Improvement in hemodynamics with a new, larger-volume (50 cc) intra-aortic balloon for high-risk percutaneous coronary intervention.

A primary cause of adverse outcomes among high-risk patients undergoing percutaneous coronary intervention (PCI) may be a diminished capacity to tolerate the hemodynamic and ischemic insults that can occur during the procedure. A common means of mechanical support during PCI has been the intra-aortic balloon pump (IABP). We describe successful periprocedural mechanical support with a new, 50 cc IABP in a patient with both severe left ventricular dysfunction and extensive coronary arteriosclerosis, for whom PCI with stenting was indicated. The prophylactic use of this 50 cc IABP, which traditionally would be contraindicated because of the patient's height (162.6 cm), markedly increased the diastolic aortic pressure (by approximately 110 mmHg) over the baseline level, while promptly reducing left-sided heart pressures. This finding appears to exceed the average diastolic augmentation reported for smaller-volume balloons. Although the role of the IABP in high-risk PCI remains controversial, further research is warranted to clarify and compare this new 50 cc IABP to smaller-volume balloons, and ascertain whether the observed hemodynamic benefits can translate into improved clinical outcomes among patients requiring mechanical support during PCI.

Surgical revascularization for cardiac allograft vasculopathy: Is it still an option?

OBJECTIVES: Cardiac allograft vasculopathy remains a major cause of mortality after cardiac transplantation. Percutaneous revascularization has become the mainstay of therapy given the poor historical outcomes with surgery. Outcomes following surgical revascularization are evaluated to determine whether surgery remains a viable therapeutic option. METHODS: A retrospective analysis was performed of 13 heart transplant recipients who had cardiac allograft vasculopathy requiring coronary artery bypass grafting with or without adjunctive percutaneous coronary intervention for revascularization from 1999 to 2008. RESULTS: Thirteen patients had 14 coronary artery bypass grafting procedures at 141 +/- 66 months after transplantation. The average number of grafts was 2.3. Eight were performed without cardiopulmonary bypass, of which 5 were approached via left thoracotomy and the remainder via repeat sternotomy. One patient had renal failure and a cerebrovascular accident. Percutaneous coronary intervention before or after coronary artery bypass grafting was required in 3 patients. There were no perioperative mortalities. At mean follow-up of 39 +/- 36 months, 3 patients have died, 2 from progressive cardiac allograft vasculopathy and 1 from lung cancer. Kaplan-Meier survival for this group of patients was 92%, 83%, and 83% at 1, 5, and 7 years, respectively. CONCLUSIONS: Surgical revascularization for cardiac allograft vasculopathy remains a viable treatment option for appropriate patients and may be performed safely with good medium-term outcomes. However, patients remain at risk for disease progression and may require percutaneous or surgical reintervention.