High-Risk Coronary Intervention in Severe Left Ventricular Dysfunction.

markedly depressed left ventricular function is associated with a poor prognosis.1 C o r o n a r y artery bypass graft surgery has been the mainstay of treatment in such patients in the past but is associated with significant morbidity and mortality.2,3 Coronary angioplasty has been offered as an alternative to coronary artery bypass surgery in these patients. The results of PTCA in patients with left ventricular ejection fraction between 3540% have been reported and show a procedural success of >80% and a mortality of 2.7-5%.4 , 5 These reports also suggest that coronary angioplasty is usually well tolerated in patients with moderately depressed ejection fraction but coronary occlusion caused by balloon inflation or abrupt closure in such patients may result in hemodynamic collapse. Additionally, these patients may not survive the delay required to institute emergency bypass surgery. Percutaneous cardiopulmonary bypass support (CPS) provides complete systemic hemodynamic support independent of intrinsic cardiac function (Figure 1) and has been employed prophylactically in high–risk patients prior to angioplasty or emergently following abrupt closure with hemodynamic collapse or cardiac arrest.6-9 A recent report1 0 by the National Registry of Elective Supported Angioplasty indicated patients with a left ventricular ejection fraction of 20% or lower had significantly less hospital mortality when prophylactic support was employed compared with standby support. Complications are mostly related to the cannula insertion site and can be minimized by use of current techn i q u e s .1 1 The discussion that follows details my experience with the technique, the basic principles and management of patients during percutaneously established CPS in patients with poor left ventricular function undergoing coronary intervention. Emergency institution of CPS also remains an option for patients who are in cardiogenic shock or who have sustained cardiac arrest and do not respond promptly to advanced life support techniques.