Percutaneous cardiopulmonary bypass to support angioplasty and valvuloplasty. Technical considerations

To eliminate problems during percutaneous transluminal coronary angioplasties (PTCAs) or valvuloplasties (PV), percutaneous cardiopulmonary bypass (PCPB) was used in 19 high-risk patients (pts) to perform supported PTCA (12 pts, age 40-68) for low EF and/or a large area of risk (L main), and supported PV (7 pts, age 68-92) for "nonoperative" candidates with severe AS. Our experience promoted a review of the technical aspects of PCPB was needed for a successful outcome in these high-risk patients. All patients were treated with IV amnestics while awake in the catheter laboratory. Early in the experience, 20F arterial and venous cannulas were inserted via a 2 cm cutdown in the right groin; now 17F arterial and 20F venous cannulas are placed via a Seldinger technique using fluoroscopy. Traversement of the iliac vein is enhanced by a roll under the buttocks. If the artery is calcified, a cutdown, vessel loops, and direct repair are employed to assure post-PCPB patency. Total flows of 6L/min are easily achieved with nonreservoir centrifugal pump bypass. If flow or pressures fall, 200 cc of blood or crystalloid rapidly improves venous drainage and flows and unlike during reservoir bypass, alpha agonists are only rarely necessary; CaCl often produces nausea in these patients. PCWP's are brought to 0-5 mm Hg. Due to the 1,500 cc priming volume, on-pump transfusion is often required. Two patients were successfully transported to the OR on PCPB for treatment of catheter failures. With attention to technical details, percutaneous bypass supported PTCA or PV is an important new therapy for high risk patients.