Coronary reperfusion using an extracorporeal circulating system performed in cases with abruptly obliterated coronary arteries: a new method]

For the cases with the abruptly obliterated coronary artery during angioplasty or angiography, emergency bypass surgery is mandatory. However, a "bail-out" perfusion catheter with multiple side-holes, which maintains antegrade coronary flow, is not efficient in preventing the myocardium from developing ischemia, because blood flow is interfered due to pressure-dependent perfusion mechanism in the shock state. We developed a new perfusion catheter coupled with an extracorporeal circulating system and a perfusion pump. Its effectiveness and safety were tested experimentally in canine hearts. The system is composed of a perfusion catheter (125 cm in length) with 4 side-holes within 1.5 cm of the catheter tip, and a rolar pump. Maximum flow volumes were 123 ml/min, 84 ml/min, and 52 ml/min for 4.5F, 4.3F, and 4F perfusion catheters, respectively. The left anterior descending coronary artery (LAD) was ligated after the perfusion catheter was advanced into the proximal LAD under fluoroscopic control. To avoid formation of pericatheter intracoronary thrombi, 50 U/kg/hr heparin was continuously injected during a 5-hour ligation. In the nonperfusion group (n = 4), the ST segments elevated in all dogs; 2 died of ventricular fibrillation within 30 min, and one was confirmed to have myocardial necrosis by NBT staining. In the perfusion group (n = 4), neither ECG changes nor hemodynamic deterioration was observed. Intracoronary thrombi were not observed in any surviving dogs. Coronary perfusion using our new device was performed in 2 patients: one patient, a 73-year-old man with 99% stenosis in the very proximal portion of his LAD, had massive intimal dissection after PTCA, and angiography revealed total occlusion of his proximal LAD and LCX. Coronary perfusion was immediately initiated by advancing the perfusion catheter into his LAD. After that the patient recovered from shock. Emergency bypass surgery was successfully performed after 120 min coronary perfusion with the support of IABP and inotropics. The other patient, a 58-year-old man with effort angina, had intimal dissection in the proximal portion of his right coronary artery, which was supplying collaterals to the mid LAD and LCX. Successful bypass surgery was performed 320 min after the coronary perfusion without IABP and inotropics. In conclusion, coronary reperfusion with an extracorporeal circulating system proved to have a greater effect than did passive perfusion in such cases with cardiogenic shock.