Percutaneous left ventricular assist device: "TandemHeart" for high-risk coronary intervention.

Patients undergoing percutaneous coronary intervention (PCI) with severely compromised left ventricular systolic function and complex coronary lesions, including multivessel disease, left main disease, or bypass graft disease, are at higher risk of adverse outcomes from hemodynamic collapse. The TandemHeart percutaneous ventricular assist device may provide circulatory support during high-risk PCI. We implanted the TandemHeart device in eight patients who underwent high-risk PCI. The patients were considered to be at exceptionally high risk for decompensation due to procedural complexity combined with underlying LV dysfunction. The mean ejection fraction was 30% +/- 9% and five patients were turned down for surgical revascularization. Seven patients underwent multivessel PCI, including three patients who underwent unprotected left main coronary artery PCI. There was 100% procedural success. The TandemHeart was removed immediately post-PCI with no groin complications. Six patients are event- and symptom-free at 189 +/- 130 days; one patient died 10 days post-PCI after lower extremity bypass surgery and another developed acute renal failure postprocedure, requiring hemodialysis. Our initial clinical experience with the TandemHeart ventricular assist device demonstrates that hemodynamic support can be rapidly achieved percutaneously during high-risk PCI, with excellent procedural success in highly complex and critically ill patients.     

Percutaneous (nonsurgical) supported angioplasty in unprotected left main disease and severe left ventricular dysfunction

A 69-year-old patient with the equivalent of severe, unprotected left main coronary artery disease associated with marked left ventricular dysfunction with ventricular aneurysm who had Class IV angina, underwent supported angioplasty utilizing a total percutaneous approach. The patient tolerated occlusion of his main left coronary artery for a total of 7 minutes without difficulty, during dilatation of left anterior descending and two circumflex lesions. He was discharged the following day, symptom free.     

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

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. Cathet. Cardiovasc. Diagn. 45:115–119, 1998. © 1998 Wiley-Liss, Inc.     

Coronary angioplasty in high-risk patients with left main coronary stenosis: Results from the national registry of elective supported angioplasty

To assess the outcome of PTCA in circulatory supported patients with left main coronary artery (LMCA) stenosis, the National Registry of Elective Supported Angioplasty data bank was searched. Patients entered in the registry were considered high-risk PTCA and the PTCA was performed using percutaneous cardiopulmonary bypass (PCPB). Criteria for high risk was left ventricular ejection fraction <25% or a target lesion supplying >50% of functioning myocardium. Of 455 patients entered in the registry, 61 (13.3%) had LMCA stenosis >60%. There were 42 patients in whom the PTCA target vessel was the LMCA (PTCA-LMCA) and 19 in whom it was vessel(s) other than the LMCA (PTCA-OTHER). The mean age was similar in the 2 groups (65 ± 10 vs. 68 ± 9yrs, p = ns). The left ventricular ejection fraction (LVEF) was higher in PTCA-LMCA than in PTCA-other (38 ± 16% vs. 27 ± 16%, p <0.05). The number of vessels dilated/patient was higher in PTCA-LMCA than in PTCA-OTHER (2.1 ± 1.0 vs. 1.1 ± 0.3, p <0.001). There were a total of 10 in-hospital deaths (16%) in patients with LMCA >60% stenosis. This exceeds the mortality of the patients with <60% LMCA stenosis entered in the registry (4.5%, p <0.001). There were 6 in-hospital deaths (14%) in PTCA-LMCA and 4 (21%) in PTCA-OTHER (p = ns). PTCA in the presence of LMCA stenosis, whether the LMCA is the target vessel or not, carries a very high risk, independent of LVEF or the number of vessels dilated, despite the use of PCPB.     

Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal

Left main stem coronary stenosis is now uniformly treated with coronary artery bypass grafting. The advent of percutaneous transluminal coronary angioplasty has permitted a non-operative improvement in myocardial blood flow in many cases of single- and multi-vessel coronary atherosclerosis. The use of percutaneous transluminal coronary angioplasty in left main stem coronary stenosis has been sporadic and controversial. Twenty percutaneous transluminal coronary angioplasties were attempted in 19 patients as the treatment of choice for left main stem coronary stenosis in the past 66 months. The primary success rate was 95% (19/20 patients). The emergency surgery was performed only once (5%), and no death occurred secondary to percutaneous transluminal coronary angioplasty itself. In the follow-up (mean 41 months) period, 12 patients (63%) remained in satisfactory condition with no further need for surgical intervention. Seven patients (37%) ultimately required coronary artery bypass grafting. Although coronary artery bypass grafting will remain the fundamental treatment for left main stem coronary stenosis, this series delineates those anatomic and clinical exceptions wherein percutaneous transluminal coronary angioplasty may be utilized as the primary therapy for left main stem coronary stenosis.     

Percutaneous transluminal coronary angioplasty of the left main coronary artery in patients with rest angina

Left main coronary angioplasty may be a therapeutic revascularization procedure for a subset of patients with symptomatic coronary artery disease. The purpose of this study is to report procedural outcomes and long-term clinical follow-up of 15 patients who underwent either protected or unprotected left main angioplasty for rest angina. These patients represent a cohort of unstable angina patients who were considered high risk for coronary artery bypass surgery. Ten of 15 patients had Canadian Heart Class IV angina, and three patients were hemodynamically unstable. Balloon angioplasty was successful in 14 patients, and one patient was treated with directional atherectomy. Initial angiographic success was achieved in 14 of 15 patients (93%). Major complications (myocardial infarction, emergent coronary artery bypass graft, death) occurred in one patient (6%); 73% of the patients were asymptomatic or had stable exertional angina at 6 months follow-up. One year survival was 87% (13 of 15). During the follow-up period six patients had repeat catheterization for recurrent angina. Four of these patients had left main restenosis and underwent successful repeat left main angioplasty. No patient had coronary bypass surgery during follow-up. This report suggests that left main angioplasty can be a safe and effective revascularization procedure for critically ill patients with unstable angina who are at high risk for coronary bypass surgery. © Wiley-Liss, Inc.     

Percutaneous transluminal coronary angioplasty in patients with reduced left ventricular ejection fraction: effects on myocardial perfusion and left ventricular response to exercise

Many patients with coronary artery disease treated by percutaneous transluminal coronary angioplasty (PTCA) have a history of previous myocardial injury resulting in a reduced left ventricular ejection fraction (EF). The effects of successful PTCA on myocardial perfusion and left ventricular function in these patients were compared to treatment in patients with normal left ventricular EF. There were 21 patients with a normal EF (mean EF 59 +/- 2%) (Group I) and 15 patients with reduced EF (mean EF 43 +/- 1%) (Group II). Before PTCA a similar degree of reversible myocardial ischemia was present on thallium scintigraphy. At peak exercise left ventricular EF in the Group I patients decreased by 4 +/- 1% compared to 8 +/- 1% in Group II. At one month following successful PTCA there was resolution of reversible myocardial ischemia in both groups. No changes in EF at rest were observed. At the same level of exercise as before PTCA the mean EF was 5 +/- 1% higher than the pretreatment value in Group I and 10 +/- 1% higher in Group II. Thus in this study reversible myocardial ischemia was associated with severe compromise in the left ventricular response to exercise which was substantially improved by PTCA.     

Successful high-risk coronary angioplasty in a patient with cardiogenic shock under circulatory assist with a 16F axial flow pump.

We report the case of a 75-year-old patient who suffered from subacute myocardial infarction and severely impaired left ventricular ejection fraction (EF: 17%). Using a novel 16F left ventricular assist device we performed an angioplasty of the right coronary artery, and of the left anterior descending artery. As a result of the circulatory support the patient recovered from cardiogenic shock within 8 hr. At a pump speed of 45,000 rpm the axial flow pump generated flow rates up to 3.3 l/min. The 16F pump cannula was removed using local compression. The EF was 51% at 30-day follow-up examination.     

Percutaneous transluminal angioplasty in patients greater than or equal to 5 years after their last coronary bypass graft surgery

Angioplasty (PTCA) was successfully performed in 257 of 304 patients (85%) greater than or equal to 5 years after their last bypass surgery. A lesion was successfully dilated in 496 of 566 vessels attempted (88%): 332/386 coronary arteries (86%) and 164/180 vein grafts (91%). Significant complications included: 8 (2.6%) mortalities, 4 (1.3%) emergency surgeries, 13 (4.3%) Q-wave myocardial infarctions, and 14 (4.6%) distal embolizations. Distal embolization occurred in 13/180 (7%) vein graft lesions dilated and usually resulted in a non-Q-wave infarction (4/13 distal embolizations). A second PTCA was performed on 89 (35%) patients: 44% of them had lesion recurrence; 20% a new lesion requiring dilatation; and 30% both recurrence and new lesion. Follow-up (mean 3.7 years) revealed 78% of patients having an improved anginal status, and 58% no angina. The cumulative probability of survival at 60 months was 88 +/- 3%. Angioplasty can be effectively employed in patients greater than or equal to 5 years remote from their last bypass surgery in native arteries or saphenous vein grafts with good procedural and long-term success. Vein graft age inherently does not appear to be a contraindication to angioplasty.     

Emergency coronary angioplasty in patients with severe left ventricular dysfunction or cardiogenic shock after acute myocardial infarction

Emergency percutaneous transluminal coronary angioplasty (PTCA) was performed during an acute myocardial infarction (AMI) after either systemic or intracoronary thrombolytic therapy in six patients with severe ischaemic left ventricular dysfunction or cardiogenic shock, among 37 patients (17%) who were treated with PTCA during AMI over a 13-month period. Thrombolytic therapy with streptokinase (1.5 x 10 Units) was initiated after a mean (+/- SD) time delay of 5.5 +/- 1.3 h from the onset of symptoms. The infarct-related artery was found to be occluded (TIMI grade 0-1) in three patients and partially reperfused (TIMI grade 2) in the remaining patients at baseline coronary angiography. Intracoronary administration of urokinase (100-200,000 Units) was ineffective in those patients failing systemic thrombolysis and resulted in only a slight increase of residual lumen in three patients. The coronary artery could be opened by a guidewire mechanical technique in patients with persistent coronary artery occlusion and coronary dilation could be done in all patients. The mean percentage diameter stenosis of the infarct-related vessel was reduced from 98.8 +/- 2% to 27 +/- 11% (P less than 0.005). After the procedure, left ventricular ejection fraction increased from 27 +/- 8% to 41 +/- 7% (P less than 0.02), systemic blood pressure and cardiac index increased respectively from 86 +/- 10 to 126 +/- 14 mmHg (P less than 0.005) and from 2.2 +/- 0.6 to 3.3 +/- 0.6 (P less than 0.01). Left ventricular end-diastolic pressure decreased from 26 +/- 8 to 18 +/- 3 mmHg (P less than 0.05). Severe mitral regurgitation was relieved in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

Percutaneous transhepatic stenting of a restrictive atrial septal communication in hypoplastic left heart syndrome

The postnatal survival of patients with congenital cardiac defects such as hypoplastic left heart syndrome (HLHS) is dependent on the patency of the ductus arteriosus and the presence of an unrestrictive atrial septal defect (ASD). We report a six week old infant with HLHS and tricuspid valve regurgitation with restrictive ASD. Transfemoral balloon atrial septostomy provided temporary relief but further attempts were not possible. A transhepatic venous approach to stent the atrial communication was technically successful. This approach may be the only access for certain infant cardiac catheterization interventions, permitting the use of a large delivery system (≥ 8 Fr). © 2014 Wiley Periodicals, Inc.     

Percutaneous transluminal coronary angioplasty of the left internal thoracic artery graft: a case report in a child

A 9-year-old girl who had undergone previous coronary artery bypass surgery at the age of 3.5 years for stenoses of the left anterior descending and right coronary arteries resulting from Kawasaki disease presented with recurrent exertional angina. Stenosis was found at the anastomosis of the left internal thoracic artery to the left anterior descending artery. Percutaneous transluminal coronary angioplasty was successfully performed. This is the first reported case of percutaneous transluminal coronary angioplasty of an internal thoracic artery graft in a child. © 1994 Wiley-Liss,Inc..     

Adaptor device for shortening guide catheters to access distal lesions in coronary angioplasty

One of the challenges in interventional cardiology is accessing distal stenoses in both native coronary arteries and bypass grafts. This article reports the fabrication and use of an adaptor device that can be connected to the proximal segment of a shortened guide catheter for easier and safer access to these distal lesions. © 1993 Wlley-Liss, Inc     

Percutaneous transluminal coronary angioplasty using kissing balloon technique in the left main trunk

Summary This report describes the feasibility of the kissing balloon technique in the left main trunk in selected patients who had stenosis in the left main trunk involving bifurcation of the anterior descending artery and the circumflex artery and who also had enough blood flow to distal coronary to prevent left ventricular dysfunction during balloon occlusion or abrupt re-closure in the left main.     

Indications for coronary angioplasty in acute myocardial ischemic syndromes

Summary The role of coronary angioplasty for the treatment of patients with evolving myocardial infarction, unstable angina, and early postinfarction unstable angina is discussed.It has been shown that coronary angioplasty in patients with an evolving myocardial infarction is feasible and can be performed with a high initial success rate. The most beneficial timing of dilatation is still unclear, and acute reocclusion following coronary angioplasty remains a problem. Current data suggest that the left ventricular function is greater improved and peri-infarction ischemia is less with angioplasty when compared with sole thrombolytic treatment.Coronary angioplasty for unstable angina and early post-infarction unstable angina can be performed with a high initial success rate, but at an increased risk of major complications.Thus, coronary angioplasty has nowadays obtained a definitive place in the treatment of acute myocardial ischemic syndromes. Further research is needed to improve the initial and late results of coronary angioplasty, and additional randomized clinical studies are necessary to more accurately define the indications and timing of dilatation in these acutely ill patients.     

Hyperoxemic perfusion of the left anterior descending coronary artery after primary angioplasty in anterior ST-elevation myocardial infarction.

OBJECTIVES: To assess left ventricle function recovery, ST-segment changes, and enzyme kinetic in ST-elevation myocardial infarction patients treated with intracoronary hyperoxemic perfusion (IHP) after primary percutaneous coronary intervention and compare them with the results obtained in control patients. BACKGROUND: IHP has been shown to attenuate microvascular reperfusion injury, which may result in poor LV function recovery despite successful primary percutaneous coronary intervention. METHODS: Twenty seven anterior ST-elevation myocardial infarction patients treated < or = 12 hr after symptom onset by primary percutaneous coronary intervention were subjected to selective IHP into the left anterior descending coronary artery for 90 min. They were compared with 24 anterior ST-elevation myocardial infarction control patients matched in clinical and angiographic characteristics and treated with conventional primary percutaneous coronary intervention. Left ventricular function recovery was evaluated by serial 2D contrast echocardiography. RESULTS: Left anterior descending coronary artery recanalization was successful in all patients. After IHP (100% successful, duration 90 +/- 5.4 min), patients showed a 4.8 +/- 2.2 hr shorter time-to-peak creatine kinase release (P = 0.001), a shorter creatine kinase half-life period (23.4 +/- 8.9 hr vs. 30.5 +/- 5.8 hr, P = 0.006), and a higher rate of complete ST-segment resolution (78% vs. 42%, P = 0.01). A significant improvement of mean left ventricular ejection fraction (from (44 +/- 9)% to (55 +/- 11)%, P < 0.001) and wall motion score index (from 1.77 +/- 0.2 to 1.39 +/- 0.4, P < 0.001) was observed at 3 months in IHP patients only. CONCLUSION: After successful primary coronary intervention, IHP is associated with significant left ventricular function recovery when compared to conventional treatment. Enzyme kinetic and ST-segment changes suggest faster and more complete microvascular reperfusion and may explain the salutary effects of this new therapy on left ventricular function.     

Percutaneous left axillary artery approach for Impella 2.5 liter circulatory support for patients with severe aortoiliac arterial disease undergoing high-risk percutaneous coronary intervention

The use of the Impella 2.5 liter (L) device for hemodynamic support has been well described. The typical access site for the Impella 2.5 L device is the femoral artery. The use of the axillary and subclavian artery has been described via surgical cut down for the Impella 5 L device when femoral artery access is not possible. In patients with severe aortoiliac disease and difficult anatomy the femoral artery access for the Impella 2.5 L device is not feasible. We describe the successful percutaneous use of the Impella 2.5 L device for hemodynamic support via the left axillary artery in 2 patients undergoing high-risk PCI with concomitant severe aortoiliac disease.