How To Reduce Mortality During Complex Angioplasty - Dr. Srinivasa Prasad

When performing a complex angioplasty, there is a risk of the heart stopping momentarily, which can result in on-table death. To prevent death during these moments of cardiac arrest, it is crucial to maintain blood supply to other vital organs like the brain and kidneys while preventing the heart from ballooning out due to the lack of pumped blood.

1. IABP (Balloon Pump)

   By reducing the resistance to the heart's pumping, the IABP allows for more emptying of the heart, thus unloading the left ventricle and helping to maintain circulation in a slightly better way. It works best when the heart is still working and may not be effective in an arrested heart.

2. ECMO (Extracorporeal Membrane Oxygenation)

   ECMO is an external pump equipped with an oxygenator. It involves placing a cannula in an artery and another in a vein, which are connected to the ECMO circuit. This system actively sucks blood from the veins, oxygenates it, and pushes it back into the arteries, maintaining circulation and blood supply to vital organs during cardiac arrest or profound hypotension due to circulatory arrest. Chest compressions are necessary to keep the heart empty and prevent it from ballooning since ECMO does not directly empty the heart.

3. Impella

   Impella is the world's most miniature heart pump. It is inserted percutaneously into the heart and functions like a "water sump motor pump." It actively sucks blood from the heart and pumps it into the arterial circulation, effectively maintaining circulation and preventing the heart from ballooning out. Impella is particularly useful during high-risk angioplasty procedures, where cardiac arrests will have minimal impact on patient survival and tolerability of the procedure.

Case Example:

This case involved an elderly lady in her 70s who had undergone bypass surgery a decade ago. All her bypass grafts had completely blocked off, leaving only one native artery attempting to supply blood to the entire heart through small collateral channels. This artery had a critical block, which led to a recent heart attack and near-cardiac arrest. Repeat bypass surgery was ruled out due to a poor target vessel, leaving angioplasty as the only option. The procedure carried a high risk with a high chance of cardiac arrest. In this case, Impella was used, maintaining circulation and preventing the heart from ballooning out during the cardiac arrest. The patient did not experience any discomfort, remained conscious throughout, maintained stable blood pressure, and successfully underwent the procedure. She was able to ambulate the next day and was discharged home within 72 hours of the procedure.

Dr. Srinivasa Prasad

Sr. Consultant Cardiologist

Fortis Hospital, BG Road

Phone: 9901999409 / 8589922924