Intraaortic Balloon Pump Counterpulsation, Part I: History, Technical Aspects, Physiologic Effects, Contraindications, Medical Applications/Outcomes.

Intraaortic balloon pump counterpulsation is the most common form of mechanical circulatory support used in patients with myocardial ischemia and cardiogenic shock. The physiologic principles of counterpulsation include diastolic augmentation of aortic pressure and systolic reduction of left ventricular afterload, resulting in hemodynamic benefits through increased coronary perfusion pressure and improved myocardial oxygen balance in patients with myocardial ischemia. Major trials have failed to conclusively demonstrate improvements in morbidity and mortality with counterpulsation therapy for patients with acute myocardial infarction (MI), cardiogenic shock, and/or severe coronary artery disease undergoing revascularization therapy, and the debate over its applications continues. Part I of this review focuses on the history of the development of counterpulsation, technical considerations, and complications associated with its use, its physiologic effects, and evidence for its use in myocardial ischemia and cardiogenic shock.

Ventricular assist device therapy in post-cardiotomy cardiogenic shock: historical outcomes and current trends.

Ventricular assist device (VAD) therapy has been used successfully as a bridge to recovery, bridge to transplant and in the last decade as a destination therapy. The use of VAD for post-cardiotomy cardiogenic shock (PCCS) is not currently reported in national databases in the UK and Ireland. Data were collected through a telephone survey of chief perfusionists from all the cardiac surgery units in the UK and Ireland between October 2007 and October 2008. Approximately 28 000 adult cardiac surgical procedures were performed at 45 cardiac centres, of which 33 (73%) reported using VAD. The total number of patients supported was 66, of which 41% (n = 27) survived to be discharged home. About 42.5% (n = 28) died during VAD in place, and 16.5% died after successful weaning from VAD. Preferences for device types were Biomedicus (n = 25), Levitronix (n = 10), Sorin (n = 3), roller pump (n = 3) and Berlin heart (n = 2). Despite the reasonable survival rates after VAD use in post-cardiotomy heart failure, there are significant differences in their availability and individual's attitude towards their use. VAD use in PCCS should be prospectively documented in the audit returns of all the units, for further analysis and for generation of protocols.

Cardiogenic shock: a historical perspective.

Significant progress has been made over the past 60 years in defining and recognizing cardiogenic shock (CS), and there have been tremendous advances in the care of patients who have this illness. Although there are many causes of this condition, acute myocardial infarction with loss of a large amount of functioning myocardium is the most frequent cause. It was recognized early in the study of CS that prompt diagnosis and rapid initiation of therapy could improve the prognosis, and this remains true today. Although the mortality from CS remains high, especially in elderly populations, modern therapies improve the chance of survival from this critical illness.

Ruptura subaguda da parede livre do ventrículo esquerdo pós-infarto agudo do miocárdio: relato de caso e revisão de literatura / Post-infarct sub-acute left ventricular free wall rupture: case report and review of the literature

A ruptura da parede livre do ventrículo esquerdo é uma complicação potencialmente fatal e de tratamento essencialmente cirúrgico. A correção cirúrgica é o tratamento de escolha, mas o manejo pré-operatório e as técnicas de correção ainda não estão claramente definidos, sendo determinados conforme as condições clínicas do paciente. Há carência na literatura de grandes séries envolvendo este tipo de afecção e os relatos são baseados nas experiências individuais, com pequeno número de pacientes. São apresentados dois casos de ruptura subaguda da parede livre do ventrículo esquerdo como complicação da evolução do infarto agudo do miocárdio. Discute-se a abordagem cirúrgica completa, com revascularização miocárdica concomitante e a utilização de circulação extracorpórea. A opção de correção do defeito por meio da sutura epicárdica com retalho de pericárdio bovino e a revascularização completa do miocárdio, sobretudo sem circulação extracorpórea, parece ser a melhor estratégia para um grupo de pacientes que apresentam ruptura subaguda da parede livre do ventrículo esquerdo pós-infarto agudo do miocárdio.

Choque cardiogênico / Shock cardiogenic

O choque cardiogênico caracteriza-se quando uma severa disfunçäo miocárdica provoca hipoperfusäo tecidual e falência orgânica. Os critérios exatos para a presença de choque cardiogênico variam muito na literatura. Além disso é extremamente importante comparar o grau da disfunçäo miocárdica quando se analisam os resultados de diferentes procedimentos. Em 1973, importante estudo multicêntrico estabeleceu os seguintes critérios para a definiçäo de choque cardiogênico: - pressäo arterial sistólica < 80 mmHg (intra-arterial); - débito urinário < 20 ml/h ou confusäo mental; - pressäo de enchimento ventricular > 12 mmHg; - pressäo venosa central > 10 cm H20. Esta definiçäo tem grande utilidade clínica pois inclui a classificaçäo de Kilip para o infarto agudo do miocárdio. Além disso, incorpora os três principais componentes do choque cardiogênico: 1) comprometimento da funçäo ventricular; 2) evidência de falência orgânica como resultado do decréscimo da perfusäo tecidual; e 3) exclusäo de hipovolemia e outras causas do choque. Uma vez que esta definiçäo já foi largamente aplicada com sucesso em estudos prospectivos, pode ser considerada padräo para estudos clínicos futuros.