Eugene Wallsh

The role of intra-aortic ballon counterpulsation in patients undergoing percutaneous transluminal coronary angioplasty

Between June, 1979, and July, 1982, 14 patients required an IABP in conjunction with PTCA. The clinical indications for balloon counterpulsation, in the performance of PTCA were (1) clinically unstable situations where PTCA might otherwise be contraindicated, e.g., left main stem disease, multivessel coronary artery disease, unstable anginal syndromes, and cardiogenic shock; (2) preoperative insertion of an IABP for added safety following unsuccessful angioplasty; (3) abrupt vessel closure during a PTCA procedure in which the patient becomes hemodynamically unstable; and (4) late vessel closure following an initially successful angioplasty resulting in hemodynamic compromise. Of the 14 cases requiring balloon counterpulsation, 13 survived hospitalization and were alive at the time this report was submitted. We conclude that IABP is a useful adjunct to PTCA in a variety of clinical circumstances.

Percutaneous transluminal coronary angioplasty in left main stem coronary stenosis: a five-year appraisal

Left main stem coronary stenosis is now uniformly treated with coronary artery bypass grafting. The advent of percutaneous transluminal coronary angioplasty has permitted a non-operative improvement in myocardial blood flow in many cases of single- and multi-vessel coronary atherosclerosis. The use of percutaneous transluminal coronary angioplasty in left main stem coronary stenosis has been sporadic and controversial. Twenty percutaneous transluminal coronary angioplasties were attempted in 19 patients as the treatment of choice for left main stem coronary stenosis in the past 66 months. The primary success rate was 95% (19/20 patients). The emergency surgery was performed only once (5%), and no death occurred secondary to percutaneous transluminal coronary angioplasty itself. In the follow-up (mean 41 months) period, 12 patients (63%) remained in satisfactory condition with no further need for surgical intervention. Seven patients (37%) ultimately required coronary artery bypass grafting. Although coronary artery bypass grafting will remain the fundamental treatment for left main stem coronary stenosis, this series delineates those anatomic and clinical exceptions wherein percutaneous transluminal coronary angioplasty may be utilized as the primary therapy for left main stem coronary stenosis.

The renin-angiotensin system is not responsible for hypertension following coronary artery bypass grafting

Systemic hypertension following coronary artery bypass graft (CABG) procedures has been reported to occur in 15% to 80% of cases. Previous reports have implicated the renin-angiotensin system as being responsible, at least in part, for this phenomenon. In this prospective study, 18 previously normotensive subjects were studied before, during, and after CABG. In 4 patients (22%), paroxysmal postoperative hypertension developed (systolic blood pressure greater than 150 mm Hg). There were no differences between the normotensive and hypertensive groups in plasma renin activity, angiotensin II level, or aldosterone level. Despite the trend toward elevation of these variables during cardiopulmonary bypass (CPB), all had returned to control levels within two hours after CPB, whether or not hypertension developed. Serum norepinephrine levels were elevated (.10 greater than p greater than .05) in the hypertensive group at the time hypertension developed. No other relationship or pattern could be defined to distinguish the hypertensive from the normotensive group. The renin-angiotensin system does not appear to be responsible for paroxysmal hypertension following CABG.

Manual Coronary Endarterectomy with Saphenous Bypass: Experience with 263 Patients

From January, 1972, until August, 1980, 271 manual coronary endarterectomies with bypass were performed in 263 patients. All patients underwent additional cardiac procedures simultaneously. The group contained 254 distal right and 17 left endarterectomies (including 8 double endarterectomies). Clinical follow-up was 100%, operative mortality was 2.3% (6 out of 263), and the rate of perioperative infarction was 4.9% (13 out of 263). Cineangiography was performed on 72 patients between 1 and 60 months after operation (mean, 15.4 months). Patency was 85% (61 out of 72). Endarterectomy in a dominant right coronary artery could be planned electively. Left coronary endarterectomy was performed only when diffuse disease prevented standard bypass. Coronary endarterectomy may be used to extend operability with excellent clinical results, low perioperative mortality, and high late patency. Careful attention to technical aspects of core removal and myocardial protection are necessary for consistent results.

Current status of intra-aortic balloon counterpulsation in critical care cardiology.

Retrospective analysis revealed that intra-aortic balloon counterpulsation was attempted in 321 patients at our institute from August 1, 1974, to July 1, 1982. The intra-aortic balloon pump (IABP) was successfully inserted in 298 cases (93%). Indications for an IABP included: cardiogenic shock (84 cases), preoperative hemodynamic coverage (15 cases), low-output syndrome (73 cases), pre- and postinfarction angina (75 cases), intractable congestive heart failure (12 cases), refractory ventricular arrhythmia (9 cases), percutaneous transluminal coronary angioplasty (14 cases), cardiac arrest (7 cases), and a miscellaneous group (9 cases). The overall major complication rate was 9%. The data from this experience support aggressive management of cardiogenic shock, i.e., early balloon insertion, angiography, and cardiac surgery, which significantly increases the survival rate (83%) over medical therapy combined with balloon counterpulsation alone. The IABP was also extremely effective in managing other high-risk categories when combined with some form of definitive mechanical correction, e.g., coronary revascularization, valve replacement, or percutaneous transluminal coronary angioplasty. Left ventricular (LV) function was a significant indicator of long-term survival in our series. Patients with normal or moderately impaired LV function had higher survival rates (95% and 82%, respectively) than patients with poor LV function (42%).

Comparison of wire-guided percutaneous insertion and conventional surgical insertion of intra-aortic balloon pumps in 151 patients

Over a 25-month period, percutaneous wire-guided balloon catheter insertion was attempted in 51 patients, and intra-aortic balloon pump insertion was attempted by conventional surgical method in 100 patients. The success rate in the group undergoing percutaneous insertion was 90.2 percent (46 of 51) and 90 percent in the group undergoing surgical insertion (90 of 100). The indications for intra-aortic balloon counterpulsation were diverse in both groups. The major complication rate in the patient population undergoing percutaneous intra-aortic balloon pump insertion was 15.2 versus 15.6 percent for the surgical group, and there were no cases of leg amputation or aortic dissection in the percutaneous group; however, two cases of leg amputation and one case of aortic dissection resulting in death occurred in the surgical group. The percutaneous intra-aortic balloon pump insertion technique was successfully employed in conjunction with percutaneous transluminal coronary angioplasty in six cases. It is concluded that the wire-guided percutaneous balloon catheter method is a highly successful and rapid means of instituting intra-aortic balloon counterpulsation in a wide variety of clinical situations. However, because of the significant associated complication rate, the decision to institute balloon counterpulsation must weigh the benefit-to-risk ratio, and this procedure must still be evaluated on a case-by-case basis.

Transluminal coronary angioplasty during saphenous coronary bypass surgery: a preliminary report.

A previously described balloon tipped dilatation catheter has been used during revascularization surgery to dilate lesions which potentially could limit the runoff of the saphenous bypass grafts. A total of 34 lesions were dilated in 25 patients. Restudy of 12 patients (15 lesions) demonstrated positive results and no clinically significant complications. These preliminary results suggest an important role for transluminal coronary dilatation in the operative treatment of coronary artery disease.

Reduced incidence of intraoperative myocardial infarction during coronary bypass surgery with use of intracoronary shunt technique

Intraoperative myocardial infarction is a recognized complication of aortocoronary bypass surgery. One major cause of such infarction may be interruption of coronary blood flow, particularly in patient with poor coronary collateral circulation. In 30 patients use of an intracoronary shunt made it possible to limit the period of coronary occulusion during graft construction to a few minutes. Use of this shunt was associated with a reduced incidence of intraoperative myocardial infarction (as judged by the appearance of new Q waves) when these patients were compared with 50 patients operated on without this procedure (6 of 50 [12 percent] versus 0 of 30). The incidence of postoperative persistent S-T segment elevation was reduced from 21 of 50 (42 percent) to 5 of 30 (17 percent). Except for use of the shunt, the surgical technique was identical in the two groups of patients.

Adjunctive operative coronary artery balloon-catheter dilatation: Review of Lenox Hill experience

Operative transluminal coronary angioplasty (OTCA) has been used as an adjunct to coronary artery bypass surgery in 65 patients over a 56-month period beginning in May 1978. Experience has led us to use OTCA primarily in the left anterior descending coronary artery. The angioplasty catheter has undergone a number of modifications. Late restudy (8 to 56 months; mean, 24.1) data in 17 patients demonstrated that 15 of 19 angioplasty segments (78.9%) were patent.

Transluminal Coronary Angioplasty: Results, Complications, Follow-up, and Consideration of Extension of Indications. An Analysis of 409 Procedures

This communication represents the combined clinical experience in percutaneous transluminal coronary angioplasty (PTCA) collated from St. Mary’s Hospital in San Francisco and the Lenox Hill Hospital Medical Center in New York. It represents all cases attempted in the 3 year period from 1 March 1978, and is the original block of PTCA material performed in the United States.