Transbrachial insertion of a 7.5-Fr intra-aortic balloon pump in a severely atherosclerotic patient

Objective: Preoperative intra-aortic balloon pumping (IABP) improves the results of complex coronary surgery. However, its insertion may be harmful or contraindicated in cases of severe and diffuse atherosclerosis of the descending aorta and peripheral arteries. We sought to evaluate the efficacy and safety of transbrachial insertion of the new 7.5-Fr IABP to support a severely ill patient with eggshell distal aorta and femoro-iliac arteries undergoing coronary artery bypass grafting (CABG).Design. Case report.Setting: An 18-bed adult cardiac surgery unit at a university hospital.Patient A 68-yr-old man with ongoing unstable angina, left main disease, and eggshell calcification in the abdominal aorta and iliacofemoral arteries, needing IABP for CABG.Intervention., Percutaneous sheathless right transbrachial insertion of 7.5-Fr IABP, followed by CABG.Measurements and Main Results. Fluoroscopy and chest radiograph were used to confirm the exact position of the IABP, in the preoperative and postoperative time, respectively. A digital pulse oximeter was applied to monitor distal perfusion. Anticoagulation consisted of nadroparin 4000 lU daily until the second postoperative day, followed by 150 mg of aspirin daily thereafter. Transbrachial IABP support allowed uneventful CABG and postoperative course, without IABP-related complications. Pulse oximetry demonstrated constant good values, the radial artery pulse was always present, and the hand appeared constantly warm. IABP was withdrawn 20 hrs following surgery, and the patient was discharged home on the ninth postoperative day.Conclusions. The miniaturization of IABP, with the recent introduction of a 7.5-Fr balloon catheter, opens the door for the safe, effective transbrachial method of insertion in patients with severe peripheral atherosclerosis

Radial artery graft function is not affected by age

Objective: Extensive arterial grafting with the radial artery in elderly patients is still debated, because of the reduced life expectancy and the supposedly higher periprocedural morbidity caused by an accelerated atherosclerosis of arterial grafts in elderly patients, which might hamper functional results.Methods: We reviewed our experience with patients undergoing radial artery myocardial revascularization ( coronary artery bypass grafting) between January 2003 and December 2006, divided into 2 groups: elderly patients ( >= 70 years, group A) and young patients ( <= 60 years, group B). Hospital outcome and transit-time flowmetric maximum and mean flow, pulsatility index, and graft flow reserve were compared. Results were stratified by target vessel, surgical technique, and subgroups at risk.Results: Hospital outcome, troponin I levels, and echocardiographic segmental kinetics were comparable in the 2 groups. Stratifying patients for target vessels, no differences in radial artery transit-time flowmetric results were recorded between the 2 groups either on-pump or off-pump, as free grafts or Y grafts, or in diabetic patients and hypertensive patients. Although graft flow reserve was significantly improved in all patients ( P <.05 in the young and elderly groups, regardless of the target vessel, the surgical technique, and the comorbidities), graft flow reserve of radial artery grafts was comparable between elderly and young patients.Conclusions: Radial artery coronary artery bypass grafting showed similar transit-time flowmetric functional results in elderly and young patients, regardless of the target vessel, the use or avoidance of cardiopulmonary bypass, the construction of proximal anastomoses, and the presence of comorbidities. These data explain the reported better results of arterial revascularization in the elderly and suggest an increase in extensive radial artery grafting in the last decades of life

C-Kit Positive Cells from Failing Human Hearts: Role of Culturing Media on Cardiomyogenic Potentials

Background: The possibility of culturing heart cells in order to regenerate damaged tissue is a challenging problem. Recent observations have demonstrated the possibility of isolating and expanding resident cardiac stem cells, which could favor regeneration and functional improvement of the myocardial tissue.Aims: To investigate two different culturing media: one promoting c-kit cells’ growth and the other promoting differentiation in cardiac muscle cells.Methods: We obtained primary cultures from left ventricle myocardial tissues of 10 human hearts of patients with end-stage heart failure who received heart transplantation. Cells were first cultured in a medium containing high serum and low calcium/magnesium (Ca2+ /Mg2+) to promote cell growth (medium A). Than they were cultured in another medium that contained lower serum concentration and a variety of different factors in order to induce cell differentiation (medium B). The presence of c-kit, specific for stem cells, α-sarcomeric actin (SA), specific for skeletal and cardiac muscle cells, and α-smooth muscle actin (SMA), specific for smooth muscle cells was studied by immune-cytochemical analysis.Results: A high percentage of c-kit+, SMA-, SA- cells was observed in medium A; in medium B with lower serum and higher Ca2+/Mg2+ concentrations cells became c-kit-, AML+, SA+. In medium A, 78% of the cells were positive for c-kit. After culturing the same cell populations in medium B with lower serum and higher Ca2+ /Mg2+ concentrations, the percentage of c-kit positive cells decreased to 21% while the cells positive for SMA and for SA increased respectively from 28 to 82% and from 0 to 59%.Conclusions: Our results confirm the presence of a high percentage of c-kit positive cells in failing human myocardium and, for the first time, suggest a key role of calcium/magnesium concentration in promoting both c-kit cells’ growth and their differentiation in human cardiac muscle.</p

Transbrachial intraaortic balloon pumping in severe peripheral atherosclerosis

Preoperative intraaortic balloon pumping improves the results of complex coronary surgery; however, insertion may be harmful or contraindicated in severe and diffuse atherosclerosis of the descending aorta and peripheral arteries. We report our experience with 10 consecutive patients with severe peripheral atherosclerosis or distal abdominal aortic aneurysms, in whom a 7.5F intraaortic balloon catheter was inserted through the brachial artery. Intraaortic balloon pumping was maintained until hemodynamic stability was established; no complications or ischemia of the hand related to the intraaortic balloon pump occurred. Transbrachial intraaortic balloon pumping with a 7.5F catheter is as safe and effective as the transfemoral method in patients with unavailable femoral arteries

Intraaortic balloon pumping during cardioplegic arrest preserves lung function in patients with chronic obstructive pulmonary disease

Background. Linear flow during cardiopulmonary bypass is considered a potential mechanism of lung damage in patients with chronic obstructive pulmonary disease (COPD). We evaluated differences in lung function of patients with COPD undergoing preoperative intraaortic balloon pumping (IABP), between linear flow during cardiopulmonary bypass (IABP-off) and maintenance of pulsatile flow (IABP-on at automatic 80 bpm) during cardioplegic arrest.Methods. Fifty patients with COPD undergoing preoperative IABP were randomized between January 2004 and July 2005 to receive nonpulsatile cardiopulmonary bypass with IABP discontinued during cardioplegic arrest (25 patients; group A), or IABP-induced pulsatile cardiopulmonary bypass (25 patients; group B). Hospital outcome, need for noninvasive ventilation, oxygenation (partial pressure of oxygen, arterial to fraction of inspired oxygen [PaO2/FIO2]), respiratory system compliance, and scoring of chest radiographs were compared.Results. There were no hospital deaths, no IABP-related complications, and no differences in postoperative noninvasive ventilation (group A: 6 of 25, 24.0% vs group B: 5 of 25, 20%; p = not significant [NS]). One patient in both groups developed pneumonia (p = NS). intensive care and hospital stay were comparable (p = NS). Group B showed lower intubation time (8.3 +/- 5.1 hours versus group A: 13.2 +/- 6.0; p = 0.001), better PaO2/FIO2 at aortic declamping (369.5 +/- 93.7 mm Hg vs 225.7 +/- 99.3; p = 0.001) at admission in intensive care (321.3 +/- 96.9 vs 246.2 +/- 109.7; p = 0.003), and at 24 hours (349.8 +/- 100.4 vs 240.8 +/- 77.3; p = 0.003). The respiratory system compliance was better in group B at the end of surgery (56.4 +/- 8.2 mL/cm H2O vs 49.4 +/- 7.0; p = 0.004) and 8 hours postoperatively (76.4 +/- 8.2 vs 59.4 +/- 7.0; p = 0.0001), as well as scoring of chest radiograph at intensive care admission (0.20 +/- 0.41 vs 0.38 +/- 0.56; p = 0.05) and on the first day (0.26 +/- 0.45 vs 0.50 +/- 0.67; p = 0.025).Conclusions. Automatic 80 bpm IABP during cardioplegic arrest preserves lung function in patients with COPD