Ann Thorac Surg 1996;61:1539-1541
© 1996 The Society of Thoracic Surgeons
Case Report
Effects of Intraaortic Balloon Pumping on Coronary and Carotid Flow During Percutaneous Cardiopulmonary Support
Alexander Geppert, MD,
Bernhard Frey, MD,
Harald Gabriel, MD,
Christoph Kratochwill, MD,
Peter Siostrzonek, MD
Department of Cardiology, University of Vienna, Vienna, Austria
Accepted for publication November 16, 1995.
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Abstract
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Previous studies have suggested an improved clinical outcome when percutaneous cardiopulmonary support is combined with intraaortic balloon counterpulsation in patients with cardiogenic shock. We evaluated the effect of combined intraaortic balloon counterpulsation and percutaneous cardiopulmonary support therapy on coronary and cerebral blood flow by Doppler measurements in the coronary and the carotid arteries in a patient with cardiac arrest. During pacemaker stimulation, intraaortic balloon counterpulsation in addition to percutaneous cardiopulmonary support markedly improved coronary and carotid blood flow. Possible mechanisms are discussed.
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Introduction
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Percutaneous cardiopulmonary support (PCPS) is increasingly used in various clinical settings such as resuscitation or cardiogenic shock refractory to conventional treatment [1, 2]. However, there has been concern that inadequate myocardial perfusion may occur during PCPS. Experimental data indicate that the addition of intraaortic balloon counterpulsation (IABP) to PCPS may preserve myocardium during acute ischemia [3]. Accordingly, IABP has been successfully applied as an adjunct to PCPS in patients with cardiogenic shock [1, 2]. We recorded coronary and carotid Doppler flow velocity profiles in a patient with cardiogenic shock and cardiac arrest simultaneously treated with PCPS, IABP, and pacemaker stimulation to evaluate clinically the effects of the combined use of PCPS with IABP on myocardial and cerebral blood flow.
A 61-year-old man had been accepted for heart transplantation because of end-stage heart failure due to ischemic cardiomyopathy. He had an anterior wall myocardial infarction in 1981, aortocoronary bypass grafting with aneurysmectomy in 1984, and documented occlusion of all bypass grafts in 1992. He was admitted to the intensive care unit in October 1994 because of ongoing cardiogenic shock due to subendocardial ischemia. On admission he had total atrioventricular block with a slow ventricular escape rhythm. The patient was intubated and placed on mechanical ventilation. Transvenous VVI pacing was established and an intraaortic balloon pump (Datascope System 90 with a Percor Stat-DL 9.5F, 40-mL balloon; Datascope Corp, Fairfield, NJ) was inserted via the right femoral artery. Despite adequate cardiac filling pressures and increasing dosages of inotropic drugs (dobutamine, dopamine, and epinephrine) cardiac index was constantly less than 1.6 L•min-1•m-2 and mean arterial blood pressure remained less than 40 mm Hg. Therefore, after insertion of a 21F cannula via the left femoral vein into the right atrium and a 19F cannula via the left femoral artery in the descending aorta, PCPS (Bio-Medicus; Medtronic Inc, Minneapolis, MN) was instituted. With a constant PCPS flow of 4 L/min, a pacing rate of 100 beats/min, and 1:1 intraaortic balloon counterpulsation, mean arterial blood pressure values greater than 60 mm Hg were achieved. Metabolic derangement was normalized and renal function was progressively restored.
To evaluate the optimum support mode for coronary and cerebral blood flow, we performed serial Doppler recordings in the ascending aorta, the left main coronary artery, and the right common carotid artery during various mechanical support modes: (1) PCPS (flow of 4 L/min) with the pacemaker set to VVI 100 beats/min and the IABP set to 1:1 pumping, (2) PCPS (flow of 4 L/min) with the pacemaker set to VVI 100 beats/min but without IABP support, (3) PCPS (flow of 4 L/min) with IABP set on internal mode (f = 120 cycles/min) without pacemaker, and (4) PCPS (flow of 4 L/min) without IABP and without pacemaker. Flow recordings in the ascending aorta and the left coronary artery were performed with a 5-MHz transesophageal probe and recordings in the common right carotid artery with a 3.25-MHz transducer connected to a VINGMED 800 system (Diasonics, Horten, Norway). For each recording site and support mode Doppler flow profiles were recorded twice in random order. Peak flow velocity and the velocity time integral were measured, and values obtained for three cardiac cycles with optimum signal quality were averaged. Velocity time integral times heart rate was calculated as a measure of blood flow per minute. Typical Doppler flow profiles during the various support modes are shown in Figure 1
, and Doppler data together with the corresponding hemodynamic parameters are given in Table 1.
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Fig 1. . Serial Doppler recordings (from left to right) in the ascending aorta (column 1), the common carotid artery (column 2), and the left coronary artery (column 3) during the following support modes: Lane 1: percutaneous cardiopulmonary support (PCPS), 4 L/min; intraaortic balloon counterpulsation (IABP) rate 1:1; (PM), 100 beats/min. Lane 2: PCPS, 4 L/min; IABP off; PM, 100 beats/min. Lane 3: PCPS, 4 L/min; IABP on (internal mode, f = 120 cycles/min [The aortic flow tracing during this support mode was recorded for an internal IABP rate of 1:2, ie, effective IABP pumping rate 60 cycles/min]); PM off. Lane 4: PCPS, 4 L/min; IABP off; PM off.
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Comment
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From the data presented it can be noticed that total coronary and cerebral blood flow was strikingly higher for both support modes that included pacemaker stimulation, and that in case of pacemaker stimulation coronary and carotid blood flow was further increased by the addition of IABP. Therefore the present data confirm that cardiac output as obtained by VVI pacing during asystole is essential for coronary and cerebral blood flow even in patients on PCPS. After cardiac arrest Scholz and associates [4] have demonstrated an immediate decrease of myocardial perfusion pressure to about half of the initial value with a further gradual decrease over the following minutes despite a constant PCPS flow. This decline in myocardial perfusion pressure could, however, be largely reversed by effective left ventricular venting. In the present patient during constant PCPS flow an immediate decrease in mean arterial blood pressure and coronary as well as carotid blood flow was observed with the occurrence of asystole, while central venous pressure slightly increased (see Table 1
). These parameters were restored immediately after reinitiation of pacemaker support. Therefore, even in patients placed on PCPS, restoration of left ventricular output is essential to optimize myocardial and cerebral blood flow.
Recently, the combined use of PCPS and IABP in cardiogenic shock has been suggested. Phillips and associates [2] reported a favorable clinical outcome in 16 patients with combined PCPS and IABP therapy. Moreover, during experimental ischemia in pigs, a beneficial effect of the combined use of PCPS and IABP on area of tissue necrosis, local acidosis, and myocardial contractility has been demonstrated [3]. Accordingly, the present Doppler measurements suggest increased coronary and cerebral blood flow by IABP during PCPS, which might provide an explanation for the observed experimental [3] and clinical [2] results. A comparable enhancement of coronary blood flow has been reported by the combined use of left ventricular assist devices and IABP [5]. However, left ventricular assist devices provide antegrade aortic flow, whereas PCPS delivers retrograde flow into the descending aorta distal to the intraaortic balloon. During the combined use of PCPS and IABP diastolic inflation of the intraaortic balloon may intermittently compromise retrograde PCPS flow. This might explain why in our patient, IABP failed to augment mean arterial blood pressure and coronary blood flow during asystole and why a beneficial effect of IABP on coronary and cerebral flow was observed only after restoration of VVI pacing.
In conclusion, a regular cardiac rhythm is essential even for patients on PCPS. In these patients coronary and carotid blood flow can be markedly improved by the addition of IABP.
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Footnotes
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Address reprint requests to Dr Geppert, Department of Cardiology, University of Vienna, AKH, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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References
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- Rees MR, Browne T, Sivananthan UM, et al. Cardiac resuscitation with percutaneous cardiopulmonary support. Lancet 1992;340:513–4.[Medline]
- Phillips SJ, Zeff RH, Kongtahworn C, et al. Benefits of combined balloon pumping and percutaneous cardiopulmonary bypass. Ann Thorac Surg 1992;54:908–10.[Abstract/Free Full Text]
- Lazar LH, Treanor P, Yang XM, Rivers S, Bernard S, Shemin RJ. Enhanced recovery of ischemic myocardium by combining percutaneous bypass with intraaortic balloon pump support. Ann Thorac Surg 1994;57:663–8.[Abstract/Free Full Text]
- Scholz KH, Schröder T, Hering JP, et al. Need for active left-ventricular decompression during percutaneous cardiopulmonary support in cardiac arrest. Cardiology 1994;84: 222–30.[Medline]
- Kyo S, Matsumura M, Takamoto S, Omoto R. Transesophageal color Doppler echocardiography during mechanical assist circulation. Trans Am Soc Artif Intern Organs 1989;35:722–5.
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Abstract
Introduction
