Emergency percutaneous cardiopulmonary bypass support for acute myocardial infarction

A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients

Extracorporeal membrane oxygenation (ECMO) comprises a commonly used method of extracorporeal life support. It has proven efficacy and is an accepted modality of care for isolated respiratory or cardiopulmonary failure in neonatal and pediatric populations. In adults, there are conflicting studies regarding its benefit, but it is possible that ECMO may be beneficial in certain adult populations beyond postcardiotomy heart failure. As such, all intensivists should be familiar with the evidence-base and principles of ECMO in adult population. The purpose of this article is to review the evidence and to describe the fundamental steps in initiating, adjusting, troubleshooting, and terminating ECMO so as to familiarize the intensivist with this modality.

Percutaneous cardiopulmonary support-supported percutaneous coronary intervention: a single center experience

Background and Objectives

Percutaneous cardiopulmonary support (PCPS) has proven to be a valuable technique in high-risk coronary patients undergoing percutaneous coronary intervention (PCI). However, there have been few studies on PCI associated with PCPS in Korea. We summarized our experience with PCPS-supported PCI.

Subjects and Methods

We retrospectively reviewed 19 patients with PCPS-supported PCI between August 2005 and June 2009. PCPS was used as an elective procedure for 10 patients with at least two of the following conditions: left-ventricular ejection fraction <35%, target vessel(s) supplying more than 50% of the viable myocardium, high risk surgical patients, and patients who refused coronary bypass surgery. In the remaining 9 patients PCPS was used as an emergency procedure, to stabilize and even resuscitate patients with acute myocardial infarction and cardiogenic shock, in order to attempt urgent PCI.

Results

Among the 19 patients who were treated with PCPS-supported PCI, 11 (57.9%) survived and 8 (42.1%) patients did not. ST elevation myocardial infarction with cardiogenic shock was more prevalent in the non-survivors than in the survivors (75% vs. 27.3%, p=0.04). The elective PCPS-supported PCI was practiced more frequently in the survivors than in the non-survivors (72.7% vs. 25%, p=0.04). In the analysis of the event-free survival curve between elective and emergency procedures, there was a significant difference in the survival rate (p=0.025). Among the survivors there were more patients with multi-vessel disease, but a lower Thrombolysis in Myocardial Infarction grade in the culprit lesions was detected in the non-survivors, before PCI. Although we studied high-risk patients, there was no procedure-related mortality.

Conclusion

Our experience suggests that PCPS may be helpful in high risk patients treated with PCI, especially in elective cases. More aggressive and larger scale studies of PCPS should follow.

Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states

BACKGROUND

Cardiogenic shock and cardiac arrest are common, lethal, debilitating and costly. Percutaneous cardiopulmonary bypass is an innovative strategy for treating these disorders that consists of rapid initiation of cardiopulmonary bypass and extracorporeal maintenance of circulation until restoration of an effective cardiac output. Multiple case reports suggest that percutaneous bypass is efficacious in patients with these disorders but these experiences have not been collated. Therefore, we have reviewed systematically the published experience with percutaneous bypass in patients with cardiogenic shock or cardiac arrest.

OBJECTIVES

The objectives were to describe the proportion of patients with cardiogenic shock or cardiac arrest who achieved restoration of spontaneous circulation or survival to discharge with percutaneous bypass. A secondary objective was to describe adverse effects associated with percutaneous bypass, if feasible.

DESIGN

Articles were identified by using a comprehensive search of English-language MEDLINE from 1966 to September 2005.

PATIENTS

Individuals in cardiogenic shock or cardiac arrest.

INTERVENTIONS

Percutaneous cardiopulmonary bypass.

ANALYSIS

Effects were summarized as inverse-variance weighted means, standard errors, median and interquartile range.

RESULTS

Included were 85 studies of 1494 patients with cardiogenic shock, cardiac arrest or both. Studies were case reports, case-series or case-control studies of heterogeneous interventions in heterogeneous patients. The proportion of patients weaned was mean, 76.8+/-4.2%, and median, 66.0% (IQR 50%, 100%). The proportion of patients who survived to discharge was mean, 47.4+/-4.5%, and median 40.0% (IQR 20%, 75%). Fifty-two studies included 533 patients in cardiogenic shock. The proportion of patients who survived to discharge was mean, 51.6+/-6.5%, and median 38.5% (IQR 23.4%, 76.3%). Fifty-four studies included 675 patients in cardiac arrest. The proportion of patients who survived to discharge was mean, 44.9+/-6.7%, and median, 42.3% (IQR 15.4%, 75%). Five studies with 286 subjects had both patients with cardiogenic shock or cardiac arrest.

CONCLUSIONS

Percutaneous bypass is an efficacious intervention in patients with cardiac arrest or cardiogenic shock. Adequately-powered experimental studies of current percutaneous bypass technologies are required to demonstrate whether it is safe, effective and cost-effective.

Left ventricular assist system through the left ventricle for acute myocardial infarction: report of a case

A 49-year-old man, who had suffered from acute myocardial infarction due to left main trunk occlusion, developed cardiogenic shock and was successfully treated with an implantation of a left ventricular assist system with left ventricular apical drainage. At present he is awaiting a heart transplant at approximately 485 days since the operation. The timely application of a left ventricular assist system before the development of multiple organ failure is thus considered to be effective for patients demonstrating acute myocardial infarction with cardiogenic shock.

Successful emergency aortic valve replacement following percutaneous cardiopulmonary support for the patient with aortic stenosis and cardiac arrest

We present a 57-year-old woman with severe aortic stenosis. She was diagnosed with acute myocardial infarction by electrocardiography and the detection of elevated creatine phosphokinase in another hospital. Soon after transfer to our hospital, this patient developed cardiac arrest. Percutaneous cardiopulmonary support (PCPS) was established, and subsequently performed coronary angiography revealed normal coronary arteries. However echocardiography revealed severe aortic stenosis. Emergency aortic valve replacement (AVR) was performed, and the patient was discharged from hospital 30 days after surgery in good health. Prompt establishment of PCPS maintained her systemic circulation, and allowed us to conduct investigations for diagnosis. In patients with critical aortic stenosis, emergency AVR should be performed as early as possible following diagnosis.

Percutaneous cardiopulmonary support in critical patients needing coronary interventions with stents

Percutaneous cardiopulmonary support (CPS) has proven to be a technique of value in high-risk coronary patients undergoing percutaneous balloon angioplasty. Since May 1994, we have combined the use of CPS and coronary stent revascularization in 92 patients. In 68 of them, the CPS was used as a prophylactic procedure (group 1); in the remaining 24, the CPS was used as an emergency procedure to stabilize and even resuscitate patients with acute myocardial infarction and circulatory collapse, in order to attempt urgent percutaneous coronary stent treatment (group 2). Primary success was achieved in 66 patients from group 1 (97%). One patient died and another had a myocardial infarction. After 28 +/- 19 months of follow-up, 20 patients (30%) from group 1 had a major adverse cardiac event. The remaining 46 patients (68%) are alive, with persistent clinical benefit. In group 2, reperfusion and stent treatment was always achieved. However, 14 patients had an in-hospital death. Five patients from group 2 had a major adverse event at follow-up (47 +/- 20 months). Nine patients (38%) remain at present in functional class I-II. Percutaneous CPS provides safe conditions to accomplish stent coronary revascularization in high-risk patients and those with acute myocardial infarction and failing heart. Long-term follow-up of survivors shows persistent benefit in most patients.

Right ventricular infarction with cardiogenic shock treated with percutaneous cardiopulmonary support: a case report

A patient with a right ventricular infarction was resuscitated with percutaneous cardiopulmonary support (PCPS), after attempts at reperfusion, high-dose inotropic support and intra-aortic balloon counterpulsation failed to improve the hemodynamic compromise. Emergency PCPS improved the cardiogenic shock and the reduced right ventricular load, allowing the ischemic right ventricle to recover in the setting of unsuccessful reperfusion. This case demonstrates the use of PCPS as a hemodynamic support device for spontaneous recovery of the ischemic right ventricle. PCPS may be a potential therapy for patients with right ventricular infarction.

Digest

Professor Seiki Matsuno and Dr Michiaki Unno, Chief Editors of Surgery Today (The Japanese Journal of Surgery), have selected from the July–September 1998 issues of the journal for this quarter's digest. A digest of BJS for the same period written by Mr Colin Johnson, European Editor, appears in the Japanese journal.