Prevention of ischemia during percutaneous transluminal coronary angioplasty by transcatheter infusion of oxygenated Fluosol DA 20%.

Abstract

Catheter balloon inflation performed during percutaneous transluminal coronary angioplasty (PTCA) results in temporary interruption of coronary blood flow and subsequent myocardial ischemia. This produces transient but profound regional left ventricular dysfunction. In an effort to mitigate this inflation-related dysfunction, oxygenated Fluosol DA 20%, a perfluorochemical oxygen transport fluid, was infused distal to the balloon through the central lumen of the dilating catheter during balloon inflation. Regional wall motion during PTCA was assessed by simultaneous continuous two-dimensional echocardiography and was quantified by computer analysis. During control inflations accompanied by no intracoronary infusion or by transcatheter infusion of Ringer's lactate solution or nonoxygenated Fluosol DA 20%, there was profound regional left ventricular dysfunction with a greater than 90% decrease in regional contraction. In contrast, regional contraction during transcatheter infusion of oxygenated Fluosol DA 20% remained at normal levels throughout balloon inflation. Distal infusion of Fluosol DA 20% during balloon inflation is a useful adjunct to PTCA, allowing longer inflation times and perhaps permitting PTCA to be performed safely in patients with significant myocardium at ischemic risk or with limited left ventricular reserve for whom the procedure is currently believed to be too hazardous. Circulation 74, No. 3, 555-562, 1986. PERCUTANEOUS transluminal coronary angioplasty (PTCA) is a procedure that has gained wide acceptance. However, balloon inflation during this procedure results in transient interruption of coronary artery blood flow and subsequent regional ischemia. Using two-dimensional echocardiography, we have demonstrated reproducible transient regional left ventricular wall motion abnormalities during balloon inflation in patients undergoing PTCA. 1,2 Prevention of regional mechanical abnormalities incurred during balloon inflation may allow prolongation of the inflation period and expansion of the patient population currently deemed eligible for PTCA. Recent evidence suggests that prolonged inflation times result in superior primary success rates and lower residual gradients and angiographic stenoses.3 4 In addition, a subset of patients with large regions of myocardium at risk or limited contractile reserve caused by prior inflation are cur- rently at high risk for hemodynamic instability as a result of profound contractile dysfunction during balloon inflation. Efforts to mitigate regional ischemia during balloon inflation have involved intracoronary infusion of whole blood distal to the dilatation balloon.5 The viscosity characteristics of whole blood make its delivery via the distal lumen of the dilating catheter difficult and its infusion at high flow rates may potentially result in significant hemolysis. Fluosol DA 20% is a perfluorochemical emulsion that can deliver oxygen effectively to ischemic tissue at adequate flow rates and has been used as a blood substitute. Therefore we tes...

Influence of low-flow infusion and magnesium on tissue necrosis during regional ischemia in the canine myocardium

“…They suggested that passive arterial perfusion may be a useful adjunctive intervention in patients who fail PTCA and are waiting for coronary bypass surgery; however, without appropriate surgical intervention subendocardial infarction does occur. In clinical studies with oxygenated Fluosol delivered during balloon occlusion, myocardial function was significantly preserved and the effects of myocardial ischemia markedly reduced (Cleman et al 1986;Tokioka et al 1987;Roberts et al 1986). …”

“…Intracoronary injection of pharmacologic agents, or distal coronary artery perfusion with saline using an autoperfusion catheter, appears to afford considerable protection to acutely ischemic myocardium (Zdewski et al 1990;Cleman et al 1986;Tokioka et al 1987). The objective of the present study was to assess the effects of low-flow continuous coronary infusion, with or without Mg"+, on cardiac hemodynarnics and tissue necrosis in a canine preparation s f permanent regional ischemia and evolving myocardial infarction.…”

Haemoglobin, oxygen carriers and perioperative organ perfusion

“…Fluosol-DA has been the first PFC shown to protect the heart during percutaneous transluminal coronary angiography (PTCA) and it has been market approved for PTCA in 1989 [124][125][126][127][128]. However, it showed no efficacy in the treatment of anaemia and has been withdrawn several years later when improvements in balloon angioplasty catheters limited its use [123,129,130].…”

Clinical Potential of Nonhemoglobin Oxygen Therapeutics in Cardiac and General Surgery

“…[33,34] Despite evidence of less myocardial dysfunction during angioplasty with transcatheter infusion of oxygenated perflunafene, this technique has not gained widespread acceptance, and human trials have not been conducted with other PFC emulsions.…”