Emergency portable cardiopulmonary bypass for abrupt left main occlusion during coronary angioplasty. Excellent long-term survival.

A 53-year-old man had total occlusion of the left main coronary artery with subsequent cardiac arrest during attempted angioplasty of the circumflex coronary artery. Conventional resuscitation was unsuccessful. However, emergent portable cardiopulmonary bypass support in the catheterization laboratory contributed to excellent long-term survival. Portable cardiopulmonary bypass support is a valuable resuscitative tool readily available in the catheterization laboratory setting.     

Emergency percutaneous cardiopulmonary bypass support in cardiogenic shock from acute myocardial infarction

Emergency percutaneous cardiopulmonary bypass support was instituted in 8 consecutive patients, ages 42 to 80 years, in cardiogenic shock for 30 to 180 minutes (mean 106) due to acute myocardial infarction. The location of the infarction was inferior in 4, anterior in 3 and lateral in 1. Four patients had a history of prior myocardial infarction. Two patients were in cardiac arrest; the remaining 6 had a mean blood pressure of 43 to 55 mm Hg before the bypass. Five had pulmonary capillary Wedge pressure greater than or equal to 20 mm Hg. One patient, with a right ventricular infarction, had a pulmonary wedge pressure of 10 mm Hg. Percutaneous insertion of 20Fr cannulas was carried out. Flow rates of 3.2 to 5.2 liters/min were achieved. Two patients in cardiac arrest regained consciousness while still in ventricular fibrillation or asystole. Left ventricular ejection fraction ranged from 17 to 40% (mean 32). One patient had left main, 4 had multivessel, and 4 had 1-vessel coronary disease. Seven patients had successful angioplasty of 15 of 16 lesions attempted, with all infarct-related vessels successfully dilated. One patient had lesions unsuitable for either bypass or angioplasty and died. Need for blood transfusion was the most frequent complication. One patient required surgical repair of the femoral artery. All 7 patients are alive at a mean follow-up of 8.2 months. It is concluded that cardiopulmonary bypass can be safely instituted percutaneously, hemodynamically stabilize patients in cardiogenic shock and facilitate emergency complex coronary angioplasty, which may be life-saving.     

A nursing guide for patient care after percutaneous cardiopulmonary support.

Information is presented about a relatively new procedure being used in the critical care area. The percutaneous insertion technique for the initiation of cardiopulmonary bypass support (PCPS) has given new hope for patients who are considered high risk for elective coronary angioplasty and to those who suffer cardiopulmonary arrest in the cardiac catheterization laboratory or critical care unit. The initiation process of cardiopulmonary bypass support and the criteria for elective cases are reviewed and two case studies follow. Specific attention is given to the immediate postprocedural phase, where nursing responsibilities and prioritization of patient care are addressed. A nursing care guide is included.     

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.     

Clinical application of percutaneous cardiopulmonary bypass for high risk coronary angioplasty

Percutaneous cardiopulmonary bypass support was electively instituted prior to coronary angioplasty in 16 patients at high risk for hemodynamic collapse. In all cases the dilated artery supplied greater than 2/3 of the functioning myocardium. Eight patients had moderate LV dysfunction with ejection fraction 25-40%. Eight patients had an ejection fraction less than 20%. A 21 French cannula and a 17 French cannula were percutaneously inserted into the femoral vein and artery. Cardiopulmonary bypass support was instituted using a Bio-Medicus centrifugal pump just prior to coronary angioplasty at flow rates of 3.5-5 liters/minute. Thirteen patients had single vessel angioplasty and three patients had multivessel angioplasty. Complete loss of systolic function was observed in 9 (56%) patients. This finding when present confirms the absolute requirement for cardiopulmonary support. Technical success was achieved in all 16 patients (100%), clinical success was achieved in 14 patients (88%). Patient followup (mean 10 months) revealed 3 patients with class I-II angina and 10 patients were asymptomatic. There was one late death. In conclusion, percutaneous cardiopulmonary bypass support for carefully selected high risk patients may allow coronary angioplasty to be performed safely and effectively despite complete loss of systolic function during balloon inflation.     

The role of extracorporeal membrane oxygenation in emergent percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock and cardiac arrest

Patients with myocardial infarction (MI) who have out-of-hospital cardiac arrest and cardiogenic shock have a high mortality rate. Although intra-aortic balloon counterpulsation is frequently used in patients with cardiogenic shock, it does not provide complete hemodynamic support. We report 2 cases in which extracorporeal membrane oxygenation was instituted emergently in the cardiac catheterization laboratory in patients with MI and cardiac arrest who underwent percutaneous coronary intervention and who were hemodynamically unstable despite inotropic agents and intraaortic balloon counterpulsation.     

Recent advances in assisted circulation using centrifugal pump in surgical and non-surgical patients with acute heart failure or related conditions.

During the last 3 years, left or bi-ventricular support using a centrifugal pump as a ventricular assistance device was performed in 10 patients after open heart surgery. The basic lesions were coronary heart disease in 8 and valvular disease in 2 patients. Bypass support ranged in time from 33 to 240 h (average 114 h), and 3 patients received biventricular support. Six patients have survived in this group. Other supportive methods, in the form of emergency or elective use of portable cardiopulmonary bypass support, were used in 8 patients; 4 with cardiogenic shock and 4 for supported percutaneous coronary angioplasty. These assisted circulations appear to be useful and promising in the management of the critical cardiac patient.     

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

Fifty-one consecutive patients in whom percutaneous cardiopulmonary bypass support was instituted to enhance the safety of high-risk elective coronary angioplasty were studied. All patients had a low ejection fraction, a large amount of viable myocardium perfused by the target artery(s) or both. Thirty-five men and 16 women, mean age 63 years, with Canadian Cardiovascular Society class III angina (23 patients) or class IV (28 patients) were studied. There was a history of myocardial infarction in 45 (88%), bypass surgery in 14 (27%) and congestive heart failure in 17 (33%). Forty-six (90%) had impaired left ventricular function. Twenty (39%) had an ejection fraction of less than or equal to 25%. Left main stenosis was present in 9 (18%), 3-vessel disease in 48 (94%) and 2-vessel disease in 2 (4%). Twenty (39%) were considered at a prohibitive risk for bypass surgery (14 were turned down for surgery). Bypass was instituted percutaneously with flows ranging from 2 to 5 liters/min (mean 3.6). Angioplasty was successful in 115 of the 117 lesions attempted with the culprit vessel dilated in all. Dilatation of the only remaining vessel was performed in 14 (27%). Inflation times up to 10 minutes were well tolerated. Bypass was discontinued after a mean bypass time of 37 minutes. Hemostasis was achieved by external clamp compression in 50. There were 3 hospital deaths unrelated to bypass. Patient follow-up at 2 to 8 months (mean 4.9) disclosed 1 late death, 31 (66%) asymptomatic patients, 12 (26%) patients in class I and 4 patients (9%) in class II. Thus, this study demonstrates the safety and efficacy of percutaneous bypass support in selected patients undergoing high-risk coronary angioplasty.     

Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass

OBJECTIVE: To compare cardiac troponin T release and lactate metabolism in coronary sinus and arterial blood during uncomplicated coronary grafting on the beating heart with conventional coronary grafting using cardiopulmonary bypass. DESIGN: A prospective observational study with simultaneous sampling of coronary sinus and arterial blood: before and 1, 4, 10, and 20 minutes after reperfusion for analysis of cardiac troponin T and lactate. Cardiac troponin T was also analysed in venous samples taken 3, 6, 24, 48, and 72 hours after surgery. SETTING: Cardiac surgical unit in a tertiary referral centre. PATIENTS: 18 patients undergoing coronary grafting on the beating heart (10 single vessel and eight two-vessel grafting) and eight undergoing two-vessel grafting with cardiopulmonary bypass. RESULTS: Cardiac troponin T was detected in coronary sinus blood in all patients by 20 minutes after beating heart coronary artery surgery before arterial concentrations were consistently increased. Peak arterial and coronary sinus cardiac troponin T values on the beating heart during single (0.03 (0 to 0. 05) and 0.09 (0.07 to 0.16 microg/l, respectively) and two-vessel grafting (0.1 (0.07 to 0.11) and 0.19 (0.14 to 0.25) microg/l) were lower than the values obtained during cardiopulmonary bypass (0.64 (0.52 to 0.72) and 1.4 (0.9 to 2.0) microg/l) (p < 0.05). The area under the curve of venous cardiac troponin T over 72 hours for two-vessel grafting on the beating heart was less than with cardiopulmonary bypass (13 (10 to 16) v 68 (26 to 102) microg.h/l) (p < 0.001). Lactate extraction began within one minute of snare release during beating heart coronary surgery while lactate was still being produced 20 minutes after cross clamp release following cardiopulmonary bypass. CONCLUSIONS: Lower intraoperative and serial venous cardiac troponin T concentrations suggest a lesser degree of myocyte injury during beating heart coronary artery surgery than during cardiopulmonary bypass. Oxidative metabolism also recovers more rapidly with beating heart coronary artery surgery than with conventional coronary grafting. Coronary sinus cardiac troponin T concentrations increased earlier and were greater than arterial concentrations during beating heart surgery, suggesting that this may be a more sensitive method of intraoperative assessment of myocardial injury.     

Safety and efficacy of percutaneous transluminal coronary angioplasty performed at time of diagnostic catheterization compared with that performed at other times

Performing diagnostic cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA) as a single, combined procedure might provide savings in patient hospitalization days and more efficient use of catheterization laboratory time. To assess the safety and efficacy of combined diagnostic coronary angiography and PTCA, we reviewed all elective PTCA procedures performed at our institution during 1985 and 1986 so that we could compare patients who had diagnostic angiography and angioplasty on separate days (n = 404) with those who had the combined procedure (n = 120). The success rate and incidences of urgent bypass surgery, acute myocardial infarction, transient azotemia and procedure-related death were not different in the 2 groups. The mean hospitalization time was 6.2 days in the group with combined angiography and angioplasty, and 7.3 days in the group having separate procedures.     

Benefits of training physicians in advanced cardiac life support

Unexpected cardiopulmonary arrests occur commonly both in the prehospital setting and in the course of hospital care. Survival after prehospital arrest is improved if bystanders and paramedics are trained in basic and advanced cardiac life support. However, within the hospital, the bystanders are the physicians; it is not known if life support training of these hospital-based physician bystanders leads to improved survival. Therefore, we reviewed the outcome of resuscitation attempts in a teaching hospital during two matching six-month periods, before (period 1) and after (period 2) institution of a mandatory course in Advanced Cardiac Life Support (ACLS) for medical houseofficers. It was concluded that survival after inhospital cardiopulmonary arrest is significantly increased if house officers who staff the Code teams are trained in ACLS.     

Preliminary experience with a percutaneous cardiopulmonary support system.

Percutaneous cardiopulmonary bypass has been introduced to support circulation in critical patients. In our preliminary experience we resuscitated two patients who sustained a prolonged cardiac arrest (52 min. and 31 min.) after coronary angiography and elective cardiac surgery, respectively. Cannulation was achieved percutaneously within 10 min. in both cases. Pump flow ranged from 2 to 31/m. Total support lasted from 52 min. to 180 min.. Both patients were successfully weaned. Patient 1 was declared brain dead and expired 17 days later. Patient 2 was discharged from the hospital and is doing well. Cannulation was attempted in a third patient after 30 min. of cardiac arrest. Despite surgical cut down of the femoral vessels, it was impossible to advance the arterial cannula because of bilateral occlusive disease. We conclude that PCPS is a powerful technique in selected patients to recover a stable cardiac function after prolonged cardiac arrest.     

Anaesthetic considerations for noncoronary surgery on a perfused beating heart under cardiopulmonary bypass

Myocardial revascularisation on a beating heart with or without cardiopulmonary bypass has significantly reduced the incidence of cardioplegic myocardial injury. With this advantage in view, noncoronary open heart surgery was performed on a beating heart under cardiopulmonary bypass. We discuss the anaesthetic management of such cases. Thirty-three patients aged 14-56 years underwent open heart surgery on a perfused beating heart. Eleven of them underwent open mitral valvotomy, eighteen underwent mitral valve replacement, repair of atrial septal defect was performed in 3 patients and one had removal of left atrial myxoma. Cardiopulmonary bypass was instituted with aortic and bicaval cannulation. At normothermia, aorta was cross-clamped and continuous coronary perfusion was maintained through an aortic root needle at a rate of 4-6 mL/Kg/minute facilitating a beating heart. Trans-oesophageal echocardiography was routinely deployed. Anaesthetic considerations were focused towards the maintenance of the beating state of the heart, that included, strict control of electrolyte balance, maintenance of adequate perfusion pressure and ST segment monitoring. All the patients could be weaned off cardiopulmonary bypass without defibrillation or significant inotropic support. There was no operative mortality. Open heart surgery on a beating heart for non-coronary cardiac conditions appears to be a good and reproducible option to protect the myocardium from deleterious effects of cardioplegic arrest.     

Percutaneous transluminal coronary angioplasty in silent ischemia

The short- and long-term outcome of percutaneous transluminal coronary angioplasty were analyzed in 34 patients who had documented coronary artery disease without symptoms. Of the 34 patients, 33 had abnormal stress tests before angioplasty. Angioplasty was successful in 31 patients (91%). Follow-up was 100% for a mean period of 36 +/- 15 months. Follow-up exercise test was normal or improved in 29 of the 31 patients who had successful angioplasty. Follow-up catheterization was performed in 24 of the 31 patients (77%). Restenosis of the previously dilated segment was found in seven patients. Actuarial cardiac survival at 3 years was 100%. Freedom from myocardial infarction, bypass surgery, angioplasty for a new lesion, and death was 87%. We conclude that although the most effective treatment for silent ischemia remains to be determined, our data suggest that coronary angioplasty is a therapeutic option in these patients.     

High risk coronary angioplasty using percutaneous cardiopulmonary bypass support.

Twenty high risk patients with severe angina were subjected to balloon angioplasty after instituting percutaneous cardiopulmonary bypass support to enhance the safety of high risk elective coronary angioplasty. All patients had a low ejection fraction, a large amount of viable myocardium perfused by the targeted artery or both (left ventricular ejection fraction < or = 25% in 15 patients). Three vessel disease was present in all. Angioplasty of the only remaining vessel was done in 14 patients, 2 vessels in 5 patients and a sequential graft in 1 patient. Bypass flows ranged from 2.8-4.5 litres. Bypass was discontinued after a mean bypass time of 35 min. Haemostasis was achieved by external clamp compression in 16 patients. The angioplasty was successfully performed in all the patients and the procedure was well tolerated. During the bypass period the pulmonary artery diastolic pressures ranged from 0-8 mm Hg. There was 1 hospital death due to abrupt vessel closure. Two patients required surgical help to repair femoral artery. During the follow up period of 1-12 months, 67% patients have no angina and only 1 has died. Our experience demonstrates the safety and efficacy of percutaneous bypass support in selected patients undergoing high risk coronary angioplasty.     

Primary PTCA in a Rural Hospital

The results of primary percutaneous transluminal coronary angioplasty (PTCA) to treat patients with acute myocardial infarction in a rural hospital were reviewed. Thirty-five patients presenting with acute myocardial infarction, including 40% considered high risk, were treated using the strategy of primary angioplasty. Following cardiac catheterization, two patients were found to have anatomy deemed unsuitable for primary angioplasty and subsequently underwent urgent coronary artery bypass graft (CABG) surgery. Thirty-three patients underwent primary angioplasty with a procedural success rate of 94%. Procedural success was defined as reduction of the infarct arteries stenosis to less then 50% and the establishment of TIMI-III flow. Six percent of these patients required urgent CABG surgery because of unsuccessful angioplasty. In-hospital cardiac mortality was 3%. Six month follow-up was achieved for all patients. There were no cardiac deaths following hospital discharge. Recurrent ischemia occurred in 17% of the patients. Favorable in-hospital and late results were achieved. This review indicates that the strategy of primary angioplasty to treat myocardial infarction may be successfully applied in a rural setting.     

非体外循环下冠状动脉旁路移植术中应用正性肌力药物的相关因素

目的:观察和分析冠状动脉旁路移植手术(coronary artery bypass graft,CABG)中应用正性肌力药物的相关因素。方法:以2012年1月~2013年12月在北京市大兴区人民医院心脏中心接受非体外循环下CABG的患者630(男351,女279)例为研究对象。按术中是否应用正性肌力药物分为应用组(n=330)和未应用组(n=300)。通过回顾原始病历收集临床资料。需要应用正性肌力药物被定义为使用多巴胺剂量超过5μg/(kg·min)、任何剂量的肾上腺素或去甲肾上腺素、米力农。结果:确定了3个应用正性肌力药物的独立的相关因素:1心脏指数(CI)≤2.5 L/(min·m2);2左室射血分数(LVEF)≤35%;3左室舒张末压(LVEDP)≥25 mm Hg。结论:CI≤2.5 L/(min·m2)、LVEF≤35%和LVEDP≥25 mm Hg是增加非体外循环下CABG中应用正性肌力药物风险的独立相关因素。     

Phlebotomy via the pulmonary artery catheter introducer for intraoperative autotransfusion

Fear of the acquired immune deficiency syndrome and other blood-transmitted diseases has created a revival of autologous transfusion during cardiac surgery. The present report is of 200 patients undergoing cardiopulmonary bypass during cardiac surgery in whom phlebotomy was performed via the sideport of the introducer for the pulmonary artery catheter for later reinfusion. Each unit of phlebotomized blood was replaced with 500 mL of normal saline. Cardiac output and mean arterial blood pressure decreased significantly after phlebotomy (P < 0.05) and returned toward control values after administration of the sodium chloride. The autologous blood was replaced after cardiopulmonary bypass. Fresh frozen plasma and platelets were not administered to the patients in the operating room. Eleven patients undergoing coronary artery bypass grafting received fresh frozen plasma in the recovery room because they were receiving aspirin and dipyridamole up to the day of surgery. Prolonged duration of cardiopulmonary bypass in two double-valve replacements, and one coronary artery bypass graft patient who required insertion of an intra-aortic balloon, accounted for the administration of fresh frozen plasma and platelets in three patients. The average volume of phlebotomized blood was 875 mL, which resulted in a decrease of the hematocrit from 40.5% ± 0.5% (P < 0.05) to 29.75% ± 0.5% and 30.5% ± 0.5% at the end of surgery and at discharge from the hospital, respectively. Phlebotomy via the Y port of the introducer of the pulmonary artery catheter is an easy, simple, and cost-effective way to remove autologous blood in patients undergoing cardiac surgery.     

Cardiac catheterization for patients with postinfarction angina

A retrospective review was conducted to determine the incidence of cardiac catheterization for postinfarction angina, the associated coronary anatomy, and the subsequent clinical course. Over one year, 30 of 178 myocardial infarctions were complicated by postinfarction angina resulting in cardiac catheterization. This was 18% of cardiac catheterizations for evaluation of coronary artery disease. Among the 30 patients, 3 had left main disease, 3 had triple-vessel disease, 11 had double-vessel disease, 11 had single-vessel disease, and 2 had no significant disease. Nine patients had proximal left anterior descending disease without left main disease. In contrast to previous autopsy or surgical series, the extent of coronary artery involvement was less severe and followed a distribution similar to that found in uncomplicated myocardial infarctions. Nevertheless, 17 of the 30 patients underwent revascularization with angioplasty or bypass surgery compared with 41 of 137 without postinfarction angina (p = 0.01). Clinical characteristics of the patients with postinfarction angina did not predict who would ultimately require revascularization. Cardiac catheterization is necessary for management of patients with postinfarction angina, because a majority of them will require revascularization.     

Angioplasty of the proximal left anterior descending coronary artery: initial success and long-term follow-up.

From 1984 to 1987, 537 consecutive patients (mean age 58 years; range 34 to 79) underwent angioplasty for proximal left anterior descending coronary artery disease. The procedure was clinically successful in 516 (96.1%). Procedural complications included myocardial infarction (2.2%; Q wave 0.9%, non-Q wave 1.3%), in-hospital bypass surgery (3%) and death (0.4%). Follow-up was obtained in 534 patients (99.8%) for a mean duration of 44 months (range 8 to 75). Follow-up cardiac catheterization, performed in 391 patients (76%), demonstrated a 39.6% angiographic restenosis rate. Ninety-eight (19%) of the patients with a clinically successful result required additional revascularization for recurrent left anterior descending artery disease by angioplasty (12.8%) or coronary artery bypass grafting (4.7%), or both (1.5%). During follow-up there was a 2.5% incidence rate of myocardial infarction (anterior myocardial infarction 1.6%), and 27 patients (5.2%) died, 14 (2.7%) of cardiac causes. The actuarial 5-year cardiac survival rate was 97%, freedom from cardiac death and myocardial infarction was 94% and freedom from cardiac death, myocardial infarction, coronary artery bypass surgery and repeat left anterior descending artery angioplasty was 77%. At last follow-up 76% of patients were free of angina and 88% reported sustained functional improvement. Angioplasty is an effective treatment for proximal left anterior descending coronary artery disease that has a high success rate, low incidence of procedural complications and provides excellent long-term cardiac survival, freedom from cardiac events and sustained functional improvement.