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PubMed1996

Can angiographic findings predict which coronary patients will benefit from enhanced external counterpulsation?

Enhanced external counterpulsation is an effective treatment for chronic angina. Theoretical considerations predict greatest benefit in patients with at least 1 patent conduit in this group of 50 patients (all of whom improved clinically). Improvement in radionuclide stress perfusion imaging was seen in 80% of treated patients and was inversely related to extent of coronary disease.

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PubMed1999

Pneumatic external counterpulsation: a new noninvasive method to improve organ perfusion.

Pneumatic external counterpulsation, which is operated by applying electrocardiographic-triggered diastolic pressure via air-filled cuffs to the vascular limbs of lower limbs, is a relatively new therapeutic option for patients with angina pectoris and cerebrovascular diseases like transient ischemic attacks or sudden deafness. In this study, an augmentation in flow volume in the carotid, renal, and hepatic arteries from 20% to 25% and in the coronary arteries from 20% to 40%, as well as an increase in stroke volume by 12% was demonstrated; this shows the therapeutic results in patients with diseases caused by disturbed organ perfusion.

Adult↗
PubMedDate not supplied

Psychosocial effects of enhanced external counterpulsation in the angina patient.

Enhanced external counterpulsation (EECP) is a noninvasive pantaloon device designed to increase coronary artery flow in the treatment of angina. This pilot study, conducted in 1992-1993, which used psychosocial testing pre- and posttreatment, yielded data suggesting that EECP is well tolerated psychosocially and produces improvement in the anginal syndrome. More comprehensive research is under way to test these preliminary conclusions.

Activities of Daily Living↗
PubMed2002

Treatment of post resuscitation myocardial dysfunction: aortic counterpulsation versus dobutamine.

BACKGROUND: Post resuscitation myocardial stunning is well described and recognized as a significant contributor to poor long-term outcome following cardiac arrest. Optimal strategies for treatment have not been determined. METHODS: Ten domestic swine (49+/-3 kg) underwent 15 min of untreated ventricular fibrillation before being successfully resuscitated. Left ventricular systolic and diastolic function was measured at pre-arrest baseline, at 30 min and at 6 h post resuscitation. Five animals were treated immediately after resuscitation with intra-aortic balloon counterpulsation (IABP) and five were given dobutamine (5 mcg/kg per min). RESULTS: No baseline differences were found. At 30 min post resuscitation pulmonary capillary wedge pressure and LVEDP were significantly higher (16+/-3 vs. 7+/-1 and 20+/-2 vs. 11+/-1 mmHg) while LV isovolumic relaxation ('Tau') was significantly longer (34+/-2 vs. 20+/-2 ms) in the IABP treated versus the dobutamine treated animals. Likewise, at 6 h post resuscitation LV ejection fraction was significantly less (21+/-6 vs. 39+/-4%), and LVEDP significantly higher (18 vs. 10 mmHg) in the IABP group. Heart rate was not different between the groups at any time post resuscitation. CONCLUSION: Dobutamine was superior to IABP for treatment of post resuscitation left ventricular systolic and diastolic dysfunction. The hypothesized advantage of IABP for treatment of post resuscitation myocardial stunning without excessively raising the heart rate like dobutamine was not realized.

Animals↗
PubMed1997

Thrombolysis plus aortic counterpulsation: improved survival in patients who present to community hospitals with cardiogenic shock.

OBJECTIVES: We sought to explore the potential benefit of combining intraaortic balloon counterpulsation (IABP) with thrombolysis for acute myocardial infarction (MI) complicated by cardiogenic shock. BACKGROUND: In community hospitals, this condition is usually managed with thrombolysis alone. METHODS: We reviewed the charts of 335 patients from two community hospitals who presented with acute MI and had cardiogenic shock between 1985 and 1995. RESULTS: Of 46 patients who underwent thrombolysis within 12 h of acute infarction with confirmed cardiogenic shock, 27 underwent IABP and 19 did not. Age, systolic blood pressure with shock, pulmonary artery catheter use, pulmonary capillary wedge pressure and the incidence of diabetes mellitus and anterior MI did not differ between groups. Patients treated with IABP were somewhat more likely to have prior MI and had a significantly greater cardiac index (2.0 vs. 1.5 liters/min per m2, p = 0.04). Although no deaths occurred within 2 h of presentation, patients not treated with IABP tended to die earlier (6.8 +/- 5 vs. 23.8 +/- 19 h, p = 0.13). Patients treated with IABP had a significantly higher rate of community hospital survival (93% vs. 37%, p = 0.0002), and more of them were transferred for revascularization (85% vs. 37%). Of 30 patients transferred for revascularization, 27 underwent angioplasty or bypass surgery; hospital survival was 74%. Patients treated with IABP also had a significantly higher overall hospital and 1-year survival rate (67% vs. 32%, p = 0.019). CONCLUSIONS: Survival may be enhanced and transfer for revascularization facilitated when community hospitals use both thrombolysis and IABP to treat patients with acute MI complicated by cardiogenic shock.

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PubMed1999

Chronic aortic counterpulsation with latissimus dorsi in heart failure: clinical follow-up.

BACKGROUND: Dynamic aortomyoplasty is an alternative technique to heart transplantation. The goal of our study was to evaluate the benefits of aortic counterpulsation obtained by dynamic thoracic aortomyoplasty in patients with heart failure refractory to pharmacologic treatment and contraindications to heart transplant or cardiomyoplasty. METHODS: In this study we compared preoperative and postoperative data from five out of six carefully selected patients who were treated with dynamic thoracic aortomyoplasty. This surgical technique wraps the right latissimus dorsi muscle flap around the ascending aorta. This muscle flap was electrically stimulated during diastole, following a muscle-conditioning protocol, to obtain diastolic augmentation. At the 6-month follow-up period we evaluated, invasively and noninvasively, the hemodynamic and clinical effects of aortomyoplasty. RESULTS: We observed a significant decrease in the number of hospitalizations (P = 0.01), NYHA functional class (P = 0.01), cardiothoracic ratio (P = 0.02), right ventricular diameter (P = 0.03), left atrial diameter (P = 0.04), and pulmonary artery systolic pressure (P = 0.04); and a significant increase in the 6-minute walking test (P = 0.01), cardiac index (P = 0.04), noninvasive evaluation of diastolic augmentation (P = 0.01), left ventricular shortening fraction (P = 0.01), and radioisotopic left ventricular ejection fraction (P = 0.02). We also found a nonsignificant decrease in the left ventricular diameter (P = 0.08) and wedge pressure (P = 0.19); and a nonsignificant increase in peak oxygen consumption (P = 0.13). CONCLUSIONS: Dynamic thoracic aortomyoplasty in heart failure resulted in an important improvement of hemodynamic parameters, heart functional data, and clinical functional class, when comparing preoperative data with the 6-month follow-up data.

Adult↗
PubMed2000

[Pneumatic external counterpulsation (PECP): a new treatment option in therapy refractory inner ear disorders?].

BACKGROUND: The established therapeutic principle for sudden deafness and tinnitus is based on the stimulation of the inner ear perfusion by infusion therapy using vaso-active or hemodilutive agents. Concerning a mechanically induced increase of the inner ear's blood supply, the new technique of Pneumatic External Counterpulsation (PECP) was performed. This technique had already been used successfully in patients suffering from coronary heart disease. Due to an ECG-guided pneumatic compression of the lower extremities during diastole an increase of arterial perfusion of the extracranial supplying brain vessels can be obtained by PECP-treatment. PATIENTS AND METHODS: PECP was used in 33 patients (22 males, 11 females) between 19 and 76 years of age suffering from persisting acute hearing disorders and/or tinnitus after adequate infusion therapy. 3 patients revealed mild complications during PECP-treatment (e.g. thoracic pain) which seemed to be related to the therapeutic regime and disappeared completely after cessation of PECP. 30 patients underwent PECP-treatment on 5 following days for 1 hour. This standardized hourly treatment regime was extended to 10 days in 12 patients. Therapeutic effects were determined by color-coded duplexsonography and pure tone audiometry eventually masking the audiogram. RESULTS: During treatment an increase of 19% flow volume in the internal carotid arteries and of 11% in the vertebral arteries was evaluated using color-coded duplexsonography. In 47% of cases (n = 14) decrease of tinnitus intensity and/or tinnitus appearance with an average of 16 dB was perceived after the end of the treatment series. Hearing threshold increased in 28% of cases (n = 7) with an average threshold shift of 19 dB after PECP-treatment. All patients were examined by pure tone audiometry during the follow-up after 4, 8 and 12 weeks as well as after 6 and 12 months. In all cases the audiometric benefit lasted throughout the follow-up 1 year, after treatment. CONCLUSIONS: The determination of a positive correlation between vascular flow increase in the extracranial brain-supplying vessels during PECP-treatment and the encouraging therapeutic results obtained by audiometry seem to make this new and promising therapeutic option effective, practicable and easy to handle. These preliminary results of the PECP technique should be validated in further studies featuring larger numbers of patients suffering from therapy-resistant inner ear disorders.

Adult↗
PubMed1989

[Intra-aortal balloon counterpulsation in acute myocardial infarction, ischemic left ventricle insufficiency and treatment refractory angina pectoris].

Intraaortic balloon counterpulsation (IABP) was employed between 1977 and 1988 in 132 patients (37 women and 95 men; mean age 60 +/- 9.9 years) with coronary heart disease. Indications for IABP were cardiogenic shock in 93, markedly impaired left ventricular function in 13, and treatment-refractory angina in 26. The hospital mortality rate among those patients in cardiogenic shock was 54%. The mortality rate among the 47 patients who had additional procedures (percutaneous transluminal coronary angioplasty or operation) was 40%, significantly lower than that in 46 patients without further procedure (67%). Complications of IABP occurred in 20% of patients (bleeding, vascular injury, ischaemia in the legs, embolism or infection). The complication rate was, however, reduced to 10% in the last few years by improvements in placement technique and materials. Introduction and placement of the balloon catheter is simple, rapid and reliable. The initially high success rate is particularly valuable for those patients in whom further therapeutic measures can be undertaken.

Adult↗
PubMed2005

Enhanced external counterpulsation: a new technique to augment renal function in liver cirrhosis.

BACKGROUND: Advanced liver cirrhosis is characterized by cardiovascular changes, such as low arterial blood pressure, peripheral vasodilation and renal vasoconstriction. As a consequence, renal hypoperfusion, impaired diuresis and natriuresis and eventual hepatorenal syndrome may ensue. Previous studies using head-out water immersion to increase central blood volume have demonstrated the functional nature of the renal abnormalities. Enhanced external counterpulsation (EECP) is a new non-invasive cardiac assist device to augment diastolic blood pressure by electrocardiogram-triggered diastolic inflation and deflation of cuffs wrapped around the lower extremities. We investigated whether EECP would improve renal dysfunction of liver cirrhosis. METHODS: Twelve healthy controls and 19 patients with liver cirrhosis were observed during 2 h of baseline followed by 2 h of EECP. The following parameters of renal and cardiovascular function were measured: renal plasma flow by para-aminohippurate clearance, glomerular filtration rate (GFR) by inulin clearance, urine flow rate, urinary excretion rates of sodium and chloride, mean arterial blood pressure (MAP), renal vascular resistance (RVR) and plasma concentrations of renin, atrial natriuretic peptide (ANP), endothelin-1, antidiuretic hormone, epinephrine and N-epinephrine. RESULTS: EECP was well tolerated by healthy controls and cirrhotic patients alike. EECP increased MAP (cirrhotic patients: from 74+/-18 to 88+/-20 mmHg, P<0.01; controls: from 89+/-8 to 94+/-5 mmHg, P = NS) and ANP (cirrhotic patients: from 23+/-18 to 30+/-20 ng/l, P<0.05; controls: from 11+/-4 to 16+/-5 ng/l, P<0.01). The plasma renin concentration decreased (cirrhotic patients: from 98+/-98 to 58+/-57 ng/l, P<0.01; controls: from 4.6+/-1.6 to 3.4+/-1.1 ng/l, P<0.01). This was associated with improvement of the urinary flow rate (cirrhotic patients: from 3.6+/-1.8 to 4.6+/-0.7 ml/min, P<0.05; controls: from 1.8+/-1.5 to 2.8+/-1.9 ml/min, P<0.05), as well as of the sodium and chloride excretion rates in both groups. However, in contrast to healthy controls, GFR and renal plasma flow in cirrhotic patients failed to rise significantly. Renal vascular resistance fell numerically in healthy controls (68+/-5 vs 55+/-4 mmHg . min/l; P = NS). In contrast, RVR showed a significant increase by approximately 20% in cirrhosis (67+/-4 vs 80+/-8 mmHg . min/l; P<0.05). Endothelin-1 levels fell in controls (0.38+/-0.42 vs 0.31+/-0.35; P<0.05), whereas they remained statistically unchanged in cirrhotic patients. Epinephrine, N-epinephrine and vasopressin were not altered by EECP in either group. CONCLUSIONS: EECP is an effective procedure to augment renal excretory function in healthy volunteers as well as in patients with cirrhosis. In healthy volunteers, GFR and renal plasma flow increased during EECP. In contrast, these parameters remained unchanged in the patients and their renal vascular resistance increased during EECP. Therefore, EECP improves diuresis, but does not influence the vasoconstrictive dysregulation of the kidneys in liver cirrhosis.

Adult↗
PubMed1996

Beat-to-beat augmentation of left ventricular function by intraaortic counterpulsation.

BACKGROUND: Measuring the effects of intraaortic balloon counterpulsation (IABP) in single cardiac beats may permit an improved understanding of the physiologic mechanisms by which IABP improves the circulation. The objective of the study was to use trans- esophageal echocardiography in combination with hemodynamic measurements to test the hypothesis that IABP improves global left ventricular systolic function selectively in the IABP-augmented cardiac beats by acutely decreasing left ventricular afterload. METHODS: Twenty-seven studies in which the IABP-to-R wave trigger ratio was serially changed from 1:1, 1:2, 1:4, 0:1 (IABP off) and back to 1:1 were performed in 20 anesthetized cardiac surgical patients during IABP support. Left ventricular short-axis end-diastolic cross-sectional area, end-systolic area, mean end-systolic wall thickness, and ejection time were measured by transesophageal echocardiography at the midpapillary muscle level. Aortic pressure was measured simultaneously from the central lumen of the intraaortic balloon catheter. These measurements were used to calculate the fractional area change, end-systolic meridional wall stress, and heart rate-corrected velocity of circumferential fiber shortening. The echocardiographic and hemodynamic parameters of left ventricular preload, afterload, and systolic function immediately after balloon deflation (IABP-augmented cardiac beats) were compared to the parameters measured during nonaugmented cardiac beats to determine the beat-to-beat effects of IABP on left ventricular function. RESULTS: IABP-augmented cardiac beats had a decreased systolic arterial pressure and end-systolic meridional wall stress and increased diastolic blood pressure, fractional area change, and velocity of circumferential fiber shortening compared to nonaugmented cardiac beats. IABP did not cause significant beat-to-beat changes in heart rate, pulmonary artery diastolic pressure, or central venous pressure. The improvement in left ventricular systolic function associated with IABP-augmented cardiac beats correlated with the decrease in end-systolic meridional wall stress for that cardiac beat. CONCLUSIONS: Beat-to-beat echocardiographic and hemodynamic measurements performed in anesthetized cardiac surgical patients during IABP support demonstrated improved left ventricular systolic function and decreased left ventricular systolic wall stress in the cardiac beats immediately after balloon deflation. The relationship between left ventricular systolic function and left ventricular systolic wall stress during IABP support suggests that afterload reduction was an important mechanism by which IABP instantaneously improved circulatory function in anesthetized cardiac surgical patients.

Adult↗
PubMedDate not supplied

Muscle powered circulatory assist device for diastolic counterpulsator.

A diastolic counterpulsator that uses either skeletal muscle or pneumatic actuation was developed. The unit is positioned between the latissimus dorsi and the chest wall, without interference with collateral blood supply, and is connected in series with the descending aorta. The system was able to generate stroke volumes between 52 and 16 ccs against pressures of 60 and 140 mmHg, respectively. Stroke work at 200 msec stimulation averaged 2.8 X 10(6) ergs. Power output at an afterload of 100 mmHg, and at a rate of 60 bpm, was 0.51 W. Back-up pneumatic actuation provided by an intraaortic balloon pump resulted in a 46% increase in the endocardial viability ratio (EVR).

Animals↗
PubMedDate not supplied

Intra-aortic balloon counterpulsation in newborn lambs infected with group B streptococcus.

To determine the efficacy of intra-aortic balloon counterpulsation (IABC) in neonatal group B Streptococcal (GBS) infection, we studied five lambs, 10-14 days old, weighing from 4.7 to 6.7 kg. The lambs were instrumented with arterial and venous catheters, and a 5 French intra-aortic balloon catheter with balloon volumes of 3-5 ml was inserted into the femoral artery. A continuous infusion of heat-killed GBS organisms was infused at a rate of 1.7 to 6.2 x 10(8) org/kg/min, until a 30-50% decrease in cardiac output was attained. IABC was then instituted for 30 minutes, hemodynamic measurements repeated, and IABC was stopped. GBS infusion caused significant decreases in cardiac output (282 +/- 62 vs. 165 +/- 38 ml/min/kg) and pH (7.39 +/- 0.02 vs. 7.33 +/- 0.06), and significant increases in mean pulmonary artery pressure (14.4 +/- 2.1 vs. 36.2 +/- 12.1 mm Hg) and pulmonary vascular resistance (1.20 +/- 0.38 vs. 5.08 +/- 1.49 mm Hg/L/min/kg). Institution of IABC during continuous GBS infusion significantly increased cardiac output (225 +/- 1.27 ml/min/kg). The institution of the IABC also resulted in a significant decrease in pulmonary vascular resistance (2.6 +/- 1.3 mm Hg/L/min/kg). The authors conclude that IABC improves cardiac output and decreases pulmonary vascular resistance in newborn lambs with GBS infection.

Animals↗
PubMedDate not supplied

Enhanced external counterpulsation.

Ischemic heart disease that is refractory or resistant to medical management is a concern to health team members, patients, and their families. These patients are limited in their abilities to perform activities of daily living and often find it difficult to exercise which negatively affects their quality of life. Some patients are confined to bed rest due to these limitations. Enhanced external counterpulsation (EECP) is a noninvasive outpatient procedure that has been shown to improve the patient's quality of life by decreasing ischemic symptoms and permitting increased activity. This article reviews the basic principles of EECP therapy and identifies the goals and benefits for the patient. Helpful tips and observations are discussed as to the use of this treatment using evidence-based research.

Activities of Daily Living↗
PubMed1994

Pulmonary artery balloon counterpulsation as a treatment for right ventricular failure.

Right ventricular failure (RVF) is manifested by a low cardiac output state that is potentially lethal. Pulmonary artery balloon counterpulsation is a means of treating RVF that is refractory to conventional pharmacologic interventions. This treatment is rarely used in isolation but in conjunction with mechanical circulatory support of the left ventricle.

Counterpulsation↗
PubMedDate not supplied

Predicted hemodynamic benefits of counterpulsation therapy using a superficial surgical approach.

A volume-displacement counterpulsation device (CPD) intended for chronic implantation via a superficial surgical approach is proposed. The CPD is a pneumatically driven sac that fills during native heart systole and empties during diastole through a single, valveless cannula anastomosed to the subclavian artery. Computer simulation was performed to predict and compare the physiological responses of the CPD to the intraaortic balloon pump (IABP) in a clinically relevant model of early stage heart failure. The effect of device stroke volume (0-50 ml) and control modes (timing, duration, morphology) on landmark hemodynamic parameters and the LV pressure-volume relationship were investigated. Simulation results predicted that the CPD would provide hemodynamic benefits comparable to an IABP as evidenced by up to 25% augmentation of peak diastolic aortic pressure, which increases diastolic coronary perfusion by up to 34%. The CPD may also provide up to 34% reduction in LV end-diastolic pressure and 12% reduction in peak systolic aortic pressure, lowering LV workload by up to 26% and increasing cardiac output by up to 10%. This study demonstrated that the superficial CPD technique may be used acutely to achieve similar improvements in hemodynamic function as the IABP in early stage heart failure patients.

Computer Simulation↗
PubMed2006

The immediate and long-term outcome of enhanced external counterpulsation in treatment of chronic stable refractory angina.

BACKGROUND: Treatment of angina recalcitrant to conventional pharmacological therapy and revascularization remains problematic. Safe, effective and affordable treatments with high patient acceptability are desirable. Enhanced external counterpulsation (EECP) may fulfil these criteria better than many other proposed interventions. OBJECTIVE: To examine the immediate and long-term effect of EECP in treatment of chronic stable refractory angina. DESIGN: Prospective observational study of consecutive patients treated with EECP and follow-up for 1 year. SETTING: Teaching hospital. MAIN OUTCOME MEASURES: Canadian Cardiovascular Society (CCS) angina grading, weekly angina frequency and glyceryl trinitrate (GTN) use. RESULTS: Sixty-one patients were treated with EECP and 58 completed a course of treatment. Further analysis is confined to those who completed EECP. About 52% of patients suffered from CCS III and IV angina prior to EECP. Immediately post-EECP, angina improved by at least one CCS class in 86% and by two classes in 59%. At 1-year follow-up, sustained improvement in CCS was observed in 78% of the patients. The median weekly angina frequency and GTN use were significantly reduced immediately after EECP [7 (4-14) vs. 1 (0-4) episodes per week and 7 (2-16) vs. 0 (0-2) times per week respectively, P < 0.0001; data in median (interquartile range)]. The reduction was sustained at 1-year follow-up. In 48 patients, their mean exercise time improved significantly after EECP [301 +/- 130 s vs. 379 +/- 147 s, P < 0.0001]. Major adverse treatment-related events were rare. CONCLUSION: This study shows that for patients who fail to respond to conventional measures, a high proportion gain symptomatic benefit from EECP.

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PubMedDate not supplied

Enhanced external counterpulsation as treatment for chronic angina in patients with left ventricular dysfunction: a report from the International EECP Patient Registry (IEPR).

The International Enhanced External Counterpulsation (EECP) Patient Registry tracks acute and long-term outcome for consecutive patients treated for chronic angina. Although EECP has previously been shown to be a safe and effective treatment for angina, little information is available on its use in patients with left ventricular (LV) dysfunction. This report compares the acute outcome and 6-month follow-up for a group of patients with severe LV dysfunction and a group of patients without LV dysfunction. Of 1,402 patients in the registry recruited in 1998-1999 who had recorded values of LV ejection fraction (LVEF) at baseline, 1,090 (77.7%) had preserved LV function (LVEF >35%) and 312 (22.3%) had LV dysfunction (LVEF </=35%). Six-month follow-up was available on 84% of these patients. Pre-EECP patients with LV dysfunction had a longer history of coronary artery disease (12.9 years vs. 9.1 years; p<0.001), a higher rate of congestive heart failure (60.6% vs. 20.1%; p<0.001) and myocardial infarction (83.5% vs. 61.9%; p<0.001). Patients with LV dysfunction had more severe pre-EECP angina, with 86.2% presenting with Canadian Cardiovascular Society Class III/IV vs. 73.6%; p<0.01. Patients with LV dysfunction, consistent with their more severe baseline profile, suffered more adverse events (death, unstable angina, and exacerbation of heart failure) during the treatment period and were less likely to complete the full course. Immediately post-EECP, angina decreased by at least one class in 67.8% of patients with LV dysfunction (vs. 76.2%; p<0.01), and 35.9% of LV dysfunction patients vs. 39.0% had discontinued nitroglycerin use (p=ns). At 6-month follow-up, patients with LV dysfunction showed higher rates of death (9.3% vs. 2.2%; p<0.001) and exacerbation of congestive heart failure (9.9% vs. 3.7%; p<0.001). Rates of the composite outcome of death/myocardial infarction/coronary artery bypass grafting/percutaneous coronary intervention (15.4% vs. 8.3%; p<0.001) were also higher for patients with LV dysfunction. However, patients not reporting such an event showed maintenance of their improved anginal status, with 81% of LV dysfunction vs. 83.8% of patients without LV dysfunction (p=ns) reporting angina at 6 months equal to or less severe than immediately post-EECP, and nitroglycerin use was still reduced at 46.1% for LV dysfunction vs. 37.4% (p<0.05). The rate of event-free angina maintenance at 6 months was 67.0% for patients with LV dysfunction and 70.6% of patients with preserved LV function (p=ns). Patients with LV dysfunction achieved a less robust reduction in angina than did those without LV dysfunction. For the majority of the patients in the registry, this reduction was maintained at 6 months.

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