Emergency cardiopulmonary bypass support in patients with cardiac arrest in the catheterization laboratory.

Cardiac arrest in the catheterization laboratory is fatal if unresponsive to advanced cardiac life support (ACLS). Seven patients not responding to ACLS following cardiac arrest in the catheterization laboratory underwent percutaneously instituted cardiopulmonary bypass support. Cardiac arrest occurred following abrupt closure postcoronary angioplasty in three patients, during cardiogenic shock in three patients, and during diagnostic angiography in one patient. Cardiopulmonary bypass was instituted 10-45 min (mean, 21 min) following the onset of cardiac arrest. Flows on bypass ranged from 4.0 to 5.2 liter/min. Mean blood pressure ranged from 70 to 110 mm Hg on bypass. Six of the seven patients regained consciousness after the institution of bypass. Acid-base balance was normalized in all patients. Coronary bypass surgery was subsequently performed in three patients and coronary angioplasty in two. Four patients survived. One patient died following coronary bypass surgery. Two patients, who were not suitable candidates for revascularization, expired. Total bypass time was 1.5-8.5 hr (mean, 2.7 hr). At a mean follow-up of 6 months, all four survivors are alive and asymptomatic or NYHA class 1. We conclude that cardiopulmonary bypass support 1) can stabilize patients following cardiac arrest in the catheterization laboratory, 2) can facilitate emergency coronary angioplasty or transfer to the operating room for coronary bypass surgery, and (3) can improve survival in patients unresponsive to ACLS when instituted early following cardiac arrest in the catheterization laboratory.

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.

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.

Emergent coronary angioplasty in the treatment of acute ischemic mitral regurgitation: long-term results in five cases.

Severe mitral regurgitation in the setting of an evolving myocardial infarction is associated with a high operative mortality rate. Five patients with acute severe mitral regurgitation secondary to ischemic posterior papillary muscle dysfunction underwent emergent percutaneous transluminal coronary angioplasty. Two patients were in cardiogenic shock and required intraaortic balloon counterpulsation. Angioplasty resulted in rapid improvement in hemodynamic variables, and all patients were discharged at a mean of 10 days after the procedure. Long-term follow-up study (mean 35 +/- 6 months) revealed normal mitral valve function angiographically and by Doppler echocardiography in four patients. Repeat angioplasty was required in one patient, and another underwent coronary artery bypass surgery without valve replacement for restenosis. One patient developed progressive mitral regurgitation and required elective mitral valve replacement 12 months after angioplasty. These preliminary findings suggest that emergent coronary angioplasty is a useful therapeutic intervention in the treatment of ischemic mitral regurgitation and is associated with a favorable long-term outcome.