Percutaneous Cardiopulmonary Bypass Support Research Articles

症例 左心機能低下に多臓器障害を合併した左冠動脈主幹部病変に対し経皮的人工心肺(PCPS)下に経皮的冠動脈形成術(PTCA)を施行した1症例

症例 左心機能低下に多臓器障害を合併した左冠動脈主幹部病変に対し経皮的人工心肺(PCPS)下に経皮的冠動脈形成術(PTCA)を施行した1症例

First experiences with a new miniaturised life support system for mobile percutaneous cardiopulmonary bypass

As a result of healthcare changes, interhospital transfer has become common in the care even of patients with severely deteriorated cardiopulmonary function. This study describes experience with the use of a specially downsized, lightweight extracorporeal circulation system (Emergency-MECC) which enables percutaneous cardiopulmonary bypass support in resistant cases of severe cardiac and cardiopulmonary failure. Between March 2006 and June 2007, the Emergency-MECC system, consisting of a centrifugal pump and a membrane oxygenator, was used to facilitate interhospital transfer of five adults. The technique included percutaneous cannulation, femoro-femoral venoarterial (n=4) and femoro-jugular venovenous (n=1) life support by extracorporeal membrane oxygenation. Bedside cannulation was uneventful and the extracorporeal circulation support achieved adequate systemic blood flow and oxygen delivery in all cases. Vasopressor support could be immediately reduced and hypoxaemia was treated effectively. During interhospital transfer (air ambulance in three and ground ambulance in two cases), no technical complication occurred. Hospital survival rate was 80%. The Emergency-MECC system is safe, rapid and highly effective in restoring blood flow and oxygen delivery. Interhospital transfer on cardiopulmonary bypass was made possible without extended technical or personnel support.

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.

Usefulness of percutaneous left ventricular assistance to support high-risk percutaneous coronary interventions

Percutaneous coronary intervention (PCI) has been proposed as a measure to alleviate symptoms and improve prognosis in patients with atherosclerotic heart disease and depressed heart function. Nonetheless, the risk of ischemic complications during or after the procedure is potentially increased in these patients. A number of supportive techniques have been described for high-risk angioplasty 1 Shawl F.A. Quyyumi A.A. Bajaj S. Hoff S.B. Dougherty K.G. Percutaneous cardiopulmonary bypass-supported coronary angioplasty in patients with unstable angina pectoris or myocardial infarction and a left ventricular ejection fraction ≤25%. Am J Cardiol. 1996; 77: 14-19 Abstract Full Text PDF PubMed Scopus (25) Google Scholar , 2 Scholz K.H. Dubois-Rande J.L. Urban P. Morice M.C. Loisance D. Smalling R.W. Figulla H.R. Clinical experience with the percutaneous hemopump during high-risk coronary angioplasty. Am J Cardiol. 1998; 82: 1107-1110 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar , 3 Dubois-Rande J.L. Teiger E. Garot J. Aptecar E. Pernes J.M. Tixier D. Gueret P. Loisance D. Dupouy P. Effects of the 14F hemopump on coronary hemodynamics in patients undergoing high-risk coronary angioplasty. Am Heart J. 1998; 135: 844-849 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar , 4 Schreiber T.L. Kodali U.R. O’Neill W.W. Gangadharan V. Puchrowicz-Ochocki S.B. Grines C.L. Comparison of acute results of prophylactic intraaortic balloon pumping with cardiopulmonary support for percutaneous transluminal coronary angioplasty (PCTA). Cathet Cardiovasc Diagn. 1998; 45: 115-119 Crossref PubMed Scopus (22) Google Scholar , 5 Kaul U. Sahay S. Bahl V.K. Sharma S. Wasir H.S. Venugopal P. Coronary angioplasty in high risk patients comparison of elective intraaortic balloon pump and percutaneous cardiopulmonary bypass support—a randomized study. J Interv Cardiol. 1995; 8: 199-205 Crossref PubMed Scopus (18) Google Scholar ; however, no single approach has achieved wide acceptance. Limited effectiveness in the actual support 6 Taguchi I. Ogawa K. Oida A. Abe S. Kaneko N. Sakio H. Comparison of hemodynamic effects of enhanced external counterpulsation and intra-aortic balloon pumping in patients with acute myocardial infarction. Am J Cardiol. 2000; 86: 1139-1141 Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar and device-related complications 2 Scholz K.H. Dubois-Rande J.L. Urban P. Morice M.C. Loisance D. Smalling R.W. Figulla H.R. Clinical experience with the percutaneous hemopump during high-risk coronary angioplasty. Am J Cardiol. 1998; 82: 1107-1110 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar , 4 Schreiber T.L. Kodali U.R. O’Neill W.W. Gangadharan V. Puchrowicz-Ochocki S.B. Grines C.L. Comparison of acute results of prophylactic intraaortic balloon pumping with cardiopulmonary support for percutaneous transluminal coronary angioplasty (PCTA). Cathet Cardiovasc Diagn. 1998; 45: 115-119 Crossref PubMed Scopus (22) Google Scholar , 7 Alderman J.D. Gabliani G.I. McCabe C.H. Brewer C.C. Lorell B.H. Pasternak R.C. Skillman J.J. Steer M.L. Baim D.S. Incidence and management of limb ischemia with percutaneous wire-guided intraaortic balloon catheters. J Am Coll Cardiol. 1987; 9: 524-530 Abstract Full Text PDF PubMed Scopus (87) Google Scholar have hampered a more widespread use of these methods. Recently, a newly developed percutaneous left ventricular assist device (pVAD) has been demonstrated to effectively reverse cardiogenic shock after myocardial infarction (Tandem Heart pVAD; Cardiac Assist Technologies, Inc., Ithaca, New York). 8 Thiele H. Lauer B. Hambrecht R. Boudriot E. Cohen H.A. Schuler G. Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance. Circulation. 2001; 104: 2917-2922 Crossref PubMed Scopus (233) Google Scholar This system is readily deployed by percutaneous approach in the catheterization laboratory and is able to provide a systemic output of up to 4 L/min. An inflow cannula is inserted into the left atrium via transseptal puncture and the oxygenated blood is diverted to the femoral artery by a low-speed centrifugal continuous-flow pump. In this study, we report on a series of patients who underwent high-risk PCI supported by the Tandem Heart pVAD.

Significance of percutaneous cardiopulmonary bypass support for volume reduction surgery with severe hypercapnia.

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.

Emergency Percutaneous Cardiopulmonary Bypass Support for Acute Myocardial Infarction

We assessed the efficacy of emergency percutaneous cardiopulmonary bypass support (PCPS) in the treatment of patients with acute myocardial infarction complicated by cardiogenic shock. Emergency PCPS was instituted in 21 consecutive patients beginning in 1991. After the stabilization of the hemodynamics, coronary reperfusion was performed by means of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. Of the seven patients with acute myocardial infarction involving either the left main or two-vessel territories, five survived more than 1 month, but only one patient remained alive and well after 20 months. The main cause of death for this group was low output syndrome. Four of 12 patients with acute left main trunkal occlusion in the catheter laboratory survived and showed a preserved cardiac function (mean followup 28.5 months). The main cause of death for this group was brain damage. Two patients with single-vessel territory acute myocardial infarction underwent PCPS to treat refractory ventricular fibrillation. Both patients were still alive and well at a 12-month followup. Percutaneous cardiopulmonary bypass support successfully stabilized the hemodynamics, allowing time to perform revascularization for all three groups of patients with life-threatening acute myocardial infarction. Recanalization was nevertheless unable to salvage the damaged myocardium in cases of prolonged ischemic time.

Emergency Pulmonary Embolectomy With Percutaneous Cardiopulmonary Bypass

Background. The management of patients with acute pulmonary embolism remains difficult, particularly when cardiogenic shock is involved. The preoperative incidence of cardiac arrest compromises the results of emergency pulmonary embolectomy. In an attempt to reduce the operative mortality rate, we applied percutaneous cardiopulmonary bypass support to restore vital organ perfusion before the surgical intervention.Methods. Percutaneous cardiopulmonary bypass support was preoperatively instituted in 3 patients with acute cardiopulmonary collapse caused by massive pulmonary embolism. In each patient, cardiac massage and endotracheal intubation were necessary due to loss of consciousness, hypotension, and severe cyanosis. Transesophageal echocardiography was performed to detect any evidence of thrombus in the main pulmonary artery, and each patient underwent the emergency pulmonary embolectomy using conventional cardiopulmonary bypass through a median sternotomy.Results. Percutaneous cardiopulmonary bypass support immediately provided effective cardiopulmonary resuscitation. Transesophageal echocardiography clearly demonstrated any evidence of thrombus located in the pulmonary artery. Each patient was discharged from the hospital without any postoperative complication.Conclusions. The use of percutaneous cardiopulmonary bypass support immediately resuscitated and stabilized the cardiopulmonary function and allowed for successful emergency pulmonary embolectomy. In each patient, transesophageal echocardiography was useful for prompt and noninvasive diagnosis.(Ann Thorac Surg 1997;63:1584–6)

A case of the emergency operation for severe mitral stenosis in spite of percutaneous cardiopulmonary bypass support

A case of the emergency operation for severe mitral stenosis in spite of percutaneous cardiopulmonary bypass support

Pulmonary and left ventricular decompression by artificial pulmonary valve incompetence during percutaneous cardiopulmonary bypass support in cardiac arrest.

In cardiac arrest, use of percutaneous cardiopulmonary bypass support (PCPS) may lead to left ventricular loading, with deleterious effects on the myocardium, and is often accompanied by an increase in pulmonary artery pressure. The present study was designed to assess the potential of artificially induced pulmonary valve incompetency to retrogradely decompress the left ventricle during PCPS in ventricular fibrillation. Studies were performed using a standardized experimental animal model in sheep (n = 12; body weight, 77 to 112 kg). When PCPS was used during fibrillation, an increase in left ventricular pressure (from 21.4 +/- 5.0 mm Hg after 1 minute to 28.4 +/- 9.5 mm Hg after 10 minutes of fibrillation) was observed in all animals, with a simultaneous increase in pulmonary artery pressure in 6 animals, from 15.5 +/- 3.8 to 24.3 +/- 5.4 mm Hg (group A). In these animals, artificial pulmonary valve incompetency, which was induced by a special "pulmonary valve spreading catheter," led to effective decompression of both the pulmonary circulation (decrease in pulmonary artery pressure from 24.3 to 11.3 mm Hg) and the left ventricle (decrease in left ventricular pressure from 30.5 to 17.7 mm Hg). We simultaneously measured a decrease in the myocardial release of lactate (increase in arterial coronaryvenous difference in lactate content from -0.01 to 0.14 mmol/L), demonstrating the myocardial protective effect of the procedure. In contrast, in 6 animals without an increase in pulmonary artery pressure during PCPS (group B), artificial pulmonary valve incompetency did not reduce left ventricular loading, which was probably because of competent mitral valves in these animals. In case of increasing pulmonary artery pressure during PCPS in cardiac arrest, artificial pulmonary valve incompetency might be a useful tool for effective pulmonary and retrograde left ventricular decompression.

916-86 Percutaneous Cardiopulmonary Bypass Support (PCPS) for the Treatment of Acute Fulminant Myocarditis Unresponsive to Maximum Medical Therapy

Some acute myocarditis is refractory to conventional therapies including IASP and is rapidly culminating in death without extracorporeal circulatory support. In order to study possible effectiveness of PCPS against this subgroup, acute fulminant myocarditis (AFM), we have reviewed our experiences and have examined the clinical outcome following PCPS treatment. Since 1986, we have applied emergency PCPS to 10 AFM pts (mean 38 years) with rapidly progressive cardiac dysfunction and sustained wide GRS VT/vf with hemodynamic collapse. The average interval from the onset of the very early signs of AFM (common cold like symptoms) to the induction of PCPS was 5.2 days. IASP was routinely applied before, during and after PCPS. Nafamostat mesilate (1 mg/kg/hr,iv) was also administered in combination with Heparin (ACT > 200 sec) as prophylaxis for bleeding complications. Histological examinations obtained from 12 endomyocardial biopsies and 2 autopsies revealed various inflamatory changes in myocardium in all of the 8 pts examined. Although the courses and degree of recovery varied among the pts, PCPS could be eventually weaned in all pts after a mean of 167 hours (ranging 37–302 hours). After the removal of PCPS, 2 old pts ( > 70 years) expired within 1 week due to sepsis and 1 pt expired 4 months later due to multiple organ failure. Seventy percent of pts (7 of 10) survived, 6 pts recovered to show normal cardiac function (mean EF = 0.62) and 1 pt showed DCM like chronic heart failure (EF = 0.321 Although nonsustained VT was observed in 3 of 7 survivors. they have been experiencing an event free follow-up period (mean 4.8 years). Hemodynamic support by PCPS in the acute phase of AFM was shown to be an effective treatment and the long-term outcome of the survivors was shown to be excellent in the majority of the cases.

739-1 Multivessel Supported Coronary Angioplasty in Cardiogenic Shock

Coronary Angioplasty (CA) of the only infarct-related vessel (IRV) in pts with multivessel (MV) Coronary Artery Disease (CAD) and Cardiogenic Shock (CS) has been associated with a poor prognosis. No report exists on multivessel CA in the setting of acute myocardial infarction (MI) with C.S. Eleven consecutive pts (ages 41–77 yrs) with MVCAD and acute MI (anterior in 9: inferior in 2) had percutaneous cardiopulmonary bypass support (PCPS) instituted 30–240 minutes after the onset of C.S. Eight had prior MI, 4 were on balloon pump and 4 had recent cardiac arrest. Ejection fraction (EF) ranged from 11–40% (mean 24.7 ± 3%) and TIMI flow was diminished to grade I or II in 12 of 17 non IRVs. A mean flow rate of 4.0 L/min was achieved with mean BP 6885 mmHg on PCPS prior to CA, which was attempted in 28 vessels (2.5 per ptl with angiographic success in 27 of 28 vessels. All IRV were successfully dilated. Total bypass time ranged from 41–360 min (mean 138 ± 72 min). Four pts died post CA: 2 due to acute closure of IRV, 1 due to CVA and 1 due to sepsis. All 7 survivors are alive at a mean follow-up of 24 ± 6 months, with EF increased to mean 38 ± 5% (p < 0.05). Five pts are functional class I and have required no interventions. Two other pts have required repeat interventions for restenosis. PCPS can stabilize pts in CS and facilitate MVCA which may result in improved survival.

急性心筋梗塞発症後，心停止を呈する患者の救命における救急ＰＣＰＳの役割

急性心筋梗塞発症後，心停止を呈する患者の救命における救急ＰＣＰＳの役割

Role of Percutaneous Cardiopulmonary Bypass and Other Support Devices in Interventional Cardiology

Percutaneous cardiopulmonary bypass support has a role to play in the management of the high-risk coronary angioplasty patient. This article discusses the basic principles of cardiopulmonary bypass, technique, indications, and complications of this new addition to interventional cardiology. In addition, the role of other support devices during high-risk coronary interventions is also discussed.

Percutaneous Cardiopulmonary Bypass Support: A New Approach to High-Risk Angioplasty

Percutaneous cardiopulmonary bypass is a new technique for supporting systemic blood flow during high-risk coronary angioplasty procedures. This mechanical alternative, unlike traditional methods, is not limited by dependency on adequate left ventricular stroke volume. Percutaneous cardiopulmonary bypass support offers new and demanding challenges in the care of this high-risk group of patients.

Factitious Appearance of Aortic Dissection During Portable Cardiopulmonary Bypass—A Case Report

The use of percutaneous cardiopulmonary bypass support (PCPS) has in creased as an aggressive resuscitative measure for hemodynamically compromised patients and for support during high-risk coronary angioplasty or valvuloplasty. The authors present a patient with an acute myocardial infarction and shock, in whom aortography during PCPS simulated the appearance of a Type B aor tic dissection, with apparent compression of contrast dye by a nonopacified false channel. The etiology appears to be the competitive flow between the normal forward cardiac ejection and the retrograde cardiopulmonary flow. Low cardi ac output and the differences in density between blood and radiographic dye exaggerate this phenomenon.

心原性ショックに陥った急性心筋梗塞に経皮的人工心肺補助のもと経皮的冠動脈形成術を施行した１例

心原性ショックに陥った急性心筋梗塞に経皮的人工心肺補助のもと経皮的冠動脈形成術を施行した１例

Emergency cardiopulmonary bypass support in patients with cardiac arrest

Emergency percutaneous cardiopulmonary bypass support was instituted in 11 patients in cardiac arrest refractory to conventional resuscitation measures. Emergency percutaneous cardiopulmonary bypass support was used in five patients in whom cardiac arrest occurred as a result of a complication in the cardiac catheterization laboratory (group 1) and in six other patients in cardiac arrest (group II). A 21F cannula and a 17F cannula were percutaneously inserted into the femoral vein and artery. Flow rates of 3 to 5 L/min were achieved with restoration of mean arterial pressure to 70 mm Hg (range 50 to 75). The status of all 11 patients was improved initially both clinically and hemodynamically with percutaneous cardiopulmonary bypass. Of the group II patients, three had anatomy unsuitable for percutaneous transluminal coronary angioplasty or coronary bypass grafting, could not be weaned from cardiopulmonary support, and died; three of these patients had coronary artery bypass grafting and two survived. All five group I patients underwent successful coronary bypass grafting and survived. Of the seven patients with anatomically correctable disease, all seven were discharged from the hospital. With conventional management nearly all seven of these patients would have died. Nine of 11 patients underwent a cardiac operation and seven of the nine survived. The operative mortality rate was 22% and the overall survival rate was 64%. At follow-up (mean 7 months), all seven patients are alive and six have resumed a normal and active life-style. In conclusion, emergency percutaneous cardiopulmonary bypass support is a powerful resuscitative tool that may stabilize the condition of patients in cardiogenic shock and cardiac arrest to allow for definitive intervention.

Predictors of cardiac survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction

To assess the outcome of percutaneous transluminal coronary angioplasty (PTCA) in patients with severe left ventricular (LV) dysfunction and to determine the predictors of mortality, 73 patients with LV ejection fraction ≤40% who underwent initial PTCA were analyzed. The majority of patients had prior (>1 week) myocardial infarction (62 patients, 85%). Congestive heart failure and unstable angina were present in 24 (45%) and 49 (67%) patients, respectively. Multivessel coronary artery disease was present in 60 (83%). The LV ejection fraction ranged from 14 to 40% (mean 34%). Intraaortic balloon pump (15%) and percutaneous cardiopulmonary bypass support (4%) was used infrequently. Angiographic success was obtained in 109 of 128 lesions (85%) attempted. Complete revascularization was obtained in 16 of 60 patients with clinical success. Procedure-related mortality was 5% (4 patients). All patients were followed from ≥6 to ≤71 months (average 26). The estimated survival was 79 ± 5%, 74 ± 6%, 66 ± 7% and 57 ± 8% at 1, 2, 3 and 4 years, respectively. A Cox regression analysis revealed that the presence of congestive heart failure, a lower LV ejection fraction and a higher myocardial jeopardy score for contractile myocardium were independent predictors of survival after PTCA in patients with LV dysfunction. In conclusion, a high-risk subset can be identified among patients with severe LV dysfunction who undergo PTCA.

Left ventricular rupture complicating percutaneous mitral commissurotomy: Salvage using percutaneous cardiopulmonary bypass support

Left ventricular rupture resulting in death has been reported to be a complication of percutaneous mitral commissurotomy. We report a 71-year-old man in whom a left ventricular rupture occurred during percutaneous mitral commissurotomy and resulted in hemodynamic collapse due to acute cardiac tamponade. The patient was stabilized using percutaneously instituted cardiopulmonary bypass support with subsequent repair of the left ventricle and successful mitral valve replacement. Three months later this patient remains in New York Heart Class I.

Percutaneous cardiopulmonary bypass support in the catheterization laboratory: Technique and complications

A safe and easily applied technique of percutaneous cardiopulmonary bypass support has been developed for use in the cardiac catheterization laboratory. The importance of this technique lies in its ability to maintain hemodynamic stability during high risk interventional procedures regardless of intrinsic cardiac function. Venous and arterial cannulas (18F) are inserted percutaneously over a stiff guide wire after sequential dilatation with 12F and 14F dilators. Bypass flow rates of up to 5 L/min can be achieved. This technique can be applied to support patients with cardiac arrest, hemodynamic collapse after abrupt closure during coronary angioplasty, and cardiogenic shock, as well as those undergoing high-risk elective coronary angioplasty. This form of support also permits transport of the patient to the operating room in a stable condition after an unsuccessful angioplasty. The complications are mostly related to cannula removal and can be minimized by the use of a proper technique. Although the ultimate role of this new technique remains to be completely defined, it appears that it will expand the patient population for whom coronary interventions can be applied.