapy, including drugs, pacing, and use of intraaortic balloon counterpulsation whenever possible. Apart from special cannulas, the equipment necessary for the LHAD is widely available. An asset of the system (left atrial-ascending aorta bypass of the left ventricle) is that it may be terminated without reentering the thorax to remove the cannulas. This is accomplished with precisely fitting obturators that obliterate the cannula lumens and allow the tubes to be permanently implanted. This concept is believed important since critically ill patients requiring support are precisely those in whom added risk would be imposed by a second operation. Of the 14 patients who have had intraoperative and postoperative support (up to 6.8 days), 9 were weaned from the device and 6 were dismissed from the hospital. Four patients remain alive and are improved, the longest at 22 months since operation. The favorable performance of the LHAD suggests that it may prove useful either when intraaortic balloon counterpulsation cannot be successfully deployed or when it has failed to achieve hemodynamic stability.

Assisted Circulation↗
PubMed1976

A servocontrolled atrial-aortic assist device: experimental findings and clinical experience.

A servocontrol system was developed to regulate a single roller pump left atrial-aortic (La-A) assist device. Responsiveness of the servomechanism to blood volume changes, myocardial damage, and mitral regurgitation was evaluated in 5 sheep and 6 dogs. Myocardial damage was induced by occlusion of coronary arteries. and the hemodynamic effects of La-A assistance were evaluated. While La-A assistance reduced left atrial pressures to low levels, the left ventricular end-diastolic pressure remained elevated in the severely damaged heart. LaA-assistance was used in 3 patients. Two were weaned from cardiopulmonary bypass after failure of intraaortic balloon counterpulsation, and 1 is a long-term survivor. The third was supported for 48 hours after attempt repair of complex congenital heart disease. The servocontrol device added to the safety of prolonged La-A assistance. This mode of assistance should be considered when intraaortic balloon counterpulsation has failed.

Adolescent↗
PubMed1988

Perioperative morbidity in diabetics requiring coronary artery bypass surgery.

We retrospectively evaluated the operative results in 384 patients with diabetes mellitus operated on for ischemic coronary artery disease over a six-year period compared with a random group of 396 patients selected from 2,069 nondiabetic patients who underwent operation during the same study period. In our analysis of 13 preoperative and 5 intraoperative variables, diabetics revealed a significantly increased incidence of hypertension (p less than 0.05) and a smaller proportion of men (p less than 0.05). All other variables were not significantly different. The incidence of perioperative myocardial infarction, renal failure, neurological sequelae, leg infections, or thromboembolic events was similar in diabetic and nondiabetic patients. Hospital stay, however, was significantly increased in the diabetic group (p less than 0.05). The diabetic patients requiring intraaortic balloon counterpulsation had a significantly higher incidence of all postoperative complications analyzed compared with diabetics without balloon support (p less than 0.01), whereas the nondiabetic subset requiring intraaortic balloon counterpulsation exhibited only a significantly higher incidence of renal failure (p less than 0.01) and neurological complications (p less than 0.05). These results indicate that diabetes per se does not significantly increase morbidity in coronary bypass surgery.

Coronary Artery Bypass↗
PubMed1997

Risk analysis of coronary bypass surgery after acute myocardial infarction.

BACKGROUND: Current strategies for management of acute myocardial infarction (MI) include thrombolysis, angioplasty, and coronary bypass surgery singly or in combination. This study was designed to identify contemporary risk factors for coronary bypass surgery among patients in this high-risk group. METHODS: Between June 1992 and December 1995, 1181 consecutive patients underwent isolated coronary bypass surgery. Of these, 316 underwent coronary bypass surgery within 21 days of MI. Mean age was 65 years (range, 33 to 87 years), and 73% were male. There were 166 patients with stable angina (group 1), 107 patients with unstable angina requiring intravenous nitroglycerin for a control of ischemia (group 2), 20 patients with angina requiring intraaortic balloon counterpulsation for stabilization (group 3), and 23 patients with severe postinfarction ischemia complicated by cardiogenic shock (group 4). RESULTS: The overall in-hospital mortality rate was 5.1% (16 of 316), which was higher (p < 0.05) than the 2.5% (22 of 865) among patients undergoing coronary bypass surgery without recent myocardial infarction. Mortality increased with severity of clinical preoperative status and was 1.2% in group 1, 3.7% in group 2, 20.0% in group 3, and 26% in group 4. Serious postoperative morbidity occurred in 7.3% of patients. Multivariate logistic regression analysis identified preoperative intraaortic balloon counterpulsation, left ventricular dysfunction, and renal insufficiency as the only independent correlates of mortality. CONCLUSIONS: Coronary bypass surgery can be safely performed in stable patients at any time after acute MI, with an operative mortality similar to elective surgery. Thus, in this era of medical cost containment, there is no apparent indication for prolonged stabilization attempts that delay surgery.

Adult↗
PubMed1976

Mechanical circulatory assistance for the treatment of complications of coronary artery disease.

Surgery has become an accepted method of treatment for coronary artery disease and its complications. Revascularization results in significant improvement in symptoms for patients with angina pectoris. Occasionally, patients requiring surgery for angina pectoris will sustain reversible ischemic damage during operation; such patients can be successfully weaned from cardiopulmonary bypass with full recovery when intra-aortic balloon counterpulsation is used. Arrhythmias associated with ischemic damage to the myocardium also can be controlled when IABCP is used for physiologic assistance. Patients in cardiogenicshock of pulmonary edema after acute myocardial infarction have an ominous prognosis. When decompensation occurs, IABCP may be used to stabilize the patient and to allow study and corrective surgery if possible. The prognosis is better for patients with ventricular septal defect, although selected patients without a mechanical defect of the myocardium can be salvaged if the response to IABCP is favorable. Counterpulsation has also been shown to be useful in achieving pulsatile cardiopulmonary bypass and in assisting high-risk patients through operation. External pressure circulatory assist (EPCA) is less effective than IABCP in assisting the failing myocardium; however, the external device is noninvasive and may be a useful adjunct in situations where IABCP is not feasible.

Angina Pectoris↗
PubMed1987

Incidence and management of limb ischemia with percutaneous wire-guided intraaortic balloon catheters.

In 103 patients who underwent placement of 106 percutaneous wire-guided intraaortic balloon catheters between August 1983 and January 1986, all placements were successful and the average duration of counterpulsation was 3.4 +/- 1.6 days. During counterpulsation, 45 patients developed limb ischemia that required premature balloon removal in 29 patients. The development of limb ischemia was significantly related to the presence of diabetes (risk ratio 2.0), peripheral vascular disease (risk ratio 1.9), female gender (risk ratio 1.8) and the presence of a postinsertion ankle-brachial pressure index less than 0.8 (risk ratio 7.9). There was no association between the development of limb ischemia and age, body surface area, balloon size (10.5F/12F) or adequacy of anticoagulation. Fifteen patients underwent vascular surgery for treatment of balloon-related limb ischemia, which was associated with one operative death. Nine patients had persistent limb ischemia (seven asymptomatic, two symptomatic) at the time of hospital discharge. Improvements in wire-guided balloon technology have increased the probability of successful balloon placement over that of surgical placement and have reduced the incidence of major aortic injury, but there is no evidence that these improvements have reduced the incidence of limb ischemia or its sequelae. This should be borne in mind before proceeding with balloon insertion in patients with one or more risk factors for developing limb ischemia.

Aged↗
PubMed1997

Surgical treatment for life-threatening acute myocardial infarction: a prospective protocol.

OBJECTIVE: In this paper we describe the preliminary results of a prospective operative protocol designed in order to define the role of emergent myocardial revascularization in extensive acute myocardial infarction and in post-infarction cardiogenic shock. METHODS: Entry criteria are: age < 75 years; anterior acute myocardial infarction with ST segment elevation > 4 leads, infero-postero-lateral or inferior and right ventricular within 6 h from onset of chest pain; post-infarction cardiogenic shock within 3 h from onset of shock. From November 1994 to July 1995, after emergency coronary arteriography, 23 patients were treated by coronary artery bypass grafting. Fifteen were operated for extensive acute myocardial infarction (group A, mean age 54.1 +/- 9.4 years) and eight for post-infarction cardiogenic shock (group B mean age 65.0 +/- 8.7 years). Mean time from onset was 4.4 +/- 1.3 h in group A and 2.2 +/- 0.8 h in group B. Mean left ventricular ejection fraction was 39.3 +/- 12.7% in group A and 22.6 +/- 3.5% in group B. Six out of eight group B patients needed intraaortic balloon counterpulsation preoperatively, and 2/8 cardiopulmonary resuscitation. RESULTS: Myocardial revascularization consisted in 3.4 +/- 1.1 grafts in group A (vein grafts, except for 8 patients who also received a left internal thoracic artery graft) and 3.3 +/- 1.1 vein grafts in group B. All patients in group B and 3/15 (20%) in group A underwent intraaortic balloon counterpulsation. In-hospital death occurred in 1/15 (6.7%) patients of group A and in 4/8 (50%) patients of group B. At a mean follow-up of 4.1 +/- 3.4 months for group A and 3.9 +/- 2.2 months for group B left ventricular ejection fraction was 43.4 +/- 9.0% in group A and 35.7 +/- 13.1% in group B. CONCLUSIONS: Experience of 9 months with this prospective protocol showed its effectiveness in the management of critically ill patients with acute coronary occlusion leading to low mortality rate in acute myocardial infarction and improved survival rate in post-infarction cardiogenic shock.

Aged↗
PubMed2001

Spinal cord stimulation: a comparison of efficacy versus other novel treatments for refractory angina pectoris.

Recently much attention has been directed toward novel treatment alternatives for refractory angina pectoris. Refractory angina is persistent stable class III or IV angina despite maximally tolerated medical treatment in patients with end-stage coronary artery disease. Transmyocardial laser revascularization (TMLR), gene therapy, intermittent urokinase therapy, enhanced external balloon counterpulsation, and spinal cord stimulation have all been employed to treat refractory angina pectoris. TMLR and gene therapy are invasive open-chest procedures that have yielded controversial results. Intermittent urokinase and enhanced external balloon counterpulsation studies have limited follow-up times and require multiple clinic visits for treatment. Spinal cord stimulation has a proven short- and long-term efficacy and cost-effectiveness in the treatment of refractory angina. When compared to coronary artery bypass grafting (CABG), it has been shown to decrease the frequency of anginal attacks and consumption of short-acting nitrates to the same extent in refractory angina. Spinal cord stimulation's safety profile has also been well established and it can be used concurrently with cardiac pacemakers or MRI systems, provided the proper precautions are taken. Since spinal cord stimulation is a minimally invasive procedure with a favorable efficacy and safety profile, it should be considered as a valid treatment alternative after medical management has failed in refractory angina prior to implementing invasive modalities such as TMLR or gene therapy.

Journal Article↗
PubMed1994

The use of intra-aortic balloon pump after surgical treatment of DeBakey type I dissecting aneurysm of the aorta.

The case is reported of a sixty-four-year-old patient with DeBakey type I aortic dissection in whom postoperative extensive intra-aortic balloon pumping was applied. Surgical repair involved replacing the ascending aorta with a Medtronic Hall valved conduit. After surgery severe low-output syndrome occurred. Despite the use of high-dose inotropic drugs the patient could not be hemodynamically stabilized. An intra-aortic balloon pump was finally applied as a therapeutical last resort. Within three days, under counterpulsation, the patient reached a stable hemodynamic condition. After twenty-one days in the intensive care unit, he could be transferred to a normal ward. The patient was discharged on the fifty-fourth postoperative day. During counterpulsation there were no balloon- or catheter-induced complications. Follow-up at five months showed the patient in good general health: echocardiography did not identify any lesions of the thoracic aorta which could be linked to counter-pulsation. It is concluded that the postoperative use of intra-aortic balloon pump in the event of DeBakey type I dissecting aneurysm of the aorta, and adversely affected patient hemodynamics, is a justifiable therapeutical alternative.

Aged↗
PubMed1984

Intra-aortic balloon pumping in the elderly: percutaneous versus surgical catheter insertion.

The feasibility and safety of percutaneous versus intra-aortic balloon pumping (IABP) in the elderly were evaluated in 45 patients who were over 65 years of age (range 65-79). All the patients required counterpulsation for complicated acute myocardial infarction. IABP insertion was attempted by the surgical technique in 22 patients, while the percutaneous approach was performed in 23. A consistent improvement in the incidence rate of successful insertion was attained with the use of the percutaneous technique as compared with the surgical one (91.3% v 59.1%, P is less than 0.05). Furthermore, no major complication was observed with the percutaneous catheter, while a 9.1% (2/22) incidence rate of serious complications was reported with the surgical technique. Thus, percutaneous IABP substantially decreased the unsuccessful insertions and the risk of severe complications in old patients, despite presumably severe aorto-iliac disease. No specifically age-related technical problem seems, therefore, to limit the applicability of intra-aortic counterpulsation to elderly patients, when percutaneous IABP is employed.

Aged↗
PubMed1986

Intraaortic balloon assistance in intractable cardiogenic shock.

The efficacy of intraaortic counterpulsation (IABP) in severe cardiogenic shock after acute myocardial infarction is questioned because of the lack of a large controlled series. Out of 52 patients treated for severe, prolonged cardiogenic shock 3 improved with 'conventional' treatment. Forty-nine patients did not improve and were in 'intractable' shock for an average of 10.74 +/- 7.14 h (means +/- SD). Of these, 34 were treated with IABP. Ten survived longer than a month. Of the remaining 15 patients of similar age, severity and duration of shock, in whom the balloon could not be made to operate, none survived. It is suggested that intraaortic counterpulsation can save a number of patients with severe protracted cardiogenic shock after all other available treatment modalities have failed.

Adult↗
PubMedDate not supplied

Direct cardiac potential trigger for chronic control of a ventricular assist device.

As a new trigger method for chronic drive control of a ventricular assist device (VAD), a direct cardiac potential trigger was assessed under various conditions in a chronic experimental model. A pneumatic pulsatile VAD was implanted as circulatory support between the left ventricular apex and the ascending aorta in 12 adult pigs. Hemodynamic parameters and pump output were continuously monitored. Two tips of a bipolar electrode were set on the RV anterior wall and the LV posterior wall for recording direct cardiac potential. Counterpulsation drive of the VAD was applied by using the R wave in a standard electrocardiogram (ECG) or the direct cardiac potential as an ECG trigger. As special conditions, various artifacts on ECG, electromusculogram, arrhythmia, irregular ventilation, and passive vibration (simulation of exercise) were set for assessing the ECG trigger modes. Artifacts of irregular ventilation and passive vibration made the drive control poor using a standard ECG trigger. In contrast, the direct cardiac potential trigger maintained the counterpulsation control of the VAD well in all conditions of this study, and was a safe and reliable support for the native heart. It also supported animals for up to 48 hours after operation. The above results suggested that the direct cardiac potential trigger might be useful for monitoring native heart beats and adjusting the support cycle to the native heart cycle as a chronic control method for various VADs.

Animals↗
PubMed1991

Interventions to support the failing right ventricle.

Right ventricular failure is a critical event that quickly improves or deteriorates. Interventions to support the failing right ventricle are extensive, beginning with adequate volume loading and vasopressor support. If these methods are not effective, invasive support is instituted, including intrapulmonary artery balloon counterpulsation and ventricular assist devices. This article discusses volume loading and vasopressive therapy, including drugs and doses. Invasive therapy of intrapulmonary artery balloon counterpulsation and ventricular assist devices are included, as well as institution and weaning procedures. Appropriate nursing considerations and interventions are outlined in detail.

Cardiotonic Agents↗
PubMed1985

Sheath impaction as a cause of defective intra-aortic balloon pump action in man.

Intra-aortic balloon counterpulsation became ineffective in a 63 inch (160 cm) 14 year old girl while console operation proceeded almost normally. The problem was simulated in a hydraulic model of the aorta and could be reproduced when the proximal end of the balloon engaged in the introducing sheath. Measurements of the balloon catheter and sheath against the patient indicated that such engagement had occurred during counterpulsation. The findings provide an explanation for apparent catheter 'kinkage' in other patients where there was difficulty running the Kontron console in automatic mode. Problems are preventable by total or partial withdrawal of the inserting sheath.

Adolescent↗
PubMed1989

In-vitro evaluation of a valveless cardiac-assist pump.

Diseases of the cardiovascular system are a major health-care problem. Nearly 50% of all deaths are due to cardiovascular disease. A number of cardiovascular patients experience heart failure, mostly of the left ventricle, and require some form of mechanical support. Cardiac-assist devices are used widely in the treatment of patients with damaged heart muscle. Cardiac-assist devices have been introduced recently to maintain circulation in heart failure patients, until a suitable heart transplant donor is found. Earlier types of left ventricular assist devices were the copulsation and the counterpulsation pumps, which increased the efficiency of the vascular system and decreased the workload on the failed heart. In this study, the authors investigated the performance of a valveless cardiac assist device that can be operated in copulsation, counterpulsation, or any intermediate mode with the left ventricle. The device has only one connection to the ascending aorta, no valves, and a common inlet/outlet. The authors measured the hemodynamic parameters in all modes and have suggested an optimal mode of operation in a left ventricular heart failure mode.

Heart Diseases↗
PubMed1992

Pericardiovascular approach to cardiac assist: acute feasibility study.

We tested the hypothesis that external synchronized compression of the cardiovascular system can achieve effective hemodynamic assistance while circumventing problems associated with the blood-polymer interface in traditional cardiac assist devices. Ten dogs were studied to develop and test prototype devices and evaluate their hemodynamic effectiveness. Copulsation assistance was studied in animals with fibrillating hearts using Anstadt pericardiac cups. Mean systolic arterial pressure of 81.2 mm Hg and cardiac output of 2.9 L/min were achieved. Counterpulsation assistance was studied by inflating during diastole a balloon placed between the thoracic aorta and periaortic sheath and deflating the balloon during systole. In 4 dogs, 25 +/- 8.6% (SEM) of diastolic augmentation and 8.3 +/- 1.2% of systolic unloading were achieved. These preliminary results indicate the feasibility of a pericardiovascular approach to cardiac assistance. Further device development and the integration of copulsation and counterpulsation may improve cardiac output, reduce cardiac afterload, augment coronary perfusion, and ultimately benefit patients with severe heart failure.

Animals↗