The use of the TDMAC-heparin shunt in replacement of the descending thoracic aorta.
(9/79)
The use of a flexible polyvinyl tube bonded with tridodecylmethylammonium-heparin (Gott) as a temporary shunt during the resection of lesions of the descending thoracic aorta has proven a safe and simple means of providing adequate circulation to the abdominal viscera and spinal cord. This technique avoids the metabolic consequences of ischemia to the lower body, diminishes left ventricular afterload during aortic clamping, and obviates the requirement for systemic anticoagulation associated with pump bypass. Between September 1970 and October 1974, 24 patients have been operated using the TDMAC shunt. There were two deaths (9%) among the 22 patients undergoing elective resections. Two patients with acutely dissecting and ruptured aneurysms expired. Followup data has been obtained on all patients from one to 46 months postoperative. The ease with which the shunt is inserted and its adaptability to varied clinical and anatomic situations is stressed. We feel that TDMAC-Heparin shunt provides the best method of circulatory support for elective operative procedures on the descending thoracic aorta. (+info)
Reversal of cardiogenic shock by percutaneous left atrial-to-femoral arterial bypass assistance.
(10/79)
BACKGROUND: Recovery of myocardial function after revascularization of acutely occluded coronary arteries may require several days. During this critical time, patients in cardiogenic shock may have low output. A newly developed percutaneous left ventricular assist device (VAD) may offer effective treatment for these patients by providing active circulatory support. METHODS AND RESULTS: Between May 2000 and May 2001, VADs were implanted in 18 consecutive patients who had cardiogenic shock after myocardial infarction. The device was connected to the patient's circulation by insertion of a 21F venous cannula into the left atrium by transseptal puncture; blood was returned to the iliac artery through an arterial cannula. Mean duration of cardiac assistance was 4+/-3 days. Mean flow of the VAD was 3.2+/-0.6 L/min. Before support, cardiac index was 1.7+/-0.3 L/min per m(2) and improved to 2.4+/-0.6 L/min per m(2) (P<0.001). Mean blood pressure increased from 63+/-8 mm Hg to 80+/-9 mm Hg (P<0.001). Pulmonary capillary wedge pressure, central venous pressure, and pulmonary artery pressure were reduced from 21+/-4, 13+/-4, and 31+/-8 mm Hg to 14+/-4, 9+/-3, and 23+/-6 mm Hg (all P<0.001), respectively. Overall 30-day mortality rate was 44%. CONCLUSIONS: A newly developed VAD can be rapidly deployed in the catheterization laboratory setting. This device provides up to 4.0 L/min of assisted cardiac output, which may aid to revert cardiogenic shock. The left ventricle is unloaded by diverting blood from the left atrium to the systemic circulation, making recovery more likely after an ischemic event. The influence of this device on long-term prognosis warrants further investigation. (+info)
Echocardiography of the intra-aortic balloon.
(11/79)
Echocardiography was performed on 9 patients being treated for cardiogenic shock with an intra-aortic balloon. The value of simultaneous recording of the electrocardiogram, cardiac movements, and arterial pressure, with the echocardiogram of the intra-aortic balloon is discussed. The results indicate that echocardiography provides a method of studying intra-aortic balloon function. (+info)
Mechanical circulatory assistance with intra-aortic balloon counterpulsation for major abdominal surgery.
(12/79)
Intra-aortic balloon counterpulsation (IABC) provides effective mechanical circulatory assistance (MCA) in many patients with cardiac disease characterized by low cardiac output and/or myocardial ischemia. The intra-aortic balloon pump (IABP) has been used almost exclusively in the care of patients with cardiac disease as their primary medical disorder. This report presents use of the IABP in three cases where cardiac disease was present, but abdominal pathology necessitating urgent surgical intervention was the primary medical concern. Experience with these three cases suggest that operative and early postoperative use of IABC in patients with documented heart disease undergoing major non-cardiac surgical procedures may reduce the high incidence of cardiac complications. (+info)
The influence of combined intra-aortic balloon counterpulsation and hyperosomotic mannitol on regional myocardial blood flow in ischemic myocardium in the dog.
(13/79)
We investigated the combined effectiveness of intra-aortic balloon counterpulsation and hyperosmotic mannitol (25%) on regional myocardial blood flow during acute coronary insufficiency. Cardiac output and paced heart rate were held constant in chloralose-anesthetized dogs during right heart bypass. Acute coronary insufficiency was produced by ligation of the proximal left anterior descending coronary artery (LAD). Regional myocardial blood flow was measured using radioactive microspheres. Left ventricular end-diastolic pressure, mean aortic pressure, maximum left ventricular dp/dt, and hematocrit were unchanged by combined mannitol infusion and balloon pumping. Studies of combined treatment with balloon pumping and mannitol immediately after the second of two 13-minute consecutive reversible ligations of the LAD demonstrated that (1) collateral coronary blood flow increased 46% (P less than 0.02) in ischemic myocardium compared with mannitol infusion along during the first LAD ligation, and (2) collateral coronary blood flow increased 27% (P less than 0.05) in ischemic myocardium compared with balloon pumping along during the first LAD ligation. Studies in which combined treatment was delayed until 20 minutes after LAD ligation demonstrated that collateral coronary blood flow was elevated by 33% (P les than 0.05) in ischemic myocardium compared to control studies in which balloon pumping alone had no effect. The results suggest that the increase in collateral coronary blood flow was in part a result of an increased transmural pressure gradient produced by balloon diastolic augmentation and the ability of mannitol to reduce coronary vascular resistance in ischemic myocardium. (+info)
Percutaneous cardiopulmonary support aids resuscitation from sustained ventricular tachycardia.
(14/79)
A 67-year-old man was transferred to hospital because of acute circulatory failure resulting from sustained left ventricular tachycardia (LVT) and dysfunction. Transthoracic echocardiography revealed severely impaired left ventricular contraction and dyskinesis of the apical wall. Neither anti-arrhythmic agents nor direct current cardioversion was effective; the patient was resuscitated by immediate use of percutaneous cardiopulmonary support and intraaortic balloon counterpulsation. Ventricular contraction returned to normal following restoration of normal sinus rhythm with amiodarone and cibenzoline. The pathogenesis of LVT accompanied by transient ventricular dyskinesis is discussed with regard to the efficient use of a mechanical circulatory support system in resuscitation. (+info)
Transmyocardial laser revascularization as an adjunct to coronary artery bypass grafting: a randomized, multicenter study with 4-year follow-up.
(15/79)
We evaluated transmyocardial laser revascularization (TMLR) with coronary artery bypass grafting (CABG) versus CABG alone for severe coronary artery disease involving 21 myocardial region unsuited for CABG. At 4 centers, 44 consecutive patients were randomized for CABG+TMLR (n = 23) or CABG alone (n = 21). Operative and in-hospital mortality and morbidity rates were monitored. Clinical status was evaluated at hospital discharge, 1 year, and 4 years. Success was characterized by relief of angina and freedom from repeat revascularization and death. Preoperatively, 20 patients (47%) were at high risk. The CABG technique, number of grafts, and target vessels were similar in both groups. Patients undergoing CABG+TMLR received 25 +/- 11 laser channels. Their < or = 30-day mortality was 13% (3/23) compared with 28% (6/21) after CABG alone (P = 0.21). There were no significant intergroup differences in the number of intraoperative or in-hospital adverse events. The follow-up period was 50.3 +/- 17.8 months for CABG alone and 48.1 +/- 16.8 months for CABG+TMLR. Both groups had substantially improved angina and functional status at 1 and 4 years, with no significant differences in cumulative 4-year mortality. The incidence of repeat revascularization was 24% after CABG alone versus none after CABG+TMLR (P < 0.05). The 4-year event-free survival rate was 14% versus 39%, respectively (P < 0.064). In conclusion, CABG+TMLR appears safe and poses no additional threat for high-risk patients. Improved overall success and repeat revascularization rates may be due to better perfusion of ischemic areas not amenable to bypass. Further studies are warranted to determine whether these trends are indeed significant. (+info)
Favourable clinical outcome in patients with cardiogenic shock due to fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation.
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AIMS: The clinical outcome of severe acute myocarditis patients with cardiogenic shock who require circulatory support devices is not well known. We studied the survival and clinical courses of patients with fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation (ECMO) and compared them with those of patients with acute non-fulminant myocarditis. METHODS AND RESULTS: Patients with acute myocarditis were divided into the following two groups. Fourteen patients who required ECMO for cardiogenic shock were defined as having fulminant myocarditis (F group), whereas 13 patients who had an acute onset of symptoms, but did not have compromised, were defined as having acute non-fulminant myocarditis (NF group). In the F group, 10 patients were weaned successfully from percutaneous ECMO. Therefore, the overall acute survival rate was 71%. Patients who were not weaned from ECMO showed smaller left ventricular end-diastolic and end-systolic dimensions, thicker left ventricular wall, and higher creatine phosphokinase MB isoform levels than those who were weaned from ECMO. When compared with patients in the NF group, the fractional shortening in the F group was more severely decreased in the acute phase [F: 10+/-4 vs. NF: 23+/-8% (mean+/-SD), P<0.001], but recovered in the chronic phase (F: 33+/-7 vs. NF: 34+/-6%). The prevalence of adverse clinical events in both groups was similar during the follow-up period of 50 months. CONCLUSION: In patients with fulminant myocarditis, percutaneous ECMO is a highly effective form of a haemodynamic support. Once a patient recovers from inflammatory myocardial damage, the subsequent clinical outcome is favourable, similar to that observed in patients with acute non-fulminant myocarditis. (+info)