Usefulness of postoperative percutaneous cardiopulmonary support using a centrifugal pump: retrospective analysis of complications

Between January 1992 and December 1997, we employed percutaneous cardiopulmonary support (PCPS) using a centrifugal pump in 25 patients. In 21 of them, PCPS was used postcardiotomy. These patients could not be weaned from cardiopulmonary bypass due to profound ventricular failure. As for the other 4 patients, PCPS was used preoperatively for profound cardiogenic shock, a thrombosed valve, a stuck valve, and pulmonary embolization. Nine patients (43%) were weaned from PCPS (Group 1), and 3 (14%) were discharged from the hospital. The other 12 patients (57%) had perioperative extensive myocardial infarction and could not be weaned (Group 2). The causes of death were bleeding and multiple organ failure (MOF) associated with ventricular failure. The reasons for MOF were perioperative massive transfusion and hepatic congestion caused by sustained ventricular failure. To increase the survival rate, complete hemostasis and prevention of increased central venous pressure by early use of PCPS are necessary.     

Stenting for critical airway stenosis under percutaneous cardiopulmonary support

Airway stenting for severe central airway stenosis is inherently a dangerous procedure. There is the risk of critical airway obstruction due to bleeding, tumor debris, and airway perforation during the procedure. Once such situations occur, percutaneous cardiopulmonary support (PCPS) can be one of the most valuable rescue options to prevent critical hypoxic complications. At our institute, four of 49 patients who received stenting or other airway intervention required PCPS support (8%). Two of these cases required PCPS to be performed in an emergency setting during the procedure while the procedure was elective in the other 2. All procedures were performed effectively and safely without any complications caused by PCPS, including massive airway bleeding due to anticoagulant treatment. Patients were able to be weaned off PCPS uneventfully. PCPS is considered to be a valuable procedure in remedying critical hypoxic situations during airway intervention. Read at the Fifty-sixth Annual Meeting of the Japanese Association for Thoracic Surgery, Symposium, Tokyo, November 19–21,2003.     

Strategy of circulatory support with percutaneous cardiopulmonary support

We evaluated the efficacy and problems of circulatory support with percutaneous cardiopulmonary support (PCPS) for severe cardiogenic shock and discussed our strategy of mechanical circulatory assist for severe cardiopulmonary failure. We also described the effects of an alternative way of PCPS as venoarterial (VA) bypass from the right atrium (RA) to the ascending aorta (Ao), which was used recently in 3 patients. Over the past 9 years, 30 patients (20 men and 10 women; mean age: 61 years) received perioperative PCPS at our institution. Indications of PCPS were cardiopulmonary bypass weaning in 13 patients, postoperative low output syndrome (LOS) in 14 patients, and preoperative cardiogenic shock in 3 patients. Approaches of the PCPS system were the femoral artery to the femoral vein (F-F) in 21 patients, the RA to the femoral artery (RA-FA) in 5 patients, the RA to the Ao (RA-Ao) in 3 patients, and the right and left atrium to the Ao in 1 patient. Seventeen (56.7%) patients were weaned from mechanical circulatory support (Group 1) and the remaining 13 patients were not (Group 2). In Group 1, PCPS running time was 33.1 +/- 13.6 h, which was significantly shorter than that of Group 2 (70.6 +/- 44.4 h). Left ventricular ejection fraction was improved from 34.8 +/- 12.0% at the pump to 42.5 +/- 4.6% after 24 h support in Group 1, which was significantly better than that of Group 2 (21.6 +/- 3.5%). In particular, it was 48.6 +/- 5.7% in the patients with RA-Ao, which was further improved. Two of 3 patients with RA-Ao were discharged. Thrombectomy was carried out for ischemic complication of the lower extremity in 5 patients with F-F and 1 patient with RA-FA. One patient with F-F needed amputation of the leg due to necrosis. Thirteen patients (43.3%) were discharged. Hospital mortality indicated 17 patients (56.7%). Fifteen patients died with multiple organ failure. In conclusion, our alternate strategy of assisted circulation for severe cardiac failure is as follows. In patients with postcardiotomy cardiogenic shock or LOS, PCPS should be applied first under intraaortic balloon pumping (IABP) assist for a maximum of 2 or 3 days. In older aged patients particularly, the RA-Ao approach of PCPS is superior to control flow rate easily, with less of the left ventricular afterload and ischemic complications of the lower extremity. If native cardiac function does not recover and longer support is necessary, several types of ventricular assist devices should be introduced, according to end-organ function and the expected support period.     

Recruitment maneuver and high PEEP in a patient with severe reperfusion pulmonary edema after pulmonary thromboendarterectomy

Recently open lung approach such as recruitment maneuver and high PEEP has been applied in patients with acute respiratory distress syndrome. We report here a 29-year-old man with chronic pulmonary thromboembolism (CPTE). In this case, recruitment maneuver and high PEEP relieved postoperative respiratory failure. The major complications after pulmonary thromboendarterectomy (PTE) for CPTE are: reperfusion pulmonary edema (RPE), pulmonary hypertension (PH), hypoxia and bronchial bleeding, all of which the patient has demonstrated. Preoperative examination showed high pulmonary artery pressure (85/41, mean 50 mmHg), and high pulmonary vascular resistance predicted poor postoperative course. After PTE, he developed severe RPE, PH, hypoxia and bronchial bleeding, resulting in failed weaning from cardiopulmonary bypass. Therefore he required mechanical support of percutaneous cardiopulmonary support (PCPS). In ICU we repeated recruitment maneuver (PEEP: 30 cmH2O, peak inspiratory pressure: 42 cmH2O, respiratory rate; 15 breaths.min-1, for 1 min) and kept high PEEP (15 cmH2O). After initiating this ventilatory strategy, RPE was gradually relieved, followed by improvement of oxygenation and PH. We successfully weaned him from PCPS 38 hr after surgery and he was discharged alive on the 90 post-operative day. We conclude that recruitment maneuver and high PEEP may be useful for RPE developed after PTE.     

A case of delayed diagnosis of pulmonary thromboembolism in a patient with mitral stenosis undergoing cesarean section

Cesarean section was performed under general anesthesia in a 38-year-old patient with congestive heart failure due to severe mitral stenosis. During surgery, pulmonary hypertension, right ventricular distension and the dissociation of PETCO2 and PaCO2 were observed. However, pulmonary thromboembolism (PTE) was proved after the operation when she developed severe hypotension in the intensive care unit. Although she recovered once from circulatory unstability with the use of percutaneous cardiopulmonary support (PCPS) and she could be weaned from PCPS at the 4th postoperative day, she died from tracheal bleeding and recurrent cardiopulmonary collapse 22nd day after the surgery. It should be noted that the increasing dissociation of PETCO2 and PaCO2 may be an early sign of PTE even in a patient with severe mitral stenosis and pulmonary hypertension.     

Clinical Experiences of Percutaneous Cardiopulmonary Support: Its Effectiveness and Limit

In recent years, several types of centrifugal pumps have been widely used as the main pumps for cardiopulmonary bypass (CPB) and postcardiotomy cardiac support. From April 1990 to March 1997, a percutaneous cardiopulmonary support (PCPS) system was used in 20 patients with an average age of 58 years (13 males and 7 females). They comprised 11 ischemic, 6 valvular, 2 aortic, and 1 congenital heart disease patients. Our PCPS system consists of a centrifugal pump (BioMedicus BP-80), an oxygenator, and a reservoir. The entire blood contacting surface, including that of the thin wall cannulas, is coated by heparin bonded materials. As a result of this new technology, this system can be used for the long term without systemic heparinization. No major critical thrombi were revealed inside the pumps or circuits. Of the 20 patients, 7 (35%) (Group 1) could be weaned from PCPS, and the remaining 13 (Group 2) could not. In Group 1 although 2 patients suffered from renal failure and pneumonia, respectively, both were discharged from our hospital. The long-term survival rate was 35%. In Group 2 cerebral vascular damage was recognized in 3 patients, renal failure in 4, multiple system organ failure in 4, bleeding in 2, arrhythmia in 1, and leg ischemia in 2. Pulse pressure was significantly elevated due to the recovery of the native heart in Group 1, 2 days after support. However, in Group 2, it did not elevate, and the left ventricular ejection fraction was less than 30 %, associated with high left atrial pressure. In conclusion, this heparin coated PCPS system was very simple and easy to control. It demonstrated long-term biocompatibility and was very effective in recovering deteriorated cardiac function. Quicker application of this system can play an important role in preventing severe complications and obtaining better clinical results. If long-term support is necessary, a ventricular assist device (VAD), which is more powerful, durable, and biocompatible, has to be applied instead of PCPS.     

Acute massive pulmonary thromboembolism treated with percutaneous cardiopulmonary support perioperatively

A 57-year-old female was transferred to our hospital because of sudden dyspnea. She was hypotensive and hypoxic. Acute massive pulmonary thromboembolism was detected by echocardiography and computed tomography (CT). Before the operation, she fell into severe shock and needed cardiopulmonary resuscitation. We applied percutaneous cardiopulmonary support (PCPS), and performed emergency open embolectomy under total cardiopulmonary bypass. Because of the right ventricular failure, she could not be weaned from total cardiopulmonary bypass. PCPS was required again and used continuously during postoperative management. Her cardiopulmonary state improved gradually. PCPS was stopped at 6 days after surgery, and she was extubated at 14 days after surgery. PCPS was very useful for resuscitation and stabilization of the cardiopulmonary function for acute massive pulmonary thromboembolism perioperatively.     

Clinical Experience of Percutaneous Cardiopulmonary Support

Abstract: Recently, percutaneous cardiopulmonary support (PCPS) combined with femoro-femoral bypass without reservoir has become valued because of its quick and easy application. We developed a fully preconnected compact integrated cardiopulmonary bypass (CPB) unit (priming volume of 250 ml) with a blind pore membrane oxygenator (Kuraray Menox) for PCPS. From 1990 to 1995, PCPS was performed in 49 patients of whom 26 were weaned from support. In most cases, we applied this CICU in patients with no active bleeding (22 patients); in patients with active bleeding (n = 13), we used Medtron-ic's heparin-bonded close chest support pack (CCSP). Of these, PCPS was performed uneventfully for 2 h (median) in 8 elective cases; all of these patients were weaned or were switched to a left ventricular assist system (LVAS). In 8 urgent cases, such as those with low cardiac output syndrome, PCPS was performed for 4 days (median), 1 was weaned, and 2 CICU were cases switched to other procedures. In 32 cases of shock, 5 CICU patients were weaned, and 3 of them survived. Eight patients including 5 CICU patients and 1 CCSP patient were switched to operation or LVAS, and 2 CICU patients remain alive. From these data, PCPS has been shown to support the patient's circulation in the acute phase and earn time to switch to operation or LVAS; the quick and easy set-up of the CICU can improve the clinical results. The use of the Medtronic device broadened the indication for PCPS. The CCSP enlarged the indication of PCPS but could not improve the results. To improve the results, a heparin-bonded surface is desired.     

Percutaneous cardiopulmonary support with heparin-coated circuits in postcardiotomy cardiogenic shock. Efficacy and comparison with left heart bypass.

OBJECTIVE: Percutaneous cardiopulmonary support, a simplified form of venoarterial bypass, using totally heparin-coated circuits, has recently come into clinical use. To clarify its efficacy in postcardiotomy cardiogenic shock to aid weaning from cardiopulmonary bypass, we compared results of percutaneous cardiopulmonary support with those of left heart bypass using a centrifugal pump. METHODS: We reviewed 18 patients treated between 1991 and 1998 who could not be weaned from cardiopulmonary bypass. Nine were aided by totally heparin-coated percutaneous cardiopulmonary support (PCPS group), and 9 supported by left heart bypass using a centrifugal pump (LHB group). In both groups, activated clotting time was controlled at 150-200 seconds using minimal doses of heparin as needed. RESULTS: Weaning and survival rates were higher in the PCPS group than in the LHB group (100% vs 55.6%, and 66.7% vs 22.2%). The PCPS group had a smaller amount of blood loss and needed a smaller amount of blood components in the immediate postoperative period. One percutaneous cardiopulmonary support patient required surgical re-exploration for postoperative bleeding (11.1%), but no clinical thromboembolic event occurred in the PCPS group. In the LHB group, 5 patients underwent surgical re-exploration for postoperative bleeding (55.6%), and 2 underwent thrombus extirpation in the left ventricle (22.2%). CONCLUSIONS: Although this study was retrospective and historical backgrounds could have been involved, our data suggest that totally heparin-coated percutaneous cardiopulmonary support system appears more effective as an aid to weaning from cardiopulmonary bypass and in short-term circulatory support for patients in postcardiotomy cardiogenic shock.     

Long-term application of percutaneous cardiopulmonary support system without systemic heparinization

Though the amount of systemic heparin sodium administration was reduced after the introduction of heparin sodium-coating material to percutaneous cardiopulmonary support system (PCPS), bleeding due to heparin sodium is still the one of the major complications. In 2 patients of postcardiotomy cardiogenic shock, we neutralized heparin sodium by protamine sulfate administration immediately after the institution of PCPS and did not perform systemic heparinization until hemostasis was secured. The time on PCPS without heparin sodium was 37 hours in 1 patient and 91 hours in another patient. While systemic heparin sodium was not administered, activated clotting time (ACT) ranged from 109 to 148 sec and the bypass flow rate was maintained in more than 2.5 l/min. The exchange of the devices was unnecessary during the assistance and the patients were successfully weaned from PCPS without major complications. We conclude that systemic anticoagulation can be avoided in the case of life-threatening hemorrhage.     

Outcome of the perioperative use of percutaneous cardiopulmonary support for adult cardiac surgery: factors affecting hospital mortality

Percutaneous cardiopulmonary bypass support (PCPS) has become a widespread standard modality for the treatment of circulatory collapse; however, its clinical use for postcardiotomy low cardiac output syndrome (LOS) has been reported to be unsatisfactory. We reviewed the clinical outcomes of twenty-three patients undergoing cardiac surgery and treated with PCPS. Solitary coronary artery grafting was undertaken for nine patients, while three had concomitant procedures. The remaining patients underwent valvular surgery. The indications for PCPS were preoperative shock in two patients and postcardiotomy LOS or shock in twenty-one patients. All patients except one underwent an intraaortic balloon pump. Sixteen of the twenty-three patients (69.6%) were weaned from PCPS and twelve patients (52.2%) reached hospital discharge. A univariate analysis revealed that risk factors for hospital mortality were age older than seventy years (P = 0.05), PCPS running time (P = 0.017), low cardiac function at the institution of PCPS (P = 0.004), and urine output within the initial 24 h (P = 0.041). The cardiac index (CI) in survivors was improved within 24 h, and eleven of the twelve survivors were weaned off PCPS within 48 h, whereas ten of the twelve nonsurvivors required PCPS for more than 48 h (P = 0.0006). There is little possibility of weaning patients from PCPS who do not show any signs of hemodynamic recovery within 48 h after its institution. Limited use of PCPS within 48 h may be applicable for postcardiotomy patients, but other cardiopulmonary support, such as a left ventricular assist device, may be required when hemodynamic recovery is not obtained within 48 h.     

An emergency aortic valve replacement for cardiogenic shock patient with severe aortic stenosis and regurgitaiton using percutaneous cardiopulmonary support

The percutaneous cardiopulmonary support system (PCPS) was used in a 64-year-old woman with cardiogenic shock due to sustained ventricular fibrillation (Vf) caused by severe aortic stenosis and regurgitation. The Vf attack was resistant to cardioversion and adrenaline for lack of left ventricular support by PCPS. She was transported to the operation theater with PCPS in situ and emergency aortic valve replacement was performed. Although preoperative cardiac resuscitation time was long (35 minutes), she was discharged from the hospital on foot without any neurological complications on 84th postoperative day. Because PCPS does not decrease left ventricular systolic stress in poorly contracting dilated heart, early surgical treatment is needed in patients with severely damaged heart.     

Multiple organ failure caused by end-stage liver disease successfully treated with living donor liver transplantation using perioperative percutaneous cardiopulmonary support: a case report

A 54-year-old female diagnosed with primary biliary cirrhosis (PBC) 10 years earlier was referred for a living donor liver transplant (LDLT). During her workup, she developed pulmonary edema and respiratory failure due to aspiration pneumonia, which required artificial ventilation. The PaO2/FiO2 (P/F) ratio at that time was 60. Although continuous hemodiafiltration (CHDF) and plasma exchange (PE) were initiated, improvement in the P/F ratio was limited to 133. As transplantation was the only approach to save this patient, we performed LDLT using a right lobe graft aided by percutaneous cardiopulmonary support (PCPS). The graft weight was 650 g and the graft weight/recipient weight ratio was 1.6%. During LDLT, the patient's cardiopulmonary function was stable with PCPS, and the surgical procedure was completed without complications. Following the surgery, she continued to have high-end inspiratory pressure and progressed to the chronic phase of adult respiratory distress syndrome (ARDS). We treated her with low-dose steroid therapy and she improved gradually. The patient was weaned off mechanical ventilation and was discharged approximately 25 weeks after LDLT. In the condition of cardiac or respiratory failure, cadaveric liver transplantation using plasmapheresis is contraindicated because of the associated high mortality rate. Our case suggests that if infections are controlled, a patient with multiple organ failure (MOF) due to end-stage liver disease might be successfully treated with LDLT aided by plasmapheresis and PCPS.     

Infarct exclusion for postinfarction left ventricular free wall rupture with severe congestive heart failure

A 70-year-old man was transferred to our hospital with severe congestive heart failure and ventricular arrhythmia due to acute myocardial infarction. He had experienced chest pain 3 weeks previously and was admitted to another hospital for dyspnea, where he required assist ventilation, 1 week prior to the transfer. An echocardiogram revealed a broad anteroseptal infarction and very poor left ventricular function with an ejection fraction (EF) of 22%. He remained in a severe congestive heart failure condition despite a full administration of catecholamines. Coronary angiogram findings revealed an occlusion of the proximal left anterior descending coronary artery and 1 week later severe hypotension was suddenly presented. An echocardiogram showed pericardial effusion with signs of cardiac tamponade. A pericardiocentesis was performed and hemodynamic improvement was obtained for a short time, after which the patient underwent urgent open heart surgery. During the operation, exclusion of the anteroseptal akinetic area using an oval patch was performed under a cardiopulmonary bypass and ventricular fibrillation. Severe cardiac failure remained postoperatively and the patient could not be weaned from cardiopulmonary bypass, therefore, we implanted a percutaneous cardiopulmonary support (PCPS) and started intraaortic balloon pumping (IABP). The patient was weaned from PCPS at 26 days after surgery and from IABP at 30 days. Following hospital release, he has continued to do well without heart failure for 39 months after the operation.     

Successful management of a man with fulminant myocarditis using percutaneous cardiopulmonary support

Fulminant myocarditis is a fetal disease characterized by a distinct viral prodrome, sudden onset of severe hemodynamic compromise, and marked myocardial inflammation. One possible therapy to improve the poor prognosis of such patients may be the implantation of circulatory support systems that allow myocardial recovery. We report here successful management of a patient with fulminant myocarditis using percutaneous cardiopulmonary support (PCPS), intra-aortic balloon pump (IABP), and continuous hemodiafiltration (CHDF). A 37-year-old Japanese man suddenly experienced cardiopulmonary dysfunction shortly after general fatigue, and was diagnosed as having fulminant myocarditis. PCPS was immediately initiated because catecholamine infusion and IABP were not enough to support circulation. Although severe dyskinesis was observed on his admission, cardiac function recovered twelve days after PCPS initiation with ejection fraction from 16% to 73%. Renal and hepatic failure also recovered with the improvement of cardiac function. We describe our clinical experiences in cardiogenic shock after acute fulminant myocarditis and discuss therapeutic guidelines for the use of PCPS, with its management and complications.     

Risk factors for the surgical repair of ventricular septal perforation; an 8-year multiinstitutional analysis

OBJECTIVE: The purpose of this study was to determine the surgical outcomes and risk factors for surgical repair of the ventricular septal perforation (VSP). METHOD: From 1995 to 2003, 41 patients with VSP underwent surgical repair. There were 18 males and 23 females, with the mean age of 71.7 +/- 9.2. Sixteen patients (39.0%) had the preoperative shock, while 30 patients received intraaortic balloon pumping (IABP) assistance and 1 of those required percutaneous cardiopulmonary support (PCPS). Mean durations from onset of myocardial infarction and VSP to operation were 5.8 +/- 9.4 and 2.4 +/- 8.1 days, respectively. Twenty-six patients underwent infarct exclusion technique, 11 underwent patch closure, and 4 Daggett operation. Mean cardiopulmonary and aortic cross-clamp time were 211 +/- 85 and 105 +/- 43 minutes, respectively. RESULTS: Thirty days mortality was 11 (26.8%). Nine patients (22%) required PCPS after repair, however, 2 weaned off the support and only 1 discharged the hospital. Residual shunt was found in 12 patients (29.3%), and 4 underwent the reclosure of the residual shunt 13 +/- 8.6 days after the initial operation, whereas none of patients with PCPS had residual shunt. Univariate analysis revealed the preoperative shock (p = 0.03), longer cardiopulmonary bypass time (p < 0.01), and the need for PCPS after repair (p < 0.01) were the risk factors for the early mortality. Multivariate analysis indicated the cardiopulmonary time over 210 minutes and the need for PCPS to be the significant risk factors. CONCLUSION: The long cardiopulmonary bypass support after repair and the subsequent need for PCPS imply the poor left ventricular function. Since the residual shunt was not the cause of PCPS, the surgical outcome for VSP may be limited in patients with poor left ventricular function. In these patients, other therapeutic strategies may be required, such as ventricular assisting devices, transplantation, or regenerative therapy.     

Cerebral tissue oxygen saturation during percutaneous cardiopulmonary support in a canine model of respiratory failure

Percutaneous cardiopulmonary support (PCPS) has come to be applied for cardiopulmonary resuscitation and in the management of severe respiratory failure as well as severe heart failure. We investigated cerebral tissue oxygen saturation during PCPS in a canine model of respiratory failure using near-infrared spectroscopy. Animals were mechanically ventilated with 10% oxygen to make a respiratory failure model. Perfusion with PCPS was performed via the left femoral artery and switched to that via the right axillary artery. Cerebral tissue oxygen saturation was 54.2 +/- 3.4% during PCPS via the femoral artery and was 82.3 +/- 4.6% during PCPS via the axillary artery (p = 0.001). Hepatic tissue oxygen saturation was not significantly different. LV dP/dt max increased significantly after switching to the axillary blood supply (p = 0.001). Conventional PCPS may not have the capability of supporting cerebral circulation under severe respiratory failure without organic heart disease.     

Extracorporeal Membrane Oxygenation Support for Postcardiotomy Cardiogenic Shock

Abstract: Extracorporeal membrane oxygenation (ECMO) has had promising results in life-threatening respiratory failure and postcardiotomy cardiogenic failure. From October 1994 to October 1995, 18 patients received 19 ECMOs at National Taiwan University Hospital for severe cardiogenic shock after cardiac surgery. They included patients receiving cardiac massage or repeated bolus injections of norepinephrine to maintain blood pressure (n = 10), patients who could not be weaned off cardiopulmonary bypass after several attempts despite in-traaortic balloon pumping and maximal doses of catecholamine (n = 7), and patients with progressive intractable cardiogenic shock after cardiac surgery. Venoarterial ECMO was set up via femoral artery (17 or 19 Fr cannula) and vein (19 or 21 Fr) in all patients except 2 infants. No left heart drainage was performed in any of the patients. The heparin-coated circuit (with Carmeda Bio-active Surface) was used in the last 13 patients to reduce bleeding. Ten (52.6%) of the 19 cases could be smoothly weaned off ECMO, and 6 (33.3%) of the 18 patients were discharged from the hospital in good condition. Four (80%) of the 5 patients after valvular surgery and all 3 heart transplant patients could be weaned off ECMO successfully with the survival rate being 60% and 67%, respectively. Complications included leg ischemia (n = 3), bleeding (n = 4), renal failure (n = 3), and tube rupture (n = 1). The inability to wean off ECMO was caused by multiple organ failure (n = 5), sepsis (n = 2), tube rupture (n = 1), and dysfunction of the ECMO system (n = 1). The major cause of multiple organ failure was hesitation to set up ECMO. Our preliminary results confirmed the effect of ECMO in postoperative cardiogenic shock.     

Percutaneous left ventricular assist system using a modification of the Dennis method: Initial clinical evaluation and results

A percutaneous left ventricular assist system (PLVAS) using a modification of the Dennis method was developed and implemented in 8 patients. Transseptal cannulation was performed under biplane fluoroscopy and/or transesophageal echocardiogram without encountering any problems. All the patients were in a state of severe cardiogenic shock, caused by acute myocardial infarction in 5, cardiomyopathy in 2, and postcardiotomy in 1, and were on intraaortic balloon pump support and/or percutaneous cardiopulmonary support (PCPS), in the form of partial cardiopulmonary bypass. Three patients who developed concomitant right heart failure required additional PCPS. All the patients were supported at 3.0 to 4.0l/min for 76–284h for an average time of 159h. Three patients were successfully weaned from PLVAS and one of these patients, who had suffered an acute myocardial infarction, was discharged from hospital. The complications directly related to this system were minimal. Our observations led to the conclusion that PLVAS using our modification of the Dennis method is a simple, easy, and safe means of maintaining adequate systemic circulation in severely ill patients. As PLVAS is particularly effective for patients in cardiogenic shock following acute myocardial infarction, we believe that it will be applied routinely by many cardiac surgeons and cardiologists in the future.     

A Clinical Use of the Kyocera Gyro C1E3 Centrifugal Pump

In patients with reduced respiratory function, lung resection is associated with high risk because separate ventilation is generally needed for safe management. For patients with end-stage emphysema, intraoperative respiratory management is important and particularly difficult because neither incomplete oxygenation nor selective ventilation can be performed, so the operation may be interrupted. In this study, we assess the effectiveness of the percutaneous cardiopulmonary support (PCPS) system for lung volume reduction surgery in patients with severe hypercapnia (arterial carbon dioxide tension >50 mm Hg) and discuss the significance of PCPS for patients who are beyond the standard criteria for lung volume reduction surgery (LVRS). We studied 3 patients with severe hypercapnia due to emphysema who underwent volume reduction surgery. One patient was previously treated surgically for contralateral pneumothorax. All patients had a severe smoking history and were suspected to have fragile lungs. During the operation. PCPS provided sufficient support flow. Intraoperative management using PCPS was easy, and no severe complications were observed. One patient exhibited severe hemodynamic deterioration on postoperative Day 15. Other patients' PaCO2 improved postoperatively. One had a calcification of a femoral artery, but there was no trouble inserting a cannula. Bilateral or unilateral volume reduction surgery was performed under PCPS in patients with end-stage emphysema. We conclude that PCPS is an adjunct to LVRS, useful for intraoperative management of some patients with severe hypercapnea, and the LVRS indications can be extended.