Intraaortic balloon counterpulsation with synchronized coronary venous retroperfusion: The united states experience

Abstract

Several groups have demonstrated the utility of coronary sinus retroperfusion in unstable angina [ 1,2] as well as in the setting of PTCA [3]. We attempted to determine whether coronary sinus retroperfusion could in fact support the circulation or at least partially support regional function during a failed PTCA in an animal model. We found that with adequate coronary sinus retroperfusion, the dyskinesis occurring with left anterior descending occlusions could be improved to akinesis; however, the myocardium still failed to contract during profound ischemia [4]. Unfortunately, during circumflex ischemia in the same animal model, coronary sinus retroperfusion appeared to do little to support mechanical function [4].Verdouw and colleagues [5] suggested that for regional function to be maintained in the pig model with retroperfusion, very high coronary sinus pressures were necessary. These pressures did support reasonable function for a brief period of time; however, subsequently edema in the myocardium developed with further compromise in regional function [ 5 ] . The novel modification described in this report is that of combined intraaortic balloon counterpulsation with coronary sinus retroperfusion. This certainly represents a technical tour-de-force and seemed to achieve an improved physiologic outcome in several patients. The modest decompression of the left ventricle that occurs with intraaortic balloon counterpulsation certainly could improve the collateral pressure gradient induced by coronary sinus retroperfusion.One must ask the question, however: Is this approach practical? The CPS investigators have shown us that it is extremely difficult to predict those patients who will suffer hemodynamic compromise during coronary angioplasty, excluding patients with PTCA of the last remaining vessel. Hence, if failed angioplasty unexpectedly produces hemodynamic compromise that is not readily reversible by intraaortic balloon counterpulsation, one is faced with the prospect of doing an internal jugular or subclavian puncture in heparinized patients. Clearly, such an intervention would be risky, and placement of the coronary sinus catheter via the femoral vein is difficult at best. Coronary sinus catheterization is difficult even in the most experienced of hands, and I think it would be unlikely for routine operators to be able to do this quickly in the setting of patients undergoing CPR or other heroic means to maintain some semblance of circulatory stability. Although the coronary sinus support catheter can be put in through the venous route, arterial blood is necessary for delivery to the distal coronary venous circulation, and hence it is usually necessary to place an arterial supply catheter in addition to the coronary sinus catheter for successful retroperfusion. It might be feasible to use an oversized sheath in the artery that is used for the coronary artery intervention for the source of arterial blood, but clearly, if one has an intraaortic balloon pump in one groin and angioplasty guide catheter in the o...