1. science
2. medicine
3. surgery

Review
European Heart Journal (2007) 28, 2057–2063
doi:10.1093/eurheartj/ehm191
Percutaneous left ventricular assist devices in acute
myocardial infarction complicated by cardiogenic shock
Holger Thiele1*, Richard W. Smalling2, and Gerhard C. Schuler1
1
¨mpellstr. 39, 04289 Leipzig, Germany
Department of Internal Medicine/Cardiology, University of Leipzig—Heart Center, Stru
and 2Division of Cardiovascular Medicine, Department of Internal Medicine, The Memorial Hermann Heart and Vascular
Institute, University of Texas, Houston, TX, USA
Received 8 November 2006; revised 4 April 2007; accepted 13 April 2007; online publish-ahead-of-print 22 July 2007
KEYWORDS
Shock;
Heart-assist device;
Heart failure;
Haemodynamics;
Myocardial infarction
Cardiogenic shock (CS) remains the most common cause of death in patients with acute myocardial
infarction (AMI). In addition to percutaneous coronary intervention, inotropes, and fluids, intraaortic
balloon pumping (IABP) is most widely used for initial haemodynamic stabilization. However, the
main limitation of IABP is the lack of active circulatory support and the requirement of a certain
level of left ventricular (LV) function. In many patients with severe depression of LV function, haemodynamic support and LV unloading derived from IABP is insufficient to reverse CS. The use of percutaneous LV assist devices (LVAD) with active circulatory support might be beneficial in CS patients not
responding to standard treatment including IABP support. This review reports the current experience
of percutaneous LVAD in CS complicating AMI.
The incidence of cardiogenic shock (CS) in patients with AMI
ranges from 7 to 10% after acute myocardial infarction
(AMI).1,2 Despite aggressive treatment modalities such as
percutaneous coronary interventions (PCI) and use of
intraaortic balloon support, mortality of CS remains unacceptably high (50–70%).1,3,4 Recovery of myocardial performance following successful revascularization of the
infarct related artery may require several days. During this
period many patients succumb to low cardiac output. Therefore, intraaortic balloon pumping (IABP) is the method of
choice for mechanical assistance,5 since IABP can result in
initial haemodynamic stabilization.6–8 Systematic reviews
on the mode of action, physiological response and clinical
studies have been published elsewhere.9,10 The main limitations of IABP include the lack of active cardiac support,
need for accurate synchronization with the cardiac cycle,
and requirement of a certain level of left ventricular (LV)
function. In many patients with severe depression of
cardiac function or persistent tachyarrhythmias, haemodynamic support and LV unloading derived from IABP are
insufficient to reverse CS.11
Therefore, the use of percutaneous LV assist devices
(LVAD) with active circulatory support might be beneficial
in patients with CS not responding to standard treatment,
although this is currently not supported by randomized controlled clinical data (Figure 1). Usually these devices are
* Corresponding author. Tel: þ49 341 8651426/1428; fax: þ49 341
865 1461.
E-mail address: thielh@medizin.uni-leipzig.de
used as a bridge-to-recovery, which may last several
days. In patients with mechanical complications after AMI,
LVAD are used as a bridge-to-surgery, or in patients
without recovery, the surgical implantation of a long-term
LVAD,12,13 or emergent heart transplantation might be
necessary (Figure 1). Therefore, percutaneous LVAD are
usually designed for a maximum use of 14 days.
Currently, there are several different devices and modes
of operation.
Percutaneous cardiopulmonary bypass
After introduction of the first cardiopulmonary bypass (CPB)
system with oxygenation in 1953, further developments led
to percutaneously implantable devices.14 Such systems
consist mainly of a blood pump and an oxygenator; 16–18
French arterial cannulae in the descending aorta and 18
French venous cannula advanced into the right atrium are
used (Figure 2). These cannulae are connected to an external pump and a membrane oxygenator. After pump priming
with normal saline, blood is withdrawn from the right
atrium and pumped through a heat exchanger, membrane
oxygenator, and ultimately returned into the femoral
artery. The pump provides a continuous flow with maintenance of a pulsatile arterial pressure unless the circulation
is completely supported by the CPB device. There are
several drawbacks of CPB such as large cannulae sizes with
subsequent lower limb ischaemic complications, requirement of perfusionists, lack of direct LV unloading, increased
afterload, and a limited support time (usually ,6 h).15
Therefore, percutaneous CBP has mainly been used for
patients with cardiopulmonary collapse in the cath lab.
& The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
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Introduction
2058
H. Thiele et al.
percutaneous approach, .200 patients have been treated
during resuscitation efforts or in acute severe CS.14,16–23
The survival rates of these reports range from 4–64% with
a mean survival rate of approximately 25%. There are only
limited experiences in CS after AMI,24 and for patients
with mechanical complications.25
In summary, the percutaneous CPB system has been lifesaving for a small group of patients with abrupt haemodynamic collapse in the cath lab. Its use is limited by high
associated complications, need of extracorporeal circulation
and a membrane oxygenator with subsequent activation of
cellular elements, and limited support time. The clinical
impact of new, smaller, and portable devices such as the
Lifebridge B2Tw needs to be determined in future trials.26
Axial flow pumps
Figure 1 Possible scheme for selection of patients with cardiogenic shock
complicating acute myocardial infarction for implantation of left ventricular
assist devices (not supported by randomized controlled trials).
Those patients with abrupt closure of a vessel may be supported until the situation is resolved by either PCI or until
transfer in a stable condition to the operating room for
emergency cardiac surgery. Since the introduction of a
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Figure 2 Schematic drawing of the percutaneous cardiopulmonary bypass
assist device. Transfemoral venous and arterial cannulae are inserted percutaneously. Blood is pumped from the right atrium via a pump and an oxygenator to the abdominal aorta (reprinted with permission of Scholz).
These pumps are usually positioned across the aortic valve
to provide active support by transvalvular LV assistance
(Figure 3). In 1988, Wampler et al.27 were the first to
describe an axial, catheter-mounted LVAD inserted by surgical arteriotomy via the femoral artery. The outer diameter
was 21 French and the length 26 cm. The axial flow pump
consisted of a disposable suction cannula with a turbine
driven by an external motor (Figure 4). The pumping
system consisted of an axial flow blood pump, which was
positioned in the aortic arch or the descending aorta, an
inlet cannula, and a drive cable in a polymeric sheath and
a motor. Depending on the aortic pressure, the pump
capacity was up to 3.5 L/min at a speed of 25 000 r.p.m. In
a canine infarct model, the effects of LV unloading were
assessed. Treatment with the HemopumpTM (Medtronic
Inc., Minneapolis, MN, USA) resulted in significant myocardial salvage as compared with reperfusion alone.28 In
addition, it provided superior LV unloading in comparison
to IABP.28 Similar positive results on LV unloading, myocardial perfusion pressure, and serum lactate levels were
obtained in a sheep model.29,30
In a subsequent small pilot study, the 21 French
HemopumpTM was used in 11 patients with CS after AMI.31
Haemodynamic parameters and catecholamine requirements improved significantly during the initial 24 h of
haemodynamic support. Overall mortality in this trial was
64%.31 However, a transfemoral placement of the pump via
the aortic valve was possible in only two thirds of the
patients despite surgical cutdown of the femoral artery. In
another multiinstitutional study including patients with CS,
the insertion rate of this LVAD was 77%; 30-day-mortality
was 68%.32
A smaller 14 French HemopumpTM (Medtronic Inc.) was
devised that could be inserted percutaneously.33 At a
speed of 40 000 r.p.m. the system delivered flow of up to
2.2 L/min. In a multicentre registry of the percutaneous
HemopumpTM during high-risk PCI, the overall mortality
was 12.5% for 32 patients not in CS.34 In addition, despite
the short-term use, there were significant procedure and
device-related vascular access problems (16% limb ischaemia, 25% bleeding complications).34 As a cause of the high
complication rate, the HemopumpTM never received FDA
approval and further development was not pursued.
Recently, new axial flow devices have been developed.
The Impella Recoverw LP 5.0 (Impella CardioSystems
GmbH, Aachen, Germany) axial flow pump is a microaxial
Percutaneous left ventricular assist devices
2059
Table 1 Technical features of currently available percutaneous
left ventricular assist devices for haemodynamic support in the
cath lab
Catheter size
(French)
Cannula size
(French)
Flow (L/min)
Pump speed
(r.p.m.)
Insertion/
placement
Figure 3 Axial flow pump positioned across the aortic valve into the left
ventricle.
Figure 4 Schematic drawing of the 21 French HemopumpTM . The axial pump
is fixed at the distal part of a flexible silicone suction cannula, which is positioned retrogradely across the aortic valve into the left ventricle. The pump
outlet is located in the aortic arch or in the descending aorta (reprinted with
permission of Scholz).
Impella
Recoverw
LP 5.0
Impella
Recoverw
LP 2.5
—
9
9
21 venous
21
12
12–19 arterial
Max. 4.0
Max. 7500
Max. 5.0
Max. 33 000
Max. 2.5
Max. 33 000
Peripheral
(femoral
artery þ left
atrium after
transseptal
puncture)
þ
214 days
Peripheral
surgical
cutdown
(femoral
artery)
Percutaneous
(femoral
artery)
þ
7 days
þ
5 days
þ
PMN
þþ þþ þ
þ
IDE trial
þ þþ
þ
IDE trial
þþ þ
PMN, pre-market notification; IDE, investigational device exception.
þ, anticoagulation necessary; CE-certification present; þ þ þ, high
relative costs in comparison to IABP; þþ þ þþ very high relative costs
in comparison to IABP.
flow pump capable of delivering a continuous flow of up to
5 L/min (Table 1), which is also available as a surgical insertion LVAD.35,36 By use of this device in a sheep infarction
model, oxygen consumption was reduced during ischaemia
and led to infarct size reduction.37 A drawback was the
requirement of femoral artery surgical cutdown.38
However, in comparison to the Hemopump, positioning
across the aortic valve appears to be successful in a higher
proportion of patients as a guidewire can be positioned
across the device tip. Currently, the Impella Recoverw LP
5.0 has been used in approximately 200 cases, is under
investigational use in a FDA approval study, and has received
CE mark for use in Europe.
A smaller device, the Impella Recover LPw 2.5 approved
for 5 day use in Europe, can be inserted percutaneously
and provides continuous flow up to 2.5 L/min (Table 1).
The device is equipped with a pigtail-catheter at the tip
to ensure stable positioning in the LV and to prevent it
from adhering to the myocardium (Figure 3). So far, there
is only limited clinical experience, in particular in stable
patients with high-risk PCI, and it remains unclear if 2.5 L/
min is adequate to reverse CS.39
Limitations of axial support devices are related to the position in the aortic valve. The presence of a mechanical aortic
valve or an aortic stenosis is a contraindication for the
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Anticoagulation
Recommended
duration of
use
CE-certification
FDA
Relative costs in
comparison to
intraaortic
balloon
pumping
Tandem
HeartTM
2060
implantation. Furthermore, these devices might be inefficient in severe aortic regurgitation, and some need surgical
cutdown of the femoral artery. Due to the high rotation
speed of the impeller, these devices might provoke significant haemolysis.38
Left atrial-to-femoral arterial left
ventricular assist devices
blood surface contact area resulting in reduced potential
for haemolysis and thromboemboli. The implantation procedure has been described in detail elsewhere.43 In brief,
after standard transseptal puncture and pre-dilatation of
the fossa ovalis, a venous inflow cannula is inserted into
the left atrium (Figure 5). Afterwards an arterial cannula
(usually 17 French) needs to be inserted into the femoral
artery. Once all air has been removed from the system,
the cannulae are connected to the extracorporeal centrifugal pump by standard tygon tubing. Oxygenated blood is
drawn from the left atrium and returned via the centrifugal
pump and via the arterial cannula in the femoral artery to
the lower abdominal aorta (Figure 5). After a short learning
curve this device can be inserted and LV assist instituted in
,30 min in the cath lab setting. The system is capable of
delivering flow up to 4.0 L/min at 7500 r.p.m. In a feasibility
trial, 18 patients with CS were enrolled.43 With the device,
CS could be reversed efficiently as monitored by haemodynamic and metabolic parameters, and the overall mortality rate was as low as 44%.43 In a subsequent
randomized trial comparing the Tandem HeartTM and IABP
in 41 patients with revascularized AMI complicated by CS,
the device was able to improve the haemodynamic and
metabolic variables more effectively than with IABP
support.44 However, complications like severe bleeding,
limb ischaemia, or fever were encountered more frequently
after LVAD support, whereas the 30-day-mortality was
similar (IABP 45% vs. LVAD 42%, log-rank, P ¼ 0.86).44
Figure 5 Diagram of the percutaneously inserted transseptal and arterial cannulae connected to the Tandem HeartTM centrifugal pump. Right upper corner:
close-up of the transseptal catheter with large end hole and 14 side holes in the left atrium.
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In 1962, this system was first described by the jugular
approach.40 Initially, left atrial-to-femoral arterial LVAD
were used in patients not weanable from CPB after cardiothoracic surgery.41 Subsequently, percutaneous approaches
for patients undergoing high-risk interventions for shortterm use have been reported.42 Due to the lack of a transseptal cannula that can accommodate flow rates necessary
to provide adequate circulatory support, due to risk of
thrombus formation at the impeller, and due to inherent
haemolysis of high-speed centrifugal pumps, this technique
has not achieved widespread popularity. Therefore, new
developments have been made to avoid the inherent risk
of thrombus formation and haemolysis by centrifugal pumps.
The Tandem HeartTM pVAD (Cardiac Assist Technologies,
Inc., Pittsburgh, PA, USA), which is approved for short-term
haemodynamic support (6 h) by the FDA and which is currently marketed in the USA and Europe, is a new generation
low speed centrifugal continuous flow pump with a low
H. Thiele et al.
Percutaneous left ventricular assist devices
Similar results with increased complications without a significant mortality benefit were obtained in a second multicentre trial of the Tandem HeartTM in comparison to IABP
for CS.45 The most important drawback of the left
atrial-to-femoral-arterial bypass support is the need for
large arterial cannulae to achieve the required flow.
Furthermore, currently little is known about the fate of
the transseptal puncture site. However, in recent series,
no relevant left-to-right shunt has been observed by
careful echocardiographic monitoring.43,44,46
An overview of the technical features of currently available LVAD for percutaneous support or those that can be
inserted by peripheral surgical cutdown is shown in Table 1.
Effects of left ventricular unloading
Limitations
As all percutaneous implantable LVAD provide continuous
flow, this also affects the flow in the coronary arteries,
which leads to non-physiological flow. The debate regarding
the effect of non-pulsatile flow on organ function and the
hormonal situation is extensive and remains controversial
and has not been finally determined.58–60
Active circulatory support LVAD have been used so far only
in small trials with limited number of patients enrolled.
Except the two randomized Tandem HeartTM vs. IABP
trials, there are no randomized trials that have proven a
substantial benefit of these devices over standard treatment.44,45 Although the haemodynamic effects of active
support LVAD have been proven in several trials, there is
no trial that had the power to detect differences in mortality. A large clinical trial, supporting the theoretical
advantages of an active LVAD (in particular in patients with
a significant amount of stunned myocardium not responding
to standard treatment) is warranted; however, currently
there is no larger trial on the horizon. In addition, there
are no trials assessing the merits of risks of each LVAD
against the other. Therefore, no conclusion can be drawn
regarding the different risk of embolic complication, haemolysis, inducement of aortic regurgitation, or the dislodgment
risk from the optimal site in the left atrium or LV.
There are new hypotheses that in the development and
maintenance of CS peripheral factors play an important
role besides extensive myocardial necrosis.61 Theoretically,
extracorporeal support and contact with artificial surfaces
of LVAD might further promote the systemic inflammatory
response syndrome with subsequent deterioration to a multiorgan dysfunction syndrome. A second, potentially deleterious effect of extracorporeal circulation, besides the
propagation of systemic inflammatory response, is the activation of complement and the development of coagulation
with subsequent fibrinolysis, which may progress to disseminated intravascular coagulation leading to severe bleeding
complications.62,63
Furthermore, these devices are expensive in comparison
to standard IABP treatment resulting in up to 30-fold
higher costs (Table 1). In view of these limitations, there
are some general contraindications for LVAD in addition to
specific contraindications of the different systems, such as
contraindication to anticoagulation, severe aortic regurgitation, terminal disease with limited life expectancy,
advanced multiorgan dysfunction syndrome, central
nervous system injury, right ventricular failure, severe
bleeding, sepsis, uncontrolled by antibiotics, and severe
peripheral arterial obstructive disease.
Conclusions
LVAD with active circulatory support reverse haemodynamic
and metabolic parameters in CS more effectively than with
standard IABP treatment alone. The use of these newer percutaneous devices is still in its infancy. The easier and safer
deployment of the newly developed devices may increase
their use for patients not responding to PCI, fluids, inotropes, and IABP. Although, from a theoretical point of
view, these active LVAD might be beneficial, it remains to
be proven that these actually alter the high mortality of
CS patients. Furthermore, these devices are associated
with more complications as a result of the highly invasive
procedure and the extracorporeal support in some of these
devices. Therefore, the decision making process on how to
treat CS complicating AMI in addition to standard treatment
requires an integrated stepwise approach, although the
evidence supporting this is very limited. An LVAD might be
considered on the basis of individual risk, success rates
of standard treatment, and potential periprocedural event
rates.
Conflict of interest: none declared.
References
1. Goldberg RJ, Samad NA, Yarzebski J, Gurwitz J, Bigelow C, Gore JM.
Temporal trends in cardiogenic shock complicating acute myocardial
infarction. N Engl J Med 1999;340:1162–1168.
Downloaded from by guest on October 21, 2014
Besides the haemodynamic effects of an active LVAD in
comparison to IABP support, the recovery of the myocardium
after revascularization occurs by a reduction of the LV filling
pressure, cardiac workload, and oxygen demand. Previous
animal studies have demonstrated a substantial decrease
in infarct size by use of CPB with venting of the LV and by
axial and left atrial-to-femoral LVAD with or without
revascularization of the infarct related artery.28,37,47–52
Furthermore, in animal models, LV unloading prior to
revascularization of the infarcted artery led to significant
myocardial salvage in comparison to the implementation
of unloading after reperfusion.50,53 A clinical trial supporting
this hypothesis is still pending.
In patients with end-stage heart failure, long-term
implantable LVAD were useful in improving symptoms and
in preventing or reversing heart failure by inducing neuroendocrine modulation and reverse remodelling. In terms of
neurohormonal modulation, LVAD support decreased
plasma levels of epinephrine, norepinephrine, angiotensin II,
and arginine vasopressin.54 Furthermore, serum levels of
interleukins 6 and 8 and TNF-a content in the failing myocardium could be reduced.12,55 In terms of remodelling, longterm LVAD support has been shown to significantly reduce
collagen content and decrease myocyte size.56 In addition,
improvement in myocyte contractility and myocardial
response to b-adrenergic stimulation has been observed.57
However, whether these neuroendocrine and reverse remodelling effects can be translated into the acutely failing
heart in patients with CS after AMI with short-term assisted
circulatory support is not known.
2061
2062
23. Hartz R, LoCicero J, Sanders JH, Frederiksen JW, Joob AW, Michaelis LL.
Clinical experience with portable cardiopulmonary bypass in cardiac
arrest patients. Ann Thorac Surg 1990;50:437–441.
24. Shawl FA, Domanski MJ, Hernandez TJ, Punja S. Emergency percutaneous
cardiopulmonary bypass support in cardiogenic shock from acute myocardial infarction. Am J Cardiol 1989;64:967–970.
25. Fujimoto K, Kawahito K, Yamaguchi A, Sakuragawa H, Tsuboi J, Yuri K,
Tanaka M, Endo H, Adachi H, Ino T. Percutanous extracorporeal life
support for treatment of fatal mechanical complications associated
with acute myocardial infarction. Artif Organs 2001;25:1000–1003.
26. Mehlhorn U, Brieske M, Fischer UM, Ferrari M, Brass P, Fischer JH,
Zerkowski HR. LIFEBRIDGE: a portable, modular, rapidly available
‘plug-and-play’ mechanical circulatory support system. Ann Thorac
Surg 2005;80:1887–1892.
27. Wampler RK, Moise JC, Frazier OH, Olsen DB. In vivo evaluation of a
peripheral vascular access axial flow blood pump. Trans ASAIO 1988;34:
450–454.
28. Smalling RW, Cassidy DB, Barrett R, Lachterman B, Felli P, Amirian J.
Improved regional myocardial blood flow, left ventricular unloading,
and infarct salvage using an axial-flow, transvalvular left ventricular
assist device. A comparison with intra-aortic balloon counterpulsation
and reperfusion alone in a canine infarction model. Circulation 1992;
85:1152–1159.
29. Scholz KH, Hering JP, Schro
¨der T, Uhlig P, Tebbe U, Kreuzer H, Hellige G.
Protective effects of the hemopump left ventricular assist device in
experimental cardiogenic shock. Eur J Cardiothorac Surg 1992;6:
209–214.
30. Hering JP, Schro
¨der T, Uhlig P, Scholz KH, Tebbe U, Kreuzer H, Hellige G.
Myocardial support and protection during regional myocardial ischemia
using the hemopump assist device. Thorac Cardiovasc Surg 1991;39:
257–262.
31. Smalling RW, Sweeney M, Lachterman B, Hess MJ, Morris R, Anderson HV,
Heibig J, Li G, Willerson JT, Frazier H. Transvalvular left ventricular
assistance in cardiogenic shock secondary to acute myocardial infarction.
Evidence for recovery from near fatal myocardial stunning. J Am Coll
Cardiol 1994;23:637–644.
32. Wampler RK, Frazier OH, Lansing AM, Smalling RW, Nicklas JM, Phillips SJ,
Guyton RA, Golding LA. Treatment of cardiogenic shock with the Hemopump left ventricular assist device. Ann Thorac Surg 1991;52:506–513.
33. Scholz KH, Figulla HR, Schweda F, Smalling RW, Hellige G, Kreuzer E,
Aboul-Hosn W, Wampler RK. Mechanical left ventricular unloading
during high risk coronary angioplasty—first use of a new percutaneous
left ventricular assist device. Cathet Cardiovasc Diagn 1994;31:61–69.
34. Scholz KH, Dubois-Rande J-L, Urban P, Morice MC, Loisance D,
Smalling RW, Figulla HR. Clinical experience with the percutaneous
Hemopump during high-risk coronary angioplasty. Am J Cardiol 1998;
82:1107–1110.
35. Garatti A, Colombo T, Russo C, Lanfranconi M, Milazzo F, Catena E,
Bruschi G, Frigerio M, Vitali E. Different applications for left ventricular
mechanical support with the Impella Recover 100 microaxial blood pump.
J Heart Lung Transplant 2005;24:481–485.
36. Jurmann MJ, Siniawski H, Erb M, Drews T, Hetzer R. Initial experience
with miniature axial flow ventricular assist devices for postcardiotomy
heart failure. Ann Thorac Surg 2004;77:1642–1647.
37. Meyns B, Stolinski J, Leunens V, Verbeken E, Flameng W. Left ventricular
support by catheter-mounted axial flow pump reduces infarct size. J Am
Coll Cardiol 2003;41:1087–1095.
38. Meyns B, Dens J, Sergeant P, Herijgers P, Daenen W, Flameng W. Initial
experiences with the Impella device in cardiogenic shock. Thorac
Cardiovasc Surg 2003;51:1–6.
39. Henriques JP, Remmelink M, Baan J Jr, van der Schaaf RJ, Vis MM,
Koch KT, Scholten EW, de Mol BA, Tijssen JG, Piek JJ, de Winter RJ.
Safety and feasibility of elective high-risk percutaneous coronary intervention procedures with left ventricular support of the Impella Recover
LP 2.5. Am J Cardiol 2006;97:990–992.
40. Dennis C, Carlens C, Senning A, Hall D, Moreno J, Cappeletti R,
Wesolowski S. Clinical use of a cannula for left heart bypass without
thoracotomy. Ann Surg 1962;156:623–637.
41. Pavie A, Leger P, Nzomvuama A, Szefner J, Regan M, Vaissier E,
Gandjbakhch I. Left centrifugal pump cardiac assist with transseptal
percutaneous left atrial cannula. Artif Organs 1998;22:502–507.
42. Glassman E, Chinitz LA, Levite HA, Slater J, Winer H. Percutaneous left
atrial to femoral arterial bypass pumping for circulatory support in
high-risk coronary angioplasty. Cathet Cardiovasc Diagn 1993;29:
210–216.
Downloaded from by guest on October 21, 2014
2. Holmes DR Jr, Bates ER, Kleiman NS, Sadowski Z, Horgan JH, Morris DC,
Califf RM, Berger PB, Topol EJ. Contemporary reperfusion therapy for
cardiogenic shock: the GUSTO-I trial experience. The GUSTO-I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. J Am Coll Cardiol 1995;26:
668–674.
3. Barron HV, Every NR, Parsons LS, Angeja B, Goldberg RJ, Gore JM,
Chou TM. The use of intra-aortic balloon counterpulsation in patients
with cardiogenic shock complicating acute myocardial infarction: data
from the National Registry of Myocardial Infarction 2. Am Heart J 2001;
141:933–939.
4. Hochman JS, Buller CE, Sleeper LA, Boland J, Dzavik V, Sanborn TA,
Godfrey E, White HD, Lim J, LeJemtel T. Cardiogenic shock complicating
acute myocardial infarction—etiologies, management and outcome: A
report from the SHOCK trial registry. J Am Coll Cardiol 2000;36:
1063–1070.
5. Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M,
Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ,
Ornato JP, Pearle DL, Sloan MA, Smith SC. ACC/AHA guidelines for
the management of patients with ST-elevation myocardial infarction—
executive summary. Circulation 2004;110:588–636.
6. Thiele H, Lauer B, Hambrecht R, Boudriot E, Sick P, Niebauer J, Falk V,
Schuler G. Short- and long-term hemodynamic effects of intra-aortic
balloon support in ventricular septal defect complicating acute myocardial infarction. Am J Cardiol 2003;92:450–454.
7. Scheidt S, Wilner G, Mueller H, Summers D, Lesch M, Wolff G, Krakauer J,
Rubenfire M, Fleming P, Noon G, Oldham N, Killip T, Kantrowitz A.
Intra-aortic balloon counterpulsation in cardiogenic shock. Report of a
co-operative clinical trial. N Engl J Med 1973;288:979–984.
8. DeWood MA, Notske RN, Hensley GR, Shields JP, O’Grady WP, Spores J,
Goldman M, Ganji JH. Intraaortic balloon counterpulsation with and
without reperfusion for myocardial infarction shock. Circulation 1980;
61:1105–1112.
9. Santa-Cruz RA, Cohen MG, Ohman EM. Aortic counterpulsation: a review
of the hemodynamic effects and indications for use. Cath Cardiovasc
Inter 2006;67:68–77.
10. Bates ER, Stomel RJ, Hochman JS, Ohman EM. The use of intraaortic
balloon counterpulsation as an adjunct to reperfusion therapy in cardiogenic shock. Int J Cardiol 1998;65(Suppl. 1):S37–S42.
11. Pae WE Jr, Pierce WS. Temporary left ventricular assistance in acute
myocardial infarction and cardiogenic shock: rationale and criteria for
utilization. Chest 1981;79:692–695.
12. Goldstein DJ, Oz MC, Rose EA. Implantable left ventricular assist devices.
N Engl J Med 1998;339:1522–1533.
13. Delgado DH, Rao V, Ross HJ, Verma S, Smedira NG. Mechanical circulatory
assistance. State of art. Circulation 2002;106:2046–2050.
14. Phillips SJ, Ballentine B, Slonine D, Hall J, Vandehaar J, Kongtahworn C,
Zeff RH, Skinner JR, Reckmo K, Gray D. Percutaneous initiation of
cardiopulmonary bypass. Ann Thorac Surg 1983;36:223–225.
15. Scholz KH. Reperfusion therapy and mechanical circulatory support in
patients in cardiogenic shock. Herz 1999;24:448–464.
16. Zeymer U, Reissig M, Neuhaus KL. The use of a percutaneously connected
heart–lung machine during resuscitation in cardiogenic shock after acute
myocardial infarct. Dtsch Med Wochenschr 1993;118:1755–1758.
17. Shawl FA, Domanski MJ, Wish MH, Davies M, Punja S, Hernandez TJ.
Emergency cardiopulmonary bypass support in patients with cardiac
arrest in the catheterization laboratory. Cathet Cardiovasc Diagn 1990;
19:8–12.
18. Reedy JE, Swartz MT, Raithel SC, Szukalski EA, Pennington DG. Mechanical cardiopulmonary support for refractory cardiogenic shock. Heart
Lung 1990;19:514–523.
19. Raithel SC, Swartz MT, Braun PR, Dake SB, Taub JO, Zambie MA, Miller LW,
Deligonul U, McBride LR, Pennington DG. Experience with an emergency
resuscitation system. Trans ASAIO 1989;35:475–477.
20. Reichman RT, Joyo CI, Dembitsky WP, Griffith LD, Adamson RM, Daily PO,
Overlie PO, Smith SC, Jaski BE. Improved patient survival after cardiac
arrest using a cardiopulmonary support system. Ann Thorac Surg 1990;
49:101–104.
21. Overlie PA, Walter PD, Hurd HP, Wells GA, Seger JJ, Zias J, Wey RJ,
Jensen JB, Shoukfeh MF, Levine MJ. Emergency cardiopulmonary
support with circulatory support devices. Cardiology 1994;84:231–237.
22. Mooney MR, Arom KV, Joyce LD, Mooney JF, Goldenberg IF, Von
Rueden TJ, Emery RW. Emergency cardiopulmonary bypass support in
patients with cardiac arrest. J Thorac Cardiovasc Surg 1991;101:
450–454.
H. Thiele et al.
Percutaneous left ventricular assist devices
Clinical vignette
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
reperfusion plays a major role in minimizing myocardial infarct size.
J Thorac Cardiovasc Surg 1985;90:80–85.
Achour H, Boccalandro F, Felli P, Amirian J, Uthman M, Buja M,
Smalling RW. Mechanical left ventricular unloading prior to reperfusion
reduces infarct size in a canine infarction model. Cath Cardiovasc Inter
2005;64:182–192.
James KJ, McCarthy PM, Thomas JD, Vargo R, Hobbs RE, Sapp S, Bravo E.
Effect of the implantable left ventricular assist device on neuroendocrine
activation in heart failure. Circulation 1995;92(Suppl. 9):II191–II195.
Torre-Amione G, Stetson SJ, Youker KA, Durand JB, Radovancevic B,
Delgado RM, Frazier OH, Entman ML, Noon GP. Decreased expression of
tumor necrosis factor-alpha in failing human myocardium after mechanical circulatory support: a potential mechanism for cardiac recovery.
Circulation 1999;100:1189–1193.
Bruckner BA, Stetson SJ, Perez-Vardia A, Youker KA, Radovancevic B,
Connelly Koerner MM, Entman ME, Frazier OH, Noon GP,
Torre-Amione G. Regression of fibrosis and hypertrophy in failing myocardium following mechanical circulatory support. J Heart Lung Transplant
2001;20:457–464.
Dipla K, Mattiello JA, Jeevanandam V, Houser SR, Margulies KB. Myocyte
recovery after mechanical circulatory support in humans with end-stage
heart failure. Circulation 1998;97:2316–2322.
Taylor K, Bain WH, Davidson KG, Turner MA. Comparative clinical study of
pulsatile and non-pulsatile perfusion in 350 consecutive patients. Thorax
1982;37:324–330.
Finlayson D. Con: nonpulsatile flow is preferable to pulsatile flow during
cardiopulmonary bypass. J Cardiothorac Anesth 1987;1:169–170.
Shevde K, DeBois W. Pro: nonpulsatile flow is preferable to pulsatile flow
during cardiopulmonary bypass. J Cardiothorac Anesth 1987;1:165–168.
Hochman JS. Cardiogenic shock complicating acute myocardial infarction. Expanding the paradigm. Circulation 2003;107:2998–3002.
Kirklin JK, Westaby S, Blackstone EH, Kirklin JW, Chenoweth DE,
Pacifico AD. Complement and the damaging effects of cardiopulmonary
bypass. J Thorac Cardiovasc Surg 1983;86:845–857.
Hall RI, Smith MS, Rocker G. The systemic inflammatory response to
cardiopulmonary bypass: pathophysiological, therapeutic, and pharmacological considerations. Anesth Analg 1997;85:766–782.
doi:10.1093/eurheartj/ehm002
Online publish-ahead-of-print 16 March 2007
The heart of coronary arteries
Marco Valgimigli1,2* and Patrizia Malagutti1,2
1
Institute of Cardiology, University of Ferrara, C.rso Giovecca 203, 44100 Ferrara, Italy and 2Cardiovascular Research
Centre, Salvatore Maugeri Foundation, IRCCS Gussago (BS), Italy
* Corresponding author. Tel: þ39 0532 202143; fax: þ39 0532 241885. E-mail address: vlgmrc@unife.it
A 67-year-old man with a medical history notable
for treated type II diabetes, dyslipidaemia and
hypertension, was admitted to the hospital for
repeated episodes of angina with mild effort or at
rest. A coronary angiogram showed lumen stenosis
in the mid-tract of the right coronary artery and
in the first obtuse marginal branch (Panel A). In
the proximal tract of left anterior descending
artery, a severe stenosis (Panel A, arrow) was also
observed, followed by giant heart-shaped coronary
artery aneurysm (CAA) (Panel B, magnified in the
insert). The patient underwent coronary artery
bypass grafting of the three main coronary
vessels. The 1-year follow-up was uneventful.
CAA, defined as a localized dilatation of the coronary artery with a diameter 1.5 times that of
an adjacent coronary segment, has been observed
in 0.2–5.3% of patients undergoing coronary angiography. CAA most often involves the right coronary
artery followed in frequency by the left anterior
descending. Most CAAs are atherosclerotic in
origin, although other aetiologies include congenital aneurysms, Kawasaki syndrome, infectious
arteritis, and coronary trauma, including that related to percutaneous coronary intervention.
The catheter-based treatment of coronary aneurysm through polytetrafluoroethylene-covered stent implantation or core embolization is feasible in selected cases. The safety and efficacy of the percutaneous approach in comparison with conventional surgical
treatment remain to be established.
Downloaded from by guest on October 21, 2014
43. Thiele H, Lauer B, Hambrecht R, Boudriot E, Cohen HA, Schuler G. Reversal of cardiogenic shock by percutaneous left-atrial-to-femoral arterial
bypass assistance. Circulation 2001;104:2917–2922.
44. Thiele H, Sick P, Boudriot E, Diederich KW, Hambrecht R, Niebauer J,
Schuler G. Randomized comparison of intraaortic balloon support
versus a percutaneous left ventricular assist device in patients with
revascularized acute myocardial infarction complicated by cardiogenic
shock. Eur Heart J 2005;26:1276–1283.
45. Burkhoff D, Cohen H, Brunckhorst C, O’Neill WW. A randomized multicenter clinical study to evaluate the safety and efficacy of the TandemHeart
percutaneous ventricular assist device versus conventional therapy with
intraaortic balloon pumping for treatment of cardiogenic shock. Am
Heart J 2006;152:e1–e8.
46. Lemos A, Cummins P, Lee C, Degertekin M, Gardien M, Ottervanger JP,
Vranckx P, de Feyter P, Serruys PW. Usefulness of percutaneous left ventricular assistance to support high-risk percutaneous coronary interventions. Am J Cardiol 2003;91:479–481.
47. Axelrod JI, Galloway AC, Murphy MS, Laschinger JC, Grossi EA,
Baumann FG, Colvin SB, Hunter CE, Glassman E, Spencer FC. A comparison of methods for limiting myocardial infarct expansion during acute
reperfusion—primary role of unloading. Circulation 1987;76:V28–V32.
48. Catinella FP, Cunningham JN Jr, Glassman E, Laschinger JC, Baumann FG,
Spencer FC. Left atrium-to-femoral artery bypass: effectiveness in
reduction of acute experimental myocardial infarction. J Thorac Cardiovasc Surg 1983;86:887–896.
49. Pennock JL, Pae WE, Pierce WS, Waldhausen JA. Reduction of myocardial
infarct size: comparison between left atrial and left ventricular bypass.
Circulation 1979;59:275–279.
50. Allen BS, Okamoto F, Buckberg GD, Bugyi H, Leaf J. Reperfusion conditions: critical importance of total ventricular decompression during
regional reperfusion. J Thorac Cardiovasc Surg 1986;92:605–612.
51. Fonger JD, Zhou Y, Matsuura H, Aldea GS, Shemin RJ. Enhanced preservation of acutely ischemic myocardium with transseptal left ventricular
assist. Ann Thorac Surg 1994;57:570–575.
52. Laschinger J, Grossi E, Cunningham J, Krieger K, Baumann F, Colvin S,
Spencer F. Adjunctive left ventricular unloading during myocardial
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