percutaneous cardiopulmonary support ( pcps ) provides hemodynamic support via the femoral artery and vein , using a closed artificial heart - lung system which is usually composed of a centrifugal pump and a membranous artificial lung.1)2 ) in terms of cardiac failure , the most common indications for pcps are post - cardiotomy ( in which cardiopulmonary bypass can not be taken off the patient following cardiac surgery ) , post - heart transplant ( usually due to primary graft failure ) and severe cardiac failure due to almost any other cause ( eg . , decompensated cardiomyopathy , myocarditis , acute coronary syndrome with cardiogenic shock , profound cardiac depression due to drug overdose or sepsis ) . in terms of respiratory failure ,
the most common indications include adult respiratory distress syndrome , pneumonia , trauma , and primary graft failure following lung transplantation.2 - 4 ) in particular , pcps has proven to be a technique of value in high - risk coronary patients who undergo percutaneous coronary intervention ( pci).5 - 9 ) however , there have been few studies on pcps - supported pci in korea .
we combined the use of pcps and coronary stent revascularization in 19 patients between august 2005 and june 2009 , at the yonsei cardiovascular center .
pcps was used as an elective procedure in 10 patients who satisfied at least two of the selection criteria : left ventricular ejection fraction ( lvef ) < 35% , target vessel(s ) supplying more than 50% of the viable myocardium , high risk surgical patients { old age , impending end stage of renal disease , chronic obstructive pulmonary disease , a history of coronary artery bypass graft surgery ( cabg ) } , and patients who refused cabg surgery . in the remaining 9 patients ,
pcps was used as an emergency procedure to stabilize and even resuscitate patients with acute myocardial infarction ( ami ) and cardiogenic shock , in order to attempt urgent pci .
we compared the clinical characteristics , pcps and angiographic findings , and clinical outcomes of the survivors and non - survivors .
the pcps system used in our study was the capiox emergency bypass system ( terumo , inc . ,
tokyo , japan ) , which is an all - in - one package of a heparin - coated membrane oxygenator that is preassembled with bypass circuits and a cone for the centrifugal pump .
the pcps apparatus is ready for emergency use , by a well - trained team at our hospital , ready to prepare the patient for pump placement within minutes . for the percutaneous technique ,
the tip of the arterial cannula was advanced and positioned in the common iliac artery ; the tip of the venous catheter was placed at the junction of the right atrium and the superior vena cava along a rigid backup guidewire under the fluoroscopic guidance .
the patients were fully heparinized with continuous injection at the rate of 3 mg / kg / min , to maintain an activated clotting time greater than 200 seconds .
the centrifugal pump provided a non - pulsatile flow at a rate between 1 and 5 l / min . during the procedure
then , both cannulas were clamped , and the pump was interrupted . at this point ,
one - to - one protamine neutralization of the circulating heparin was performed , allowing removal of the cannulas and prolonged groin compression .
the data are expressed as meansstandard deviations for the continuous variables , and as absolute and relative frequencies for the categorical variables .
student 's unpaired t - test was used to compare the continuous variables between the groups .
event - free survival curves were constructed by the use of the kaplan - meier method .
we combined the use of pcps and coronary stent revascularization in 19 patients between august 2005 and june 2009 , at the yonsei cardiovascular center .
pcps was used as an elective procedure in 10 patients who satisfied at least two of the selection criteria : left ventricular ejection fraction ( lvef ) < 35% , target vessel(s ) supplying more than 50% of the viable myocardium , high risk surgical patients { old age , impending end stage of renal disease , chronic obstructive pulmonary disease , a history of coronary artery bypass graft surgery ( cabg ) } , and patients who refused cabg surgery . in the remaining 9 patients ,
pcps was used as an emergency procedure to stabilize and even resuscitate patients with acute myocardial infarction ( ami ) and cardiogenic shock , in order to attempt urgent pci .
we compared the clinical characteristics , pcps and angiographic findings , and clinical outcomes of the survivors and non - survivors .
the pcps system used in our study was the capiox emergency bypass system ( terumo , inc . ,
tokyo , japan ) , which is an all - in - one package of a heparin - coated membrane oxygenator that is preassembled with bypass circuits and a cone for the centrifugal pump .
the pcps apparatus is ready for emergency use , by a well - trained team at our hospital , ready to prepare the patient for pump placement within minutes . for the percutaneous technique ,
the tip of the arterial cannula was advanced and positioned in the common iliac artery ; the tip of the venous catheter was placed at the junction of the right atrium and the superior vena cava along a rigid backup guidewire under the fluoroscopic guidance .
the patients were fully heparinized with continuous injection at the rate of 3 mg / kg / min , to maintain an activated clotting time greater than 200 seconds .
the centrifugal pump provided a non - pulsatile flow at a rate between 1 and 5 l / min . during the procedure
then , both cannulas were clamped , and the pump was interrupted . at this point ,
one - to - one protamine neutralization of the circulating heparin was performed , allowing removal of the cannulas and prolonged groin compression .
the data are expressed as meansstandard deviations for the continuous variables , and as absolute and relative frequencies for the categorical variables .
student 's unpaired t - test was used to compare the continuous variables between the groups .
event - free survival curves were constructed by the use of the kaplan - meier method .
the demographics and pre - existing co - morbidities were similar between the survivors and non - survivors .
unstable angina and non - st elevation myocardial infarction patients were more common among the survivors ; st elevation myocardial infarction ( stemi ) with cardiogenic shock was more prevalent in the non - survivor group compared to the survivors ( 75% vs. 27.3% , p=0.04 ) .
the cardiac biomarkers ( creatine kinase - mb , n - terminal pro - b - type natriuretic peptide ) were not significantly different between the survivors and non - survivors either ( table 1 ) .
the elective pcps - supported pci was more frequently practiced among the survivors compared to the non - survivors ( 72.7% vs. 25% , p=0.04 ) .
all patients were weaned from pcps in the survivor group and 6 ( 75% ) patients were weaned from pcps among the non - survivors .
the median durations of pcps support were not significantly different between the survivors and non - survivors .
there were no significant differences in culprit lesions between the survivors and non - survivors .
more patients with multi - vessel disease were in the survivors than in the non - survivors ( 90.9% vs. 50% , p=0.046 ) , however , a lower thrombolysis in myocardial infarction ( timi ) grade ( 0 - 1 ) in the culprit lesions before pci was detected among the non - survivors .
there were no significant differences in the use of intra - aortic balloon pump ( iabp ) or in the number of stents between the survivors and non - survivors ( table 2 ) .
patients who survived were discharged from the hospital and closely followed at the outpatient department .
overall in - hospital mortality was 31.6% ( 6 of 19 ) , of which 4 deaths were cardiac - related and 2 were not .
the causes of non - cardiac - related deaths were sepsis associated with pneumonia and upper gastrointestinal bleeding ( table 3 ) .
we also compared the survival rates of patients who underwent elective procedure and emergency procedure . in the analysis of the event free survival curve between elective procedure and emergency procedure ,
although we studied high - risk patients , there was no procedure - related mortality .
the most common complications were hematomas near the catheter insertion site , which disappeared by the time of discharge from hospital .
one patient who underwent emergency procedure had lower limb ischemia and gangrene , but survived without sequelae .
the demographics and pre - existing co - morbidities were similar between the survivors and non - survivors .
unstable angina and non - st elevation myocardial infarction patients were more common among the survivors ; st elevation myocardial infarction ( stemi ) with cardiogenic shock was more prevalent in the non - survivor group compared to the survivors ( 75% vs. 27.3% , p=0.04 ) .
the cardiac biomarkers ( creatine kinase - mb , n - terminal pro - b - type natriuretic peptide ) were not significantly different between the survivors and non - survivors either ( table 1 ) .
the elective pcps - supported pci was more frequently practiced among the survivors compared to the non - survivors ( 72.7% vs. 25% , p=0.04 ) .
all patients were weaned from pcps in the survivor group and 6 ( 75% ) patients were weaned from pcps among the non - survivors .
the median durations of pcps support were not significantly different between the survivors and non - survivors .
there were no significant differences in culprit lesions between the survivors and non - survivors .
more patients with multi - vessel disease were in the survivors than in the non - survivors ( 90.9% vs. 50% , p=0.046 ) , however , a lower thrombolysis in myocardial infarction ( timi ) grade ( 0 - 1 ) in the culprit lesions before pci was detected among the non - survivors .
there were no significant differences in the use of intra - aortic balloon pump ( iabp ) or in the number of stents between the survivors and non - survivors ( table 2 ) .
patients who survived were discharged from the hospital and closely followed at the outpatient department .
overall in - hospital mortality was 31.6% ( 6 of 19 ) , of which 4 deaths were cardiac - related and 2 were not .
the causes of non - cardiac - related deaths were sepsis associated with pneumonia and upper gastrointestinal bleeding ( table 3 ) .
we also compared the survival rates of patients who underwent elective procedure and emergency procedure . in the analysis of the event free survival curve between elective procedure and emergency procedure ,
although we studied high - risk patients , there was no procedure - related mortality .
the most common complications were hematomas near the catheter insertion site , which disappeared by the time of discharge from hospital .
one patient who underwent emergency procedure had lower limb ischemia and gangrene , but survived without sequelae .
based on the results of previous studies the application of pcps - supported pci on high risk patients with severe lv dysfunction is accepted as helpful.5 - 9 ) pcps provides complete systemic hemodynamic support independent of intrinsic cardiac function and rhythm , and has been successfully used prophylactically in high - risk patients during pci .
this preventative support allows for precise diagnostic and therapeutic occlusive maneuvers { e.g. , intravascular ultrasound ( ivus ) , kissing balloon of bifurcated lesions } while preserving systemic perfusion pressures , and preventing both circulatory collapse and malignant arrhythmia.10)11 ) in one study , although it was from a small number of patients , the authors recommended prophylactic cardiopulmonary bypass support in unstable patients undergoing angioplasty with ef < 25% , or in patients whose ef is low and in whom the only patent artery is the target of dilatation.12 ) even stable patients with ef < 20% may benefit from prophylactic cardiopulmonary bypass support.7 ) pcps may also be helpful when used as an emergency procedure to recover hemodynamic stability in patients with ami and cardiogenic shock .
pcps markedly decreases myocardial oxygen consumption and work , creating favorable hemodynamic conditions to impede progression of myocardial infarction .
complications such as ventricular arrhythmias frequently appear in cardiogenic shock and are also transient and reversible under pcps .
once the patient is stabilized , a coronary angiogram can be safely performed , after which a planned reperfusion and stent revascularization can be accomplished.13 - 15 ) in 1995 , ha et al.16 ) reported , for the first time , a successful case of pcps - supported pci on a high risk patient . in 2006 , rhee et al.17 ) reported the effectiveness of pcps on patients with cardiac arrest or cardiogenic shock .
we analyzed , for the first time in korea , the high - risk patients who underwent pcps - supported pci , being the elective case group and emergency case group . even though the patients in both groups had similar pre - existing co - morbidities and lower ef , the patient conditions were quite different .
those in the emergency group were in shock status even after inotropic drug administration , while patients in the elective group were in a relatively stable condition ( under general anesthesia , transfusion , etc . ) .
for this reason , among the survivors , the number of patients who underwent elective pcps - supported pci was significantly higher than among the non - survivors .
also the in - hospital mortality rate was lower in the elective case group . in this study , elective
pcps - supported pci was applied on 10 patients exhibiting at least two of the following conditions : lvef < 35% , target vessel(s ) supplying more than 50% of the viable myocardium , high risk surgical patients and those who refused coronary bypass surgery .
pcps was weaned off from all patients without serious procedure - related complications and there was no procedure - related mortality . due to underdevelopment of vascular device and stenting technology in the past , procedure - related complications were common in high risk patients who were subjected to application of lv assist.18 ) in this study , the use of a more advanced vascular device helped reducing procedure - related complications .
we could expect a more favorable prognosis with elective pcps - supported pci on high risk patients . in the case of emergency
pcps - supported pci , urgent pci was done to stabilize in patients who showed signs of stemi with cardiogenic shock and cardiac arrest .
pcps was weaned off quite successfully ( in 78% patients ) after its application . however , the prognosis was not favorable , resulting in 44.4% of cardiac related death and 55.6% of in - hospital mortality . according to the results of previously published data ,
ami with cardiogenic shock led to a 80% mortality rate , and iabp , though still applied to lower the mortality rate , resulted a relatively high mortality rate.13)19 ) in this study , we were unable to restore cardiogenic shock of 5 patients by applying iabp alone , thus need a pcps - support .
in other studies pcps - supported pci in emergency cases was more successful than that with iabp support alone.18 ) three patients of this study survived after pcps application and are now under outpatient department follow - up .
however , further study about the benefits of this procedure will be needed , considering the small number patients , and their conditions ( vital sign , co - morbidities , etc . ) , in this study .
our study has some limitations : first , this is a retrospective observational analysis of a relatively very small number of patients .
second , in the elective case group , we have not yet demonstrated that this approach is necessary or superior to unsupported angioplasty or to iabp , or to coronary bypass surgery where feasible . a randomized trial of supported versus unsupported ( with cardiopulmonary support on standby ) angioplasty maybe warranted .
third , in the emergency case group , we have applied iabp first in most of our cases , thus it is hard to conclude that the benefits came from pcps alone .
our experience suggests that pcps may be helpful in high - risk patients being or to be treated with pci , especially in the elective cases .
however , pcps - supported pci still bears considerable risks in the emergent cases . to this day , a clear guideline or indication criteria have not been established for pcps guided pci . more aggressive and
our study has some limitations : first , this is a retrospective observational analysis of a relatively very small number of patients .
second , in the elective case group , we have not yet demonstrated that this approach is necessary or superior to unsupported angioplasty or to iabp , or to coronary bypass surgery where feasible . a randomized trial of supported versus unsupported ( with cardiopulmonary support on standby ) angioplasty maybe warranted .
third , in the emergency case group , we have applied iabp first in most of our cases , thus it is hard to conclude that the benefits came from pcps alone .
our experience suggests that pcps may be helpful in high - risk patients being or to be treated with pci , especially in the elective cases .
however , pcps - supported pci still bears considerable risks in the emergent cases . to this day , a clear guideline or indication criteria have not been established for pcps guided pci .
 background and objectivespercutaneous cardiopulmonary support ( pcps ) has proven to be a valuable technique in high - risk coronary patients undergoing percutaneous coronary intervention ( pci ) . however , there have been few studies on pci associated with pcps in korea . 
 we summarized our experience with pcps - supported pci.subjects and methodswe retrospectively reviewed 19 patients with pcps - supported pci between august 2005 and june 2009 . 
 pcps was used as an elective procedure for 10 patients with at least two of the following conditions : left - ventricular ejection fraction < 35% , target vessel(s ) supplying more than 50% of the viable myocardium , high risk surgical patients , and patients who refused coronary bypass surgery . in the remaining 9 patients pcps 
 was used as an emergency procedure , to stabilize and even resuscitate patients with acute myocardial infarction and cardiogenic shock , in order to attempt urgent pci.resultsamong the 19 patients who were treated with pcps - supported pci , 11 ( 57.9% ) survived and 8 ( 42.1% ) patients did not . 
 st elevation myocardial infarction with cardiogenic shock was more prevalent in the non - survivors than in the survivors ( 75% vs. 27.3% , p=0.04 ) . 
 the elective pcps - supported pci was practiced more frequently in the survivors than in the non - survivors ( 72.7% vs. 25% , p=0.04 ) . in the analysis of the event - free survival curve between elective and emergency procedures , there was a significant difference in the survival rate ( p=0.025 ) . among the survivors 
 there were more patients with multi - vessel disease , but a lower thrombolysis in myocardial infarction grade in the culprit lesions was detected in the non - survivors , before pci . 
 although we studied high - risk patients , there was no procedure - related mortality.conclusionour experience suggests that pcps may be helpful in high risk patients treated with pci , especially in elective cases . 
 more aggressive and larger scale studies of pcps should follow . 
Introduction
Subjects and Methods
Subjects
Percutaneous cardiopulmonary support procedure
Statistics
Results
Patient clinical characteristics
Percutaneous cardiopulmonary support and angiographic findings
Clinical outcomes and complications
Discussion
Limitation of this study
Conclusion