Benefits of combined balloon pumping and percutaneous cardiopulmonary bypass.

Sixteen patients (2 women, 14 men) aged 29 to 72 years with continued cardiogenic shock during intraaortic balloon pumping (IABP) had additional treatment with percutaneous cardiopulmonary bypass (PBY). Cause of cardiogenic shock was myocardial infarction in 7 (3 survived), failed percutaneous transluminal coronary angioplasty requiring emergency coronary artery bypass grafting in 5, postoperative aortic valve replacement in 1, postoperative emergency coronary artery bypass grafting in 1, after cardiac transplantation in 1, and bridging to transplantation in 1. Mean blood pressure with PBY and IABP combined was 75 mm Hg versus 60 mm Hg with IABP off. Percutaneous cardiopulmonary bypass flows ranged from 0.8 to 2.1 L/min with a mean flow of 1.3 L/min. Time on IABP ranged from 24 hours to 1 week. Time on IABP to PBY ranged from 1 to 20 hours, and time on PBY ranged from 65 minutes to 20 hours. Ten of 16 (63%) were successfully weaned, and 3 died after weaning. Seven of 16 (44%) survive. Combined IABP with PBY appears to be a better therapy than either one individually. Staging the therapy as the balloon first in and last out appears to be a good methodology.

Sheathless insertion of the percutaneous intraaortic balloon pump: an alternate method.

A technique is described that allows insertion of a standard percutaneous intraaortic balloon without use of the larger 12F sheath. Standard 9.5-cm. Percor balloons were inserted in a series of patients without using the provided sheath. Elimination of the sheath reduced the potential vascular complications related to the extra bulk placed in the femoral artery by the sheath. No serious complications were noted in more than 25 patients.

Hemopump support for the failing heart.

Under fluoroscopy, the hemopump is passed through the aortic valve into the left ventricle through a Gortex (WF Gore, Denver, CO) chimney sewn to a surgically exposed femoral artery. The system aspirates the left ventricular blood and actively pumps it into the aorta. Five patients (four men, one woman), aged 47-71 years (mean, 62 years), were candidates for hemopump support because of refractory cardiogenic shock. Three were recovering from repeated coronary artery bypass graft (CABG) surgery, and two required postoperative emergency CABG for failed percutaneous transluminal coronary angioplasty (PTCA). One patient died during insertion, and four had the hemo-pump successfully placed. All patients had low cardiac out-put and had intraaortic balloons in place. Average insertion time took 20 min, with maintenance on the hemopump for an average of 13 hr. One patient was maintained on the hemopump for 12 hr, but because of continued deterioration, was placed on a total artificial heart (Harvik 7-70). Patients 3 (hemopump inserted transthoracically) and 4 had the hemopump discontinued because of brain death, and the fifth survived. This patient is alive and working 1 yr later. The hemopump is an effective left ventricular support system that is less invasive than conventional transthoracic systems.

Correction of total anomalous pulmonary venous connection below the diaphragm.

Six infants with total anomalous pulmonary venous connection below the diaphragm had correction by modification of conventional surgical technique. Catheterization revealed the confluence of the pulmonary veins draining into a descending vein below the diaphragm. Symptoms of pulmonary venous hypertension and low cardiac output were typical. All had repair with circulatory arrest (average time, 32 minutes). Mobilization of the pulmonary veins and the descending vein is important. The descending vein was transected at the diaphragm. Its anterior surface was incised through the confluence of the pulmonary veins, thus creating an open Y incision. This large Y-shaped vein was anastomosed to the left atrium and carried obliquely to the tip of the left atrial appendage. The anastomosis was fashioned so that the long limb of the Y rotated anteriorly and superiorly to substantially enlarge the left atrium, making the total diameter of the anastomosis larger than the mitral valve orifice. This simplified the surgical repair and allowed direct suture closure of the atrial septal defect in all patients, as the left atrial size was at least doubled. No postoperative complications occurred, and the patients were discharged an average of 4.2 days postoperatively. Restudy at an average of 3.5 years revealed normal pressures and normal architecture by angiography. Use of the descending vein as an integral part of the reconstruction and enlargement of the left atrium was the major technical factor leading to a successful outcome in these patients and eliminating a patch or transposition of the atrial septum.

Use of a double-lumen pressure monitoring catheter to facilitate pulmonary artery banding.

Pulmonary artery banding is facilitated by simultaneously measuring the pressure above and below the band. This can be accomplished with a commercially available double-lumen central venous pressure monitoring catheter. This catheter is inserted through the outflow tract of the right ventricle and positioned so that the band will be between the two lumens. Gradual tightening of the band can be accomplished while monitoring the pressures proximal and distal to the band.

Disrupted coronary artery caused by angioplasty: supportive and surgical considerations.

Of 2,859 patients having percutaneous transluminal coronary angioplasty, 201 (7%) underwent emergency coronary artery bypass grafting. Two categories of patients were reviewed. Group 1 consisted of 126 patients of 2,304 who had immediate coronary artery bypass grafting after failed elective percutaneous transluminal coronary angioplasty. Ninety-eight of these patients had angiographic evidence of occlusion of a coronary artery, and 28 had angiographic evidence of coronary artery dissection. Epicardial hemorrhage was observed at operation in 20% (25 patients). Three deaths (2.4%) occurred in group 1, and an average of 3.3 grafts was performed per patient. Group 2 comprised 75 of 555 patients who had unsuccessful attempted percutaneous transluminal coronary angioplasty during an evolving myocardial infarction and required immediate coronary artery bypass grafting. Angiography revealed coronary artery occlusion in 61 patients with dissection in 14. All group 2 patients had evidence of myocardial injury by electrocardiographic and enzymatic (myocardial-specific isoenzyme of creatine kinase) criteria. Three deaths (4%) occurred in this group, and there was an average of 3.4 grafts per patient. Percutaneous transluminal coronary angioplasty is routinely performed without surgical consultation, although an operating room and team are usually available. Supportive techniques include the intraaortic balloon pump and percutaneous cardiopulmonary bypass. In those patients with coronary artery dissection, care must be taken to reestablish the true lumen of the coronary artery. Hemopericardium should be surgically explored and broken guidewires or other foreign bodies or debris removed. From 1979 through 1986, the number of patients requiring emergency coronary artery bypass grafting after percutaneous transluminal coronary angioplasty steadily declined to less than 5%.

Percutaneous cardiopulmonary bypass: application and indication for use.

Percutaneous cardiopulmonary bypass (CPB) was used in 22 patients: 7 patients with cardiac arrest due to acute myocardial infarction; 4 patients in cardiac arrest because of failed angioplasty; 1 patient for high-risk elective angioplasty; 1 patient with massive pulmonary emboli; 2 patients with hypothermia; 2 pediatric patients (1 with sepsis and 1 in combination with extracorporeal membrane oxygenator support); 1 patient with refractory arrhythmia; and 4 patients with trauma. Percutaneous CPB involves a modified Seldinger technique that is easily applied. All patients except those with massive trauma were resuscitated with the use of percutaneous CPB. One patient requiring a very difficult proposed angioplasty received percutaneous CPB support while triple-vessel angioplasty was performed. Percutaneous CPB appears to be beneficial in resuscitating patients with refractory cardiac arrest or other forms of circulatory collapse except trauma. Limited use for brief periods in high-risk patients having elective angioplasty might be applicable.

Permanent left ventricular assistance for outpatients through surgical implantation of a modified intra-aortic balloon pump.

There is a large population of patients in end-stage congestive heart failure who cannot be treated by means of conventional cardiac surgery, cardiac transplantation, or chronic catecholamine infusions. In 2 such patients, we provided permanent left ventricular assistance on an outpatient basis by surgically implanting a modified intra-aortic balloon pump. A Dacron-velour graft to the common iliac artery served as a covering for the extravascular portion of the balloon's pneumatic tubing, which was stabilized by routing it through the iliac crest. The tubing was then carried ventrally to exit through a stoma just above the inguinal ligament. Before hospital discharge, each patient underwent a 5-day regimen of alternate pumping and ambulation. The patient was then permitted to go home, but returned daily as an outpatient in accordance with individual need, for approximately 6 hours of hemodynamic support. The 1st patient lived 3 months after pump insertion, and the 2nd patient for 38 days. Although the 1st patient developed a fever of unknown origin that prompted us to remove the intra-aortic balloon pump unnecessarily, there was no evidence of infection upon surgical exploration and subsequent tissue culturing; she died, rather, of intractable ventricular fibrillation, apparently consequent to her 36-hour loss of hemodynamic support. The 2nd patient also died of a cause unrelated to the presence of the pump, and on autopsy showed good evidence of healing and absence of infection. On the evidence of this pilot study, we conclude that intermittent left ventricular assistance, through periodic activation of a permanently implanted intra-aortic balloon pump during outpatient visits, warrants further study as an alternative for selected patients with end-stage heart disease, when medical and other surgical options have been exhausted.

Internal mammary artery versus saphenous vein graft to the left anterior descending coronary artery: prospective randomized study with 10-year follow-up.

In 1975, 80 patients undergoing revascularization were prospectively randomized to receive either a greater saphenous vein (SV) graft (41 patients, Group 1) or a left internal mammary artery (LIMA) graft (39 patients, Group 2) to the left anterior descending coronary artery (LAD). All patients were completely revascularized. The average number of grafts per patient in both groups was 3.2. Patients were followed 10 years; follow-up was 97.5% complete. Group 1 and Group 2 were compared in regard to mortality, treadmill response, myocardial infarction, reoperation, percutaneous transluminal coronary angioplasty, and return to work. Mortality in Group 1 was 17.9% versus 7.7% in Group 2 (p less than 0.05). Treadmill studies were positive in 17 Group 1 patients and 7 Group 2 patients (p less than 0.05). Myocardial infarctions occurred in 8 patients in Group 1 versus 3 in Group 2. The number of reoperations was 2 in Group 1 versus 1 in Group 2. Percutaneous transluminal coronary angioplasty was performed in 3 patients in Group 1 and 2 in Group 2. Repeat studies revealed 76.3% patency of the SV graft to the LAD (Group 1) and 94.6% patency of the LIMA graft to the LAD (Group 2). Cardiac-related mortality in Group 1 was 12.8% at 10 years (5 patients) versus 7.7% in Group 2 (3 patients). Based on this study, the IMA is a superior conduit for bypass to the LAD.

Bridging circulatory support before heart transplant without invasion of the mediastinum.

Heart transplantation is becoming a useful tool in the clinical treatment of patients with end-stage cardiac decompensation. Donor organs are not always available at a critical time for a patient waiting for a transplant. Bridging techniques have been described that use mechanical support systems. This article describes the use of femoral-venous to femoral-arterial bypass over a period of 50 hours in a 38-year-old woman waiting for a donor heart. Because the patient sustained cardiopulmonary arrest before organ availability, mechanical circulatory support that used femoral-venous to femoral-arterial bypass was instituted. The patient's own lungs were used as an oxygenator. Pump flow levels were determined by the level of central aortic oxygen saturation. Successful transplant was performed, and bridging, therefore, was done without invasion of the mediastinum.

Reperfusion protocol and results in 738 patients with evolving myocardial infarction.

Reperfusion is an accepted therapy for evolving myocardial infarction (MI), as successful reperfusion reduces morbidity and mortality. A team approach between the cardiologists and cardiac surgeons must be applied to achieve reperfusion within a finite time from the onset of coronary thrombosis. Analysis of 738 patients grouped them by successful reperfusion in the catheterization laboratory versus the operating room. Factors that predict wall motion recovery related to the onset of clinical symptoms, time to reperfusion, coronary anatomy, and collateral network were reviewed. Comparisons were made between patients with stable versus unstable hemodynamics and successful or unsuccessful reperfusion. Of the 738 patients, the initial attempt at reperfusion was made in the catheterization laboratory with success in 331. These patients all had primarily single-vessel disease. With multiple-vessel disease identified at catheterization, 189 patients were immediately treated by surgical reperfusion. This method also was used for an additional 72 patients in whom reperfusion could not be achieved in the catheterization laboratory. Of the entire group of 738 patients, 146 (20%) could not be reperfused. Overall mortality for the 592 patients reperfused was 4.9% compared with 17% for those who could not be reperfused. Time was critical for wall motion recovery if no collaterals were demonstrated on angiography. If collaterals were present, time to reperfusion was not critical. Wall motion recovered in 90% of the patients if the endocardial anatomy on the initial angiogram was smooth. However, if the endocardial anatomy looked mottled and irregular, less than 10% of patients had recovery of wall motion.(ABSTRACT TRUNCATED AT 250 WORDS)

Inflammatory epicardial reaction to processed bovine pericardium: case report.

Processed bovine pericardium is increasingly used as a pericardial substitute. It is allegedly nonreactive with epicardium, but adequate clinical data are lacking on this subject. A case report is presented wherein a dense epicardial reaction to processed bovine pericardium was found at reoperation. Histologic examination confirmed the presence of a severe inflammatory response.

A technique for immediate manual external aortic counterpulsation during cardiac surgery.

Intraaortic balloon pump counterpulsation is well established as a lifesaving measure. Aortic counterpulsation may be achieved externally as well as internally. A simple technique for manual external aortic counterpulsation during cardiovascular surgical procedures is presented. This technique is available on immediate demand and identical in effect to intraaortic balloon pumping, and it may be lifesaving in patients with acute cardiovascular decompensation since it allows time for institution of necessary emergency therapy.

Natural history of surgically treated ventricular aneurysm.

Forty-one patients underwent resection of a postinfarction ventricular aneurysm. Thirty-seven of them had associated saphenous vein grafting procedures (average, 2.3 grafts per patient). Thirty-five patients sustained left ventricular dysfunction preoperatively. Forty patients were followed until death or for a minimum of five years (1 was lost to follow-up), and functional status was evaluated. Hospital mortality was 12%. Twenty-four patients survived five years or longer, and 20 patients were alive after a mean follow-up of 84 months. Eighty percent of the nonsurvivors died of atherosclerosis-related events. Forty-nine percent of the patients who survived the operation sustained severe atherosclerotic events postoperatively. Only 2 of 15 nonsurvivors ever regained functional status as judged by return to work. Twelve of the 20 long-term survivors returned to work. Of those patients less than 50 years old at operation, only 17% returned to work. Preoperative left ventricular function was a significant predictor of long-term functional results of aneurysmectomy and saphenous vein grafting. All patients remained at high risk for continued events related to atherosclerotic cardiovascular disease, and only 37% returned to full-time, preoperative work status. Return to productive status was especially disappointing in patients less than 50 years old.

Immediate coronary bypass following failed streptokinase infusion in evolving myocardial infarction.

Since December of 1980, 184 patients with evolving myocardial infarction (EMI) have undergone streptokinase infusion, with associated percutaneous transluminal coronary angioplasty (PTCA) in 68 patients. Emergency coronary bypass was deemed necessary in 24 of these patients. All 24 patients had severe triple-vessel disease and moderate to marked ventricular dysfunction, with eight (33%) requiring intra-aortic balloon pump (IABP) support for profound cardiac decompensation preoperatively. All 24 patients underwent immediate coronary bypass (average 4.1 grafts/patient), with four operative and two late deaths. Average postoperative blood loss was 1,453 ml, and average blood transfusion postoperatively was 8.2 units per patient. Thirteen patients had normal clotting studies immediately postoperatively, and only two patients developed frank coagulopathy (hyperfibrinolysis). Four patients required reexploration; two for coagulopathy, one for surgical bleeding, and one to rule out tamponade (negative). In those patients with EMI in whom streptokinase fails to result in adequate reperfusion, immediate emergency saphenous vein bypass grafting may be performed with reasonable morbidity and with acceptable hematologic consequences.

Emergency coronary artery reperfusion: a choice therapy for evolving myocardial infarction. Results in 339 patients.

Between 1975 and 1982, 339 patients underwent emergency coronary artery reperfusion for treatment of evolving myocardial infarction (MI). Group I (112 patients) had reperfusion with intracoronary streptokinase. Group II (46 patients) had reperfusion with a combination of intracoronary streptokinase and percutaneous transluminal coronary angioplasty (PTCA). Group III (181 patients) had saphenous vein bypass grafting. Twenty Group I patients and one Group II patient had emergency bypass grafting as streptokinase and PTCA were unsuccessful and significant myocardium remained at risk due to residual stenosis in the MI artery. Seventy-nine percent of Group III patients had successful thrombectomy of the infarcted artery, 33% of Group I had significant residual lesions after clot lysis, and 16% of Group I and 17% of Group III patients had no observable lesion on restudy. There were 10 early and two late deaths in the surgical patients. There were two deaths in Group I and no deaths in Group II. All deaths occurred in patients who were in cardiogenic shock before reperfusion (Group IV). Late follow-up (220 patients to 78 months) revealed three late MIs, four cerebral vascular accidents, two late cardiac and three noncardiac late deaths, and 31 patients with residual symptoms. Patients with an emerging MI should be treated via reperfusion of the MI vessel by one of these techniques. With single-vessel involvement, streptokinase lysis of the intercoronary thrombosis should be attempted. If this is successful and there is a significant residual stenotic lesion, the vessel should undergo balloon angioplasty at that time. If PTCA is unsuccessful, then bypass grafting should be done. When significant multiple-vessel disease exists in conjunction with an acute MI, the patient should have emergency saphenous vein bypass grafting as the treatment of choice.

Percutaneous initiation of cardiopulmonary bypass.

Improved technology has allowed us to develop support pumps that can be applied rapidly and safely. A system utilizing thin-walled (4 mm inner diameter) percutaneously inserted sheaths has been designed for rapid bedside arterial and central venous cannulation to establish femoral arterial and venous cardiopulmonary bypass. The system utilizes two 30-cm-long large-bore, thin-walled (end and side holes) venous cannulas and a single 15-cm-long (end hole) arterial reperfusion cannula, which is connected to a pediatric oxygenator and a vortex pump head. Five patients with refractory cardiac arrest who could not be resuscitated by conventional means were revived with this system. Application time was approximately five minutes. This system appears to be an easily applied and reliable short-term mechanical support device.

Intravenous balloon pumping for acute right ventricular failure.

A patient with acute right ventricular failure and severe hemodynamic instability following coronary artery revascularization was treated with intra-aortic and intravenous balloon pumping. The intravenous balloon was timed to inflate during diastole and deflate during systole as did the intra-aortic balloon; in fact, the two were connected to the same system through a Y-connector. The intravenous balloon acted as an artificial atrium, which allowed approximately 20% improvement in the cardiac output when this intravenous balloon was functioning. Hemodynamic stability was achieved with this system. Intravenous balloon pumping should be considered for patients with unstable hemodynamics secondary to acute right ventricular failure.