Cath Lab Digest - January 2008 - (Page 4)

4 CLINICAL EDITOR’S CORNER JANUARY 2008 EDITORIAL Your Patient Has Critical Left Main Stenosis. Do You Need an Intra-aortic Balloon Pump? MORTON KERN, MD Clinical Editor Clinical Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California LAURIE GUSTAFSON Executive Editor REBECCA KAPUR Managing Editor ELIZABETH MCTAMNEY Layout/Production Manager A 59-year-old man with high blood pressure has progressive angina over the last six weeks. The patient’s angina occurs while brushing his teeth as well as during easy walking. He is admitted for cardiac catheterization immediately after an office visit that morning. His EKG is normal. He had only intermittent brief chest pain in the preceding days. The patient is pain-free at the time of the cath procedure. The first coronary angiographic shot (Figure 1) showed a critical left main stenosis involving the distal trifurcation of the left anterior descending (LAD) artery, Ramus and circumflex arteries. There was no coronary catheter pressure damping. The right coronary artery (RCA) was irregular but widely patent. No other angiograms were obtained. No ventriculography was performed. From the cath lab, the patient was referred to our cardiovascular surgeon, who agreed to operate on the first available surgical slot. Does this patient need an intraaortic balloon pump (IABP)? Before the simple answer, consider the conventional wisdom. An IABP is used in patients with left main coronary stenosis, cardiogenic shock, refractory ischemia and mechanical complications of acute myocardial infarction (e.g., ruptured papillary muscle or ventricular septal defect). An IABP is thought to provide clinical benefit by increasing diastolic pressure (and diastolic flow) and reducing myocardial oxygen demand by afterload reduction. To review the physiology of an IABP, recall that by inflating the 40 cc intra-aortic balloon during diastole, blood is displaced both toward the head and heart as well as toward the feet. The inflated balloon augments diastolic pressure, creating a pressure wave increasing blood flow backward into the coronary arteries. Depending on stenosis severity, it can increase coronary flow across some coronary narrowings. This augmented diastolic pressure wave can also improve coronary collateral flow in certain circumstances. The deflation of the balloon immediately before R wave of systole produces a negative space in the aorta and makes it easier for the ventricle to eject blood. Less left ventricle (LV) work means less LV oxygen demand. That is, reducing ventricular afterload reduces myocardial oxygen demand. The coronary physiology of the IABP was previously described some 15 years ago from our laboratory where we measured pressure and flow with Doppler sensor angioplasty guidewires across critical stenoses.1,2 We learned that coronary flow velocity does not increase across very severe stenosis during intra-aortic balloon pumping and that after balloon angioplasty opening of the arteries, flow velocity was increased to levels seen in the normal arteries adjacent to the target vessels. Coronary perfusion pressure is still somewhat attenuated due to the diffuse disease that is present in many of these vessels, but coronary pressure it is markedly improved by opening the artery and IABP pressure transmission can be appreciated. Recently Yoshitani et al3 confirmed the fact that severe lesions do not transmit IABP pressure. By using pressure guidewires across significant stenoses, they found that in patients with these critical lesions, pressure could not be increased by IABP. The mechanism by which the degree of lumen PAUL MACKLER President/CEO PETER NORRIS Executive Vice President/General Manager JEFFREY MARTIN Vice President/Group Publisher Cardiology Division ALEX SLONIM Vice President/Associate Publisher of Cardiology CARSON MCGARRITY Senior Account Director NICK OTRANTO Account Manager LUCINDA BESKA Classified Advertising Sales Manager FRED KLUMPP Manager of Information Systems KATHY MURPHY Production Director STEFANIE TULEYA RENEE OLSZEWSKI Special Projects Editors KIMBERLY B. CHESKY Production Director, Special Projects PATRICIA LEVY Director of NACCME MORTON KERN, MD Clinical Editor Clinical Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California mortonkern005@hotmail.com Our bottom line for the IABP is that it has the potential to increase flow across stenoses which are only moderately narrowed. 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Table of Contents Feed for the Digital Edition of Cath Lab Digest - January 2008

Cath Lab Digest - January 2008 Central Baptist Hospital Contrast Media Use in High-Risk Patients An Ergonomic Survey of Cath Lab Repetitive Stress Injuries Contents Clinical Editor’s Corner Takotsubo Cardiomyopathy, a.k.a., Transient Left Ventricular Apical Ballooning Syndrome: An Acute Coronary Syndrome Imposter Searching for the Key to D2B STEMI Intervention News STEMI Interventions: Commentary The Massachusetts Stent Study The Value of Educating Staff Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab SICP* Chapter Updates The Society of Invasive Cardiovascular Professionals Holds an RCIS Review Course at New Cardiovascular Horizons 18:20 To Denver — One Student’s First Clinical Experience CEU Education Center Meetings Calendar What Do You Think? Clinical & Industry News Classifieds The Ten-Minute Interview with…Heather Vardon, RN Advertisers Index

Cath Lab Digest - January 2008

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