Indian Perspective of Enhanced
External Counter Pulsation
Growth and Expansion of
EECP in India.
Dr.S.Ramasamy. M.B.B.S.,M...
2
CARDIAC SCENERIO IN INDIA.
Cardiovascular Disease Burden
Risk Factor 2003 2025
Diabetes 32 million 69.8 million
Hypertension 118 million 214 million
...
4
• Country 2007 Country 2025
Persons-Millions) (Persons-Millions)
• India 40.9 India 69.9
• China 39.8 China 59.3
• Unite...
5
Cardiovascular Disease.
According to recent estimates.
Cases of CVD may increase from about 20.9 Million
in 2000 to as ...
6
Estimates and trends of coronary heart disease (CHD)
cases in various age groups in India.
Source:NCMH Background Papers...
7
INDIAN CORONARY ANATOMY
INDIANS HAVE MORE COMMON
Involvement at younger age.
Small coronary arteries.
Diffuse Distal ...
8
INDIAN RESOURSE FOR EECP DATA
9
• To improve the quality of EECP patient care by
providing information, knowledge and tools;
implementing quality initia...
10
EECP PATIENT SELECTION
11
INDICATION FOR EECP THERAPY.
A. Chronic CAD
Primary utilization of EECP to revascularize Anginal
Patient refractory to ...
12
One (1) hour per day
Six (6) days per week.
Six (6) weeks
Two (2) hours per day
Six (6) days per week.
Three (3) weeks
...
13
SHORT COURSE
TREATMENT IS IT EFFECTIVE?
A modified course of Enhanced External Counterpulsation
improved myocardial perfusion in patients with severe left
ventric...
15
Background / Objectives
A standard 35 sessions of EECP has been reported
to be effective in relieving symptom and impr...
16
INTRA-AORTIC BALLOON PUMP
Systole Diastole
Deflation
Inflation
Standby Counter pulsation
Arterial Pressure
Increased
Ve...
17
Methods
Pre and Post myocardial perfusion study by I.V
injection TC99m tetrafosmin . Gated LV function
and territorial...
18
Demographic Profile of The Patients
Parameter Value
No 16
Age (years) 55 ± 9
Diabetes Mellitus 50%
Hypertension 56%
pri...
19
RESULTS
GATED LVEF AND RADIONUCLIDE TERRITORIAL SCORING
Pre EECP, Gated
LVEF, 26
Pre EECP, LAD, 44
Pre EECP, RCA, 34
45...
20
RESULTS
N=16
•12 Patients underwent CABG after treated with
modified short course EECP. ( 75%)
•IABP was avoided in7 pa...
21
Conclusion
•Short course of EECP in patient with Severe LV
Dysfunction prior to CABG improves
myocardial perfusion and ...
22
Is EECP EEFECTIVE IN DIABETIC PATIENT’S?
23
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ND D ND D
Change in Angina Class
No Angina I II III IV
Diabetes vs Non-Diab...
Enhanced External Counter pulsation improves cardiac symptoms
and function in severe ischemic cardiomyopathy patients
inde...
25
Objective
•Ischemic Cardiomyopathy patients has shown to improve in
exercise tolerance and quality of life when treated...
26
Method
•Two dimensional Echocardiography and 6min walk
test was performed pre and post EECP.
•Patients were divided in ...
27
Results- Demographics
DM(36) NDM(21) Significance
Age 61±11 60±10 NS
Hypertension 56% 56% NS
Prior MI 71% 41% P<0.001
P...
28
Changes in patients with Left Ventricular Dysfunction
With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=...
29
Changes in patients with Left Ventricular Dysfunction
With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=...
30
Changes in patients with Left Ventricular Dysfunction
With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=...
31
Changes in patients with Left Ventricular Dysfunction
With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=...
32
Conclusion.
•EECP Improves Angina and Heart failure symptom in end stage
Ischemic Cardiomyopathy patients.
•EECP improv...
33
EECP IN ISCHEMIC CARDIOMYOPATHY
34
Enhanced External Counterpulsation – Perfusion
Imaging
Author Year Method n Perfusion Changes
Lawson et al 1992 Thalliu...
35
TECHNETIUM-99 SINGLE-PHOTON EMISSION COMPUTERIZED
TOMOGRAPHY (SPECT ) EVALUATION OF ISCHEMIC HEART FAILURE
PATIENTS TRE...
36
INTRODUCTION
•Enhanced external counter pulsation (EECP) is a
recently approved treatment modality for selected
patient...
37
AIM
To evaluate the therapeutic effects of EECP by
Technetium-99 single-photon emission computed
tomography (99Tc-SPECT...
38
PATIENTS AND METHODS
•56 consecutive patients with CAD who were symptomatic
despite conventional medical, interventiona...
39
R – 30 – C, Ambattur Industrial Estate Road, Chennai – 600 101. Tel
- +91-44-26567200 / 7242 / 5772 Fax : +91 44 265651...
40
International Center For Cardio Thoracic and Vascular Diseases
( A Unit Of Frontier Life Line Ltd.)
REST
Base
DEPT.OF N...
41
Demographic Profile of The Patients
Parameter Value
No 56(M=48)
Age (years) 62.09 ± 11.78
Diabetes Mellitus 46%
Hyperte...
42
Myocardial perfusion pre and Post EECP
Pre, LAD, 34 Pre, RCA, 34
Pre, LCX, 45
Post, LAD, 48
Post, RCA, 47
Post, LCX, 49...
43
Global increase in Myocardial perfusion
Global score, Pre, 1041
Global score, Post, 1329
Pre
Post
P< 0.03*
44
Effect on LV Function
P<0.002
45
CONCLUSION
•We concluded that EECP improved LV function, as shown
by radionuclide assessment in patients with severe
co...
Effect of Enhanced External Counterpulsation on
Ejection Fraction in Patients with Ischemic Heart
Disease
William E Lawson...
47
Objective
Patients with ischemic heart disease often have
compromised left ventricular function due to a combination
o...
48
Methods
2-Dimensional Echocardiography was performed on 505
patients with ischemic heart disease, 29% with 3 V CAD.
W...
49
Methods
Patients were divided into a preplanned 2
cohorts for analysis:
Baseline Left Ventricular EF >35%
Baseline L...
50
Results- Demographics
EF >35% EF≤ 35% Significance
Age 58.1 61.3
Gender (M) 86% 88%
Diabetes Mellitus 55% 50%
Hypertens...
51
Results- All Patients
Pre EECP Post EECP p Value
Ejection Fraction 42.7±11.1 53.1±8.0 p<0.001
End Systolic
Volume (ml)
...
52
Results- Cohort ≤ 35% EF
Pre EECP Post EECP p Value
Ejection Fraction 29.3±6.3 45.1±7.9 p<0.001
Stroke Volume 67.7±8.4 ...
53
Results- Cohort > 35% EF
Pre EECP Post EECP p value
Ejection Fraction 48.1±7.4 56.3±5.5 p<0.001
Stroke Volume 78.4±8.2 ...
54
Effect of EECP on Canadian
Cardiovascular Soc Angina
Class
0
0.5
1
1.5
2
2.5
3
3.5
4
Overall > 35% < 35%
Pre-EECP
Post-...
55
Effect of EECP on LV Ejection
Fraction- All Patients
42% 43%
*51%
*53%
0
0.1
0.2
0.3
0.4
0.5
0.6
Teicholtz's Rule Simps...
56
Effect of EECP on LV End
Systolic Diameter (mm)
0
10
20
30
40
50
60
70
Overall > 35% <35%
Pre-EECP
Post-EECP
LVEndSysto...
57
Effect of EECP on LV End
Diastolic Diameter (mm)
0
20
40
60
80
100
120
140
160
Overall > 35% <35%
Pre-EECP
Post-EECP
LV...
58
Effect of EECP on LV Ejection
Fraction
0
10
20
30
40
50
60
70
Overall > 35% <35%
Pre-EECP
Post-EECP
LVEjection
Fraction...
59
Effect of EECP on Heart Rate
0
10
20
30
40
50
60
70
80
90
100
> 35% < 35%
Pre-EECP
Post-EECP
HeartRate(beats/min)
No Si...
60
Effect of EECP on Cardiac
Output
0
1
2
3
4
5
6
7
8
> 35% < 35%
Pre-EECP
Post-EECP
CardiacOutput
(L/min)
p<0.001
p<0.001
61
Discussion
•Potential mechanisms include:
–Improvement in LV contractility by collateral recruitment or
development.
–A...
62
Conclusions
•EECP significantly improved LV ejection fraction, stroke
volume, cardiac output in patients with ischemic ...
EECP scenario in India
52 centers across India.
Including University and Major Cardiac center.
2008 its covered by Tamilna...
64
Number of
Patients
Subjective improvement Objective Improvement Presented
N=505 Improves Anginal Symptom Improves EF, S...
65
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EECP® Enhanced External Counterpulsation

  1. 1. Indian Perspective of Enhanced External Counter Pulsation Growth and Expansion of EECP in India. Dr.S.Ramasamy. M.B.B.S.,M.D President and CEO Vaso-Meditech Pvt Ltd. Chennai. India.
  2. 2. 2 CARDIAC SCENERIO IN INDIA.
  3. 3. Cardiovascular Disease Burden Risk Factor 2003 2025 Diabetes 32 million 69.8 million Hypertension 118 million 214 million World Health Organization. The World Health Report 2005. Preventing Chronic diseases.
  4. 4. 4 • Country 2007 Country 2025 Persons-Millions) (Persons-Millions) • India 40.9 India 69.9 • China 39.8 China 59.3 • United States of America 19.2 United Sates of America 25.4 • Russian Federation 9.6 Brazil 17.6 • Germany 7.4 Pakistan 11.5 • Japan 7.0 Mexico 10.8 • Pakistan 6.9 Russian Federation 10.3 • Brazil 6.9 Germany 8.1 • Mexico 6.1 Egypt 7.6 • Egypt 4.4 Bangladesh 7.4 People with diabetes (20 – 79 age group) 2007 and 2025 Diabetes Atlas, 3rd Edn, 2006
  5. 5. 5 Cardiovascular Disease. According to recent estimates. Cases of CVD may increase from about 20.9 Million in 2000 to as many as 60.4 Million in 2015. Deaths from CVD will also more than double. Most of this increase will occur on account of coronary heart disease —AMI, angina, CHF and inflammatory heart disease. Source:NCMH Background Papers—Burden of Disease in India (New Delhi, India), September 2005
  6. 6. 6 Estimates and trends of coronary heart disease (CHD) cases in various age groups in India. Source:NCMH Background Papers—Burden of Disease in India (New Delhi, India), September 2005
  7. 7. 7 INDIAN CORONARY ANATOMY INDIANS HAVE MORE COMMON Involvement at younger age. Small coronary arteries. Diffuse Distal Disease. Multi vessel Disease. Higher incidence in Women.
  8. 8. 8 INDIAN RESOURSE FOR EECP DATA
  9. 9. 9 • To improve the quality of EECP patient care by providing information, knowledge and tools; implementing quality initiatives; and supporting research that improves patient care and outcomes. • To create Expert panel to organize and improve the quality of research and publication from IPER data base. Mission of the IPER
  10. 10. 10 EECP PATIENT SELECTION
  11. 11. 11 INDICATION FOR EECP THERAPY. A. Chronic CAD Primary utilization of EECP to revascularize Anginal Patient refractory to Medical treatment B. Surgery /PTCA not contemplated Patient refused Diffuse distal disease. Target lesion is inaccessible. Co-morbid states create high risk LV dysfunction – High risk CABG. Restenosis after PTCA CABG graft occlusion C. Preparation for Revascularization Severe LV Dysfunction with lot of hibernation to stabilize Heart Function. Waiting due to some other reason. D. Heart Failure Non-Ischemic Cardiomyopathy Ischemic Cardiomyopathy Patient with LV Dysfunction Patient with moderate to severe levels of CHF. E. Cardiac X Syndrome. .
  12. 12. 12 One (1) hour per day Six (6) days per week. Six (6) weeks Two (2) hours per day Six (6) days per week. Three (3) weeks One (1) hour per day 10-15 sessions. Seven(7) days per week Standard treatment protocol Modified treatment protocol Short course treatment protocol EECP Therapy Treatment For Angina & Heart Failure
  13. 13. 13 SHORT COURSE TREATMENT IS IT EFFECTIVE?
  14. 14. A modified course of Enhanced External Counterpulsation improved myocardial perfusion in patients with severe left ventricular dysfunction Pradeep G.Nayar1, S.Ramasamy1,Madhu.N.Sankar1, K.M.Cherian1 ,William E Lawson2 and John CK Hui2 Presented in American Heart failure society 12th Annual scientific Meeting. Toronto Canada. 1Frontier Lifeline & Dr.K.M.Cherain Heart Foundation, 2Cardiology, SUNY at Stony Brook, NY, USA
  15. 15. 15 Background / Objectives A standard 35 sessions of EECP has been reported to be effective in relieving symptom and improving myocardial blood flow and LV function in patient with ischemic Cardiomyopathy. However, it is not known whether short course of 10 EECP sessions can improve myocardial flow and left ventricular contractility. Modified short course of EECP is given to patients with severe LV dysfunction posted for High Risk CABG with elective or emergency requirement for IABP .
  16. 16. 16 INTRA-AORTIC BALLOON PUMP Systole Diastole Deflation Inflation Standby Counter pulsation Arterial Pressure Increased Venous Return Diastolic Augmentation Systolic Unloading Improve LV Diastolic Filling
  17. 17. 17 Methods Pre and Post myocardial perfusion study by I.V injection TC99m tetrafosmin . Gated LV function and territorial score was assessed. One day prior to starting EECP. Immediately after completing EECP. Patient received a 10 hour course of EECP treatment prior to Surgery (2 hour/day for 5 Days). Requirement for IABP and post opertaive complication is observed.
  18. 18. 18 Demographic Profile of The Patients Parameter Value No 16 Age (years) 55 ± 9 Diabetes Mellitus 50% Hypertension 56% prior MI 69% Triple vessel disease 63% Prior CABG 19%
  19. 19. 19 RESULTS GATED LVEF AND RADIONUCLIDE TERRITORIAL SCORING Pre EECP, Gated LVEF, 26 Pre EECP, LAD, 44 Pre EECP, RCA, 34 45 36* 48* Post-EECP, RCA, 39 49* Pre EECP Post-EECP
  20. 20. 20 RESULTS N=16 •12 Patients underwent CABG after treated with modified short course EECP. ( 75%) •IABP was avoided in7 patients in this group (58%) •4 patients were continued on 35 sessions EECP due to patients preference. •2 patients expired post CABG due to complications. ( 12.5%) in IABP group. •Reduced hospitalization time in patient who were able to Avoid IABP after EECP.
  21. 21. 21 Conclusion •Short course of EECP in patient with Severe LV Dysfunction prior to CABG improves myocardial perfusion and LV contractility. •Short course EECP can reduce post CABG hospitalization and IABP insertion. •Randomized trial is warranted to evaluate whether EECP prior to high risk CABG can avoid emergency IABP insertion and reduce post operative complication and hospitalization time.
  22. 22. 22 Is EECP EEFECTIVE IN DIABETIC PATIENT’S?
  23. 23. 23 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% ND D ND D Change in Angina Class No Angina I II III IV Diabetes vs Non-Diabetes Diabetes: 785 pts Non-diabetes: 1,118 pts Data from IEPR AHA 2000 (5/00) Pre-EECP Post-EECP
  24. 24. Enhanced External Counter pulsation improves cardiac symptoms and function in severe ischemic cardiomyopathy patients independent of Diabetes. Nishith Chandra,* S.Ramasamy,** C.Arumugam ** *Escrorts Heart Institute and research center New Delhi and **Frontier Lifeline Hospital Chennai.
  25. 25. 25 Objective •Ischemic Cardiomyopathy patients has shown to improve in exercise tolerance and quality of life when treated with EECP. •In the present study we examined the effect of EECP in symptoms, exercise tolerance and ventricular function in patient with diabetic and non-diabetic ischemic Cardiomyopathy.
  26. 26. 26 Method •Two dimensional Echocardiography and 6min walk test was performed pre and post EECP. •Patients were divided in to two group. Diabetes and Non-Diabetes.
  27. 27. 27 Results- Demographics DM(36) NDM(21) Significance Age 61±11 60±10 NS Hypertension 56% 56% NS Prior MI 71% 41% P<0.001 Prior CABG 39% 41% NS Prior PTCA 19% 26% NS
  28. 28. 28 Changes in patients with Left Ventricular Dysfunction With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=27) 0 200 400 600 800 1000 1200 DM Non-DM 6-minute Walk 0 0.5 1 1.5 2 2.5 3 DM Non-DM NYHA Classification 2.7 1.1 2.9 1.3 p<0.001 p<0.001 p<0.001 p<0.001 Increase 37% Increase 30% No significant difference in the increase in both group Pre-EECP Post-EECP 747 873 1,025 1,137 (ft)
  29. 29. 29 Changes in patients with Left Ventricular Dysfunction With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=27) 0 5 10 15 20 25 30 35 40 DM Non-DM Ejection Fraction 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 DM Non-DM Cardiac Output 3.1 3.9 3.3 4.1 p<0.001 p<0.001 p<0.001 p<0.001 Increase 21% Increase 20% No significant difference in the increase in both group Pre-EECP Post-EECP 29.8 29.9 36.2 35.9 (%) (l/min) Increase 25% Increase 22% No significant difference in the increase in both group
  30. 30. 30 Changes in patients with Left Ventricular Dysfunction With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=27) 0 20 40 60 80 100 120 140 160 180 DM Non-DM End-Diastolic Volume 0 20 40 60 80 100 120 140 DM Non-DM End-Systolic Volume 117.3 99.1 120.4 112.0 p<0.05 p=0.94 p<0.001 p=0.08 Decrease 7% No change Pre-EECP Post-EECP 165.7 167.2 153.9 167.7 (ml) (ml) Decrease 16% No change Diabetes group has significant reduction in EDV and ESV
  31. 31. 31 Changes in patients with Left Ventricular Dysfunction With diabetes mellitus (DM, n=36) versus non-diabetes (Non-DM, n=27) 0 20 40 60 80 100 120 140 DM Non-DM Systolic Blood Pressure 0 20 40 60 80 100 120 140 DM Non-DM Diastolic Blood Pressure 71.7 72.9 73.0 72.3 p=0.11 p<0.01 p=0.38 p=0.70 Pre-EECP Post-EECP 114.7 110.4 118.5 113.6 (mm Hg) (mm Hg)
  32. 32. 32 Conclusion. •EECP Improves Angina and Heart failure symptom in end stage Ischemic Cardiomyopathy patients. •EECP improved left ventricular ejection fraction and cardiac output. •Effect of EECP in Diabetes and non-diabetes patients are similar with more prominent reverse remodeling in diabetic group. •Effect of EECP in cardiac function in diabetic patients is promising and need further evaluation.
  33. 33. 33 EECP IN ISCHEMIC CARDIOMYOPATHY
  34. 34. 34 Enhanced External Counterpulsation – Perfusion Imaging Author Year Method n Perfusion Changes Lawson et al 1992 Thallium 18 78% pts ↑ (maximal exercise) Sjukri et al 1995 Thallium 35 87% pts ↑ (maximal exercise) Arora et al 1998 PET 11 No change (overall) No change (ischemic region) Masuda et al 2001 PET 11 23% ↑ (overall) 47% ↑ (ischemic region) Urano et al 2000 Thallium 12 46% ↑ (same workload) Stys et al Ramasamy.S 2002 Thallium/S estamibi 175 83% pts ↑ (same workload) 54% pts ↑ (maximal exercise) Tartaglia et al Ramasamy.S 2003 Sestamibi 25 64% pts ↑ (maximal exercise)
  35. 35. 35 TECHNETIUM-99 SINGLE-PHOTON EMISSION COMPUTERIZED TOMOGRAPHY (SPECT ) EVALUATION OF ISCHEMIC HEART FAILURE PATIENTS TREATED WITH ENHANCED EXTERNAL COUNTER PULSATION (EECP) C.K.Das, C.Arumugam, Joy M Thomas, S.Ramasamy, K.M.Cherian International Centre for Cardio Thoracic & Vascular Diseases,Frontier Life Line, Chennai. CUHK-Mayo Clinic-Asia Cardiovascular Summit (CMA 2009) 18-19 April 2009, Hong Kong Selected for the Best Paper Award Competition.
  36. 36. 36 INTRODUCTION •Enhanced external counter pulsation (EECP) is a recently approved treatment modality for selected patients with refractory angina and Heart failure. •However, the efficacy of EECP on Myocardial perfusion in severe left ventricular (LV) dysfunction has not been well established. •The study was aimed to determine whether EECP leads to an improvement in myocardial perfusion.
  37. 37. 37 AIM To evaluate the therapeutic effects of EECP by Technetium-99 single-photon emission computed tomography (99Tc-SPECT) in patients of multi vessel coronary artery disease with left ventricular systolic dysfunction.
  38. 38. 38 PATIENTS AND METHODS •56 consecutive patients with CAD who were symptomatic despite conventional medical, interventional or surgical therapies or not eligible for revascularization were enrolled and received EECP therapy for a total of 35 h [1 hour/day]. •From Jan 2007 to June 2008. They were subjected to 99Tc SPECT before and after EECP therapy to note the changes in Myocardial Perfusion Imaging. •During SPECT, 20 segment myocardial perfusion study and gated ejection fraction were analyzed.
  39. 39. 39 R – 30 – C, Ambattur Industrial Estate Road, Chennai – 600 101. Tel - +91-44-26567200 / 7242 / 5772 Fax : +91 44 26565150 Email:drkmlakshmipathy@rediffmail.com web: www.frontierlifeline.com. International Center For Cardio Thoracic and Vascular Diseases ( A Unit Of Frontier Life Line Ltd.) REST Base DEPT.OF NUCLEAR CARDIOLOGY PRE & POST EECP MYOCARDIAL PERFUSION SCAN PRE- EECP PRE- EECP PRE- EECP POST- EECP POST- EECP POST- EECP Study was carried out following I.v.injection of Tc99m tetrofosmin during resting ( pre & post EECP ) status. PRE EECP POST EECP PRE EECP : SCAN FINDINGS: ( 25-OCT-2007 ) L.V. Size is mildly dilated. All its segments thickness appears well maintained except apex, apico-anterior , septum and inferior. Mild decreased perfusion of tracer seen in the inferior, septum and Moderate in the apex and apico-anterior anterior and inferior wall of L.V. COMMENTS : * PRE EECP STUDY SHOWS HIBERNATING MYOCARDIUM / VIABLE MYOCARDIUM SEEN IN THE APEX AND APICO-ANTERIOR WALL OF L.V. * MODERATE HYPO PERFUSION NOTED IN THE INFERIOR AND SEPTUM WALL OF L.V. POST EECP : ( 30-NOV-2007) * POST EECP STUDY SHOWS MODERATE IMPROVEMENT NOTED IN THE GLOBAL MYOCARDIAL FUNCTIONS, L.V. SIZE / SHPAE AND GLOBAL E.F. NAME : MR.S. PANCHAPAKESAN AGE : 81 Y / M NC: 1063 / O P REF BY : DR.PRADEEP NAYAR # 2110075317 DATE : 25-OCT -2007 & 30-NOV-2007
  40. 40. 40 International Center For Cardio Thoracic and Vascular Diseases ( A Unit Of Frontier Life Line Ltd.) REST Base DEPT.OF NUCLEAR CARDIOLOGY PRE & POST EECP MYOCARDIAL PERFUSION SCAN PRE EECP NAME : MR.S. PANCHAPAKESAN AGE : 81 Y / M NC: 1063 / O P REF BY : DR.PRADEEP NAYAR # 2110075317 DATE : 25-OCT -2007 & 30-NOV-2007 PRE EECP POST EECP DISTAL MID BASAL ANTERIOR 46 68 53 ANTEROSEPTAL 51 72 41 INFEROSEPTAL 60 56 37 INFERIOR 51 54 44 INFEROLATERAL 51 65 55 ANTEROLATERAL 57 82 62 DISTAL MID BASAL ANTERIOR 68 80 50 ANTEROSEPTAL 55 83 54 INFEROSEPTAL 67 73 56 INFERIOR 61 60 45 INFEROLATERAL 73 74 47 ANTEROLATERAL 78 91 49 266 483 292 408 584 337 1041 1329 27%  40% 
  41. 41. 41 Demographic Profile of The Patients Parameter Value No 56(M=48) Age (years) 62.09 ± 11.78 Diabetes Mellitus 46% Hypertension 21% prior MI 37% Triple vessel disease 41% Prior CABG 21%
  42. 42. 42 Myocardial perfusion pre and Post EECP Pre, LAD, 34 Pre, RCA, 34 Pre, LCX, 45 Post, LAD, 48 Post, RCA, 47 Post, LCX, 49 Pre Post P < 0.03 * P < 0.04 * P < 0.3 * Statistically significant
  43. 43. 43 Global increase in Myocardial perfusion Global score, Pre, 1041 Global score, Post, 1329 Pre Post P< 0.03*
  44. 44. 44 Effect on LV Function P<0.002
  45. 45. 45 CONCLUSION •We concluded that EECP improved LV function, as shown by radionuclide assessment in patients with severe coronary artery disease and left ventricular dysfunction. • EECP can be offered as an option for patients with poor quality of life who are not a candidate for standard revascularization procedures.
  46. 46. Effect of Enhanced External Counterpulsation on Ejection Fraction in Patients with Ischemic Heart Disease William E Lawson1, Himanshu Padh2, Subramanian Ramasamy3, John CK Hui1 1SUNY, Stony Brook, NY, 2Samarpan Heart Hospital and Research Center, Jamnagar, India, 3The People’s College of Medical Sciences, Bhopal, India. Journal of American college of cardiology March 11,2008 Volume51 ,No 10 ( Sup A)
  47. 47. 47 Objective Patients with ischemic heart disease often have compromised left ventricular function due to a combination of: prior scarring, persistent severe ischemia, stress induced ischemic dysfunction, adverse remodeling. The present study was conducted to examine whether EECP would effect left ventricular structure and function (ejection fraction and end-diastolic, end-systolic volumes) in patients with ischemic heart disease.
  48. 48. 48 Methods 2-Dimensional Echocardiography was performed on 505 patients with ischemic heart disease, 29% with 3 V CAD. Within 1 week prior to starting EECP. Within 1 week of completing course of EECP. Patient received a 35 hour course of EECP treatment (1 hour/weekday for 6 weeks).
  49. 49. 49 Methods Patients were divided into a preplanned 2 cohorts for analysis: Baseline Left Ventricular EF >35% Baseline Left Ventricular EF ≤ 35% Comparative analysis of pre and post 2-D Echo results by 2-tailed paired t-test with significance at p<0.05. Analysis of demographic differences by chi squared or t-test as appropriate.
  50. 50. 50 Results- Demographics EF >35% EF≤ 35% Significance Age 58.1 61.3 Gender (M) 86% 88% Diabetes Mellitus 55% 50% Hypertension 75% 72% Hyperlipidemia 64% 62% Prior MI 48% 49% Prior CABG 21% 31% Prior PCI 13% 8%
  51. 51. 51 Results- All Patients Pre EECP Post EECP p Value Ejection Fraction 42.7±11.1 53.1±8.0 p<0.001 End Systolic Volume (ml) 56.0±8.7 48.7±7.3 p<0.001 End Diastolic Volume (ml) 131.9±11.9 135.0±11.5 NS Canadian Cardiovascular Society Class 2.56±1.24 0.63±0.81 p<0.001
  52. 52. 52 Results- Cohort ≤ 35% EF Pre EECP Post EECP p Value Ejection Fraction 29.3±6.3 45.1±7.9 p<0.001 Stroke Volume 67.7±8.4 75.0±9.2 p<0.001 Heart Rate 78±13 77±13 NS End Systolic Volume (ml) 59.3±10.4 53.6±8.4 p<0.001 End Diastolic Volume (ml) 127.0±10.8 128.6±10.9 NS
  53. 53. 53 Results- Cohort > 35% EF Pre EECP Post EECP p value Ejection Fraction 48.1±7.4 56.3±5.5 p<0.001 Stroke Volume 78.4±8.2 85.6±9.3 p<0.001 Heart Rate 78±13 77±13 NS End Systolic Volume (ml) 54.6±7.6 50.4±6.0 p<0.001 End Diastolic Volume (ml) 133.8±11.8 136.0±10.4 NS
  54. 54. 54 Effect of EECP on Canadian Cardiovascular Soc Angina Class 0 0.5 1 1.5 2 2.5 3 3.5 4 Overall > 35% < 35% Pre-EECP Post-EECP CCSAnginaClass p<0.001 p<0.001 p<0.001
  55. 55. 55 Effect of EECP on LV Ejection Fraction- All Patients 42% 43% *51% *53% 0 0.1 0.2 0.3 0.4 0.5 0.6 Teicholtz's Rule Simpson's Rule Pre-EECP Post-EECP
  56. 56. 56 Effect of EECP on LV End Systolic Diameter (mm) 0 10 20 30 40 50 60 70 Overall > 35% <35% Pre-EECP Post-EECP LVEndSystolicDiameter(mm) p<0.001 p<0.001 p<0.001
  57. 57. 57 Effect of EECP on LV End Diastolic Diameter (mm) 0 20 40 60 80 100 120 140 160 Overall > 35% <35% Pre-EECP Post-EECP LVEndDiastolicDiameter(mm) No Significant Change with EECP
  58. 58. 58 Effect of EECP on LV Ejection Fraction 0 10 20 30 40 50 60 70 Overall > 35% <35% Pre-EECP Post-EECP LVEjection Fraction p<0.001 p<0.001 p<0.001
  59. 59. 59 Effect of EECP on Heart Rate 0 10 20 30 40 50 60 70 80 90 100 > 35% < 35% Pre-EECP Post-EECP HeartRate(beats/min) No Significant Change with EECP
  60. 60. 60 Effect of EECP on Cardiac Output 0 1 2 3 4 5 6 7 8 > 35% < 35% Pre-EECP Post-EECP CardiacOutput (L/min) p<0.001 p<0.001
  61. 61. 61 Discussion •Potential mechanisms include: –Improvement in LV contractility by collateral recruitment or development. –Afterload reduction with mitigation of adverse remodeling. –“Normalization” of endovascular tone and function improving coronary perfusion and decreasing impedance.
  62. 62. 62 Conclusions •EECP significantly improved LV ejection fraction, stroke volume, cardiac output in patients with ischemic heart disease and –Left ventricular EF > 35% –Left ventricular EF ≤ 35% •The increase in Left Ventricular EF is mediated predominately by a decrease in end-systolic volumes.
  63. 63. EECP scenario in India 52 centers across India. Including University and Major Cardiac center. 2008 its covered by Tamilnadu government Insurance Scheme . Star Insurance BHEL insurance. .
  64. 64. 64 Number of Patients Subjective improvement Objective Improvement Presented N=505 Improves Anginal Symptom Improves EF, Stroke Volume and Cardiac output ACC 2008 ( Smarpan Hospital Gujarat and People Medical college) N=110 Improves Anginal Symptom Improves EF ESC 2008.( Harvey Chennai) N=16 Improves Surgical outcome Improves myocardial perfusion and gated LVEF HFSA 2008 ( Frontier Lifelie& Dr.K.M.Cherian Heart Foundation) N=63 Improves Anginal and heart failure symptom Improves 6 min walk test, ACC 2009(Sub)( Escorts Delhi) N= 50 Improves Myocardial perfusion and Gated LVEF Cardiology Society of Indian 2008. Chennai. Frontier Lifeline & Dr.K.M.Cherian Heart Foundation. INDIAN DATA ON EECP
  65. 65. 65
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