EECP is a non-invasive treatment that uses external pulsation to improve coronary blood flow. It works by inflating compression cuffs on the legs in a sequential pattern synchronized with the heartbeat. This augments diastolic pressure and improves endothelial function. Studies show EECP can reduce angina and improve exercise tolerance, quality of life, and various measures of cardiac function like ejection fraction. It is indicated for stable angina when other options are unsuitable and provides benefits with minimal risk as it is non-invasive and does not require hospitalization.

2. CONUNDRUM OF ENHANCED
EXTERNAL COUNTER PULSATION
DR. G N SHIRBUR
MD, FCCP FICC (CARD) FIAMS FICP, FACCG, FCSI
ENHANCED HEALTH CARE, BANGALORE
EECP 21ST CENTURY CARDIAC CARE
DR. DEMITRY C. PYRROS
CARDIOVASCULAR – THORACIC SURGEON, BOSTON

3. PROGRESSION OF CAD
ANGINA
CORONARY
ARTERY
AMI CARDIOMYOPATHY
DISEASE
(ISCHEMIA)
EVENTS
HEART FAILURE

4. TERMINAL
EVENT
HEART FAILURE
ACUTE EVENTS
FAST TRACK
UNSTABLE ANGINA AMI
PROGRESS – CORONARY HEART DISEASE
ASYMPTOMATIC/SYMPTOMATIC
SLOW TRACK
POTENTIAL ATHEROSCLEROSIS
CORONARY ARTERIES
AGE/SEX/FAM/DM/HTN/LIPIDS/OTHER RISKS
CHD- CONFLUENCE OF NATURE AND NURTURE
PROGRESSION OF CAD PYRAMID OF POPULATION AFFECTED OVER A
PERIOD OF DECADES OF LIFE SPAM

5. THE MNEMONIC EECP REPRESENTS:
ENHANCED – STATE OF THE ART ELECTRONIC EQUIPMENT.
EXTERNAL – THERAPEUTIC MODALITY EXTENDED FROM OUTSIDE.
COUNTER PULSATION – PULSE PRESSURE DELIVERY DURING RELAXATION (DIASTOLE), COUNTER TO
NORMAL CONTRACTION (SYSTOLE).
MECHANICALLY INDUCED SEQUENTIAL COUNTER PULSATIONS.
ELECTRONIC MICROPROCESSOR CONTROLLED.
GATED WITH ECG AND FINGER PLATHYSMOGRAPHY FOR ACCURACY AND EFFICIENCY.

6. 1960 – IABP
HISTORICAL REVIEW OF CORONARY
REVASCULARIZATION IN CAD
1966 – CABG
1977 – PTCA, ROTOBLATOR,
ATHERECTOMY
1990 – STENTS
1994 – SPINAL CORD STIMULATION
(TRANSCUTANEOUS)
BECAME ALASER REVASCULARIZATIONADVENT OF
1995 – REALITY WITH
ANGIOCARDIOGRAPHY
2000 – EECP

7. WHAT IS BEHIND THE CURTAIN?
• NATIONAL INSTITUTE OF HEALTH INTRODUCED SEQUENTIAL
• KANTROWITZ AND KANTROWITZ ANIMAL EXPERIMENTS TO IMPROVE
COMPRESSIONS TO INCREASE THE RATIO OF DIASTOLIC: SYSTOLIC I.E.
1970 CORONARY CIRCULATION CONCEPT DIASTOLIC AUGMENTATION.
INCREASE PRELOAD AND DECREASE AFTER LOAD.
1953
• • BRITWELL AND OTHERS: ECG UTILIZATION FOR TIMING AN EXTERNAL
ZANG AND COLLEAGES USED HYDROLIC COMPRESSIONS AND CHANGED
OVER TO AIR COMPRESSIONS TREATED 200 PTS AT SUN UNIVERSITY,
PUMPING DEVICE THAT PROVIDED ASYNCHRONOUS PULSE WAVE FOR
1970
1955 CHINA.
DEVELOPING COLLATERALS IN ANIMAL EXPERIMENTS.
• FIRST EXTERNAL COUNTER PULSATION (ECP) DEVELOPED AND MARKETED
• MOULOPOULOSMEDICA APPARATUS ANDAORTIC BALLOON PUMP.
BY GANGZHONG S.D: DEVELOPED INTRA INSTRUMENT COMPANY.
1983
1960
• • ADRION KENTROWITZ CLINICAL USE OF IABP.
ECP APPROVED BY CHINA NATIONAL DRUG ADMINISTRATION
1990
1968
• • SAROF COLLEAGUES CARDIAC ASSIST SYSTEM TO INCREASE
APPROVED BY USA FDA.
CORONARY BLOOD FLOW TO REDUCE LV WORK AND OXYGEN DEMAND.
1992
2000
• • GORLIN COINED THE TERMUK APPROVAL.
NATIONAL HEALTH SERVICE “COUNTER PULSATION”
1995
2003

8. CONCEPT AND PRINCIPLE OF EECP
AORTIC DIASTOLIC
“PHASE SHIFT” OR DIASTOLIC
AUGMENTATION DUE TO SHEAR
AUGMENTATION.
STRESS INDUCES CORONARY
ARTERY PHYSIOLOGICAL
“FLOW WORK” AND IMPROVEMENT
RESPONSE WITH “PRESSURE WORK”
I.E. SUPPLY DEMAND RATIO OF OXYGEN
IN VASOMOTOR FUNCTION DUE
TO:
MECHANICAL COUNTER
i. INCREASE IN NITROUS OXIDE
PULSATION DURING DIASTOLE - ↑
PRELOAD IMPROVEMENT IN
ii. DOWN REGULATION OF ENDOTHELIN
DIASTOLIC DYSFUNCTION.
iii. OVERALL IMPROVEMENT IN ENDOTHELIAL FUNCTION
iv. ENDOTHELIAL DYSFUNCTION - ATHE
ROOTS OF EECP ARE IN
SCIENCE OF IABP.
PRIMARY CAUSE OF ATHEROSCLEROSIS IS
CORRECTED

9. MECHANISM OF EECP EFFECT
INCREASED INCREASED IMPROVED OPENING NEOVASCU ENHANCED
DECREASED CORONARY
CORONARY MYO- OF LARISATION MYO-
CORONARY FLOW
ARTERIES CARDIAL DORMANT OF ANGIO- CARDIAL
RESISTANCE
FILLING VELOCITY PERFUSION COLLATERALS GENESIS. EFFICIENCY.

10. INDICATIONS FOR EECP
AT ANY AGE, BOTH GENDERS.
ANGINA OF ANY CLASS (EXCEPT UNSTABLE ANGINA)
AS AN ALTERNATIVE TO INVASIVE PROCEDURES.
CHF AT STAGE I – II
ANY CONTRAINDICATIONS TO INVASIVE PROCEDURES SUCH AS RENAL
DYSFUNCTION
CONFIRMED CAD AT ANY STAGE – PRIMARY/SECONDARY/TERTIARY.
PRIOR TO CABG
ANGINA RESISTANT TO MEDICAL THERAPY.
CHOICE OF THE PATIENT
RECURRENCE OF ANGINA AFTER INVASIVE PROCEDURES – PTCA / STENTING /
CABG.

11. CONTRAINDICATIONS FOR EECP
RECENT MI OR INVASIVE PROCEDURES.
UNSTABLE ANGINA.
SIGNIFICANT HYPERTENSION BP > 180/110 MM OF HG.
PERMANENT PACEMAKER OR ICD.
NON-BYPASSED LAD > 50%
SYMPTOMATIC PVD.
ARRHYTHMIAS – AF OR MULTIPLE VPBS.
SEVERE THROMBOPHLEBITIS AND VARICOSE VIENS IN THE LOWER LIMBS.

12. EECP EQUIPMENT MAIN COMPONENTS:
CONSOLE CONTROL MONITOR.
VASOMEDICAL LUMENAIR
EECP THERAPY SYSTEM
SPECIALLY DESIGNED BED WITH REGULATED
VALVES.
INFLATABLE CUFFS (3 PAIRS) OF VARIABLE SIZES.
AN AIR COMPRESSOR DELIVERY SYSTEM.
FINGER PLATHYSMOGRAPHY.
ECG MONITORING
THE SYSTEM COMPONENTS ARE ERGONOMICALLY DESIGNED FOR MAXIMUM
COMFORT AND SAFTY WITH ITS CONFIGURATION ENGINEERED FOR MAXIMUM
BENEFITS AND SAFETY.

13. PROCEDURE
ECG GATING FOR
SYNCHRONIZATION OF
INFLATION IN
SUPINE POSITION INFLATION CUFFS FINGER
DIASTOLE
WITH TIGHT ELASTIC APPLIED TO LEGS, PLATHYSMOGRAPHY
SYNCHRONOUSLY
PANTS. THIGHS, BUTTOCKS. TO MONITOR BP.
WITH PROMPT
DEFLATION IN
SYSTOLE.
THE PROCEDURE IS INFLATION PRESSURE
INSTANTANEOUS
ONE HOUR DAILY, 5 VARIES FROM 0 – 350 SEQUENTIAL
DEFLATION AT THE
DAYS IN A WEEK, MMHG ACCORDING INFLATION OF CUFFS
BEGINNING OF
TOTAL 35 HOURS I.E. 7 TO THE COMFORT OF AT 50 M SEC.
SYSTOLE.
WEEKS. PATIENT.
DAILY PROCEDURE THE PROCEDURE CAN
UNDERTAKEN BEFORE BE UNDER TAKEN
DURING THE
GOING TO WORK OR TWICE A DAY
PROCEDURE PATIENT
AFTER RETURNING DEPENDING ON THE
READ / LISTEN TO
FROM WORK. COMFORT OF PATIENT
MUSIC / WATCH TV OR
WITHOUT WITH AT LEAST 6
SLEEP.
COMPROMISING HOURS BETWEEN THE
WORKING DAYS. SESSIONS.

14. ADVANTAGES OF EECP
NO SEDATIVES
NO INJECTIONS
NON INVASIVE
NO HOSPITALIZATION
NO ANAESTHESIA
JUST A FEELING OF STRONG HUGGING
SENSATION WITH PLEASANT FEELING.

15. BENEFITS OF EECP
SUBJECTIVE: IMPROVEMENTS IN CHF:
OBJECTIVE:
• INCREASE IN PEAK OXYGEN UPTAKE.
• STABLE HEART RATE
• RELIEF OF ANGINA • EFFECTIVE CONTROL OF BP
• INCREASE IN PRE-LOAD ADJUSTED MAXIMUM
• IMPROVEMENT IN LV FUNCTION:
POWER.
• IMPROVED EXERCISE TOLERANCE –
INCREASED EXERCISE DURATION
–
INCREASED TIME TO ST – SEGMENT
• IMPROVEMENT IN EJECTION FRACTION. DURING TMT.
DEPRESSION
• REDUCTION DOSAGE AND
– IMPROVEMENT IN MYOCARDIAL
FREQUENCY OF MEDICINES
• IMPROVED DIASTOLIC FILLINGPERFUSION OBSERVED IN RADIONUCLIDE
PRESSURE.
PET / 3DCCG STUDIES – COMPARED WITH
• IMPROVED QUALITY OF LIFE.IN BNP / PRO BNP. PRE AND POST PROCEDURES.
• DECREASE
– INCREASES IN CARDIAC OUTPUT.
– INCREASE IN GROWTH FACTORS LIKE
• RELIEF OF CHF SYMPTOMS LIKE –
• INCREASED LEVELS OF NITROUS OXIDEFGFB.
VEGF, HGF, AND
BREATHLESSNESS, LEG SWELLING,
DECREASE IN ENDOTHELIN -1. IMPROVEMENT IN EJECTION FRACTION.
–
CONGESTION IN LUNGS,
IMPROVED DAILY ACTIVITY.
• INCREASE IN RENAL PERFUSION AND DECREASE
• IMPROVEMENT IN DIASTOLIC
IN PLASMA RENNIN ACTIVITY WITH ↓ UREA AND
DYSFUNCTION.
↓ CREATININE LEVELS.

16. BENEFITS OF EECP VARIOUS STUDIES CONFIRMATION
MULTICENTRE
STUDY (MUST EECP)
5 YRS FOLLOW UP.
(J. Ame. Cardi.June
1999)
INTERNATIONAL
EECP REGISTRY
(IEPR) UNIVERSITY
OF PITTSBURG:
TREATMENT • IEPR – I : > 5000
PATIENTS ACROSS 90
BENEFITS IN EECP COUNTRIES (CENTERS)
CONSORTIUM FOR SAFETY AND
(CARDIOL – 2000). EFFICIENCY.
• IEPR – II : 2500
PATIENTS CLINICAL
OUTCOME OF
TREATMENT
LV SYSTOLIC
UNLOADING AND
AUGMENTATION OF
INTRACORONARY CHRONIC HEART
PRESSURE AND FAILURE (CHF)
DOPPLER FLOW STUDY (J. CHF 2002)
DURING EECP
PROCEDURE. (CIRC
– 2002)
LONG TERM
PROGNOSIS – 5YRS
FOLLOW UP FOR
MAJOR
CARDIOVASCULAR
EVENTS. (MALE)
(CLIN. CARDIOL –
2000)

17. BENEFITS OF EECP IN OUR STUDY
• ANGINA CLASS III TO I OR NIL
SYMPTOMATIC • CHF CLASS IV TO II – I
RELIEF: • IMPROVED EXERCISE
TOLERANCE
• IMPROVED QUALITY OF LIFE
OBJECTIVE • TMT, ECHO, CARTOGRAPHY,
ASSESSMENT THALLIUM STUDY.
OBSERVED:

18. CONCLUSION
EECP TREATMENT MODALITY WITH NO
EECP NON-INVASIVE
MESSAGE:
DISCOMFORT OR RISK.
FOR MEDICAL FRATERNITY:
BUILD YOUR PRACTICE, BROADEN YOUR
EECP IS A HAEMODYNAMIC SUPPORT SYSTEM DEVICE.
SPECTRUM OF SERVICE FOR A BETTER WORLD
WITH EECP TREATMENT MODE.
EECP COULD BEPATIENTS: ALTERNATIVE THERAPY FOR
FOR ANGINA A BETTER
ALL CATEGORIES OF PATIENTS WITH CORONARY ARTERY
DISEASE (CAD). THE BENEFITS BY BELIEVING IN
ANTICIPATE
TECHNOLOGY AT THE ESTIMATED NO RISK WITH
EXPECTED OBJECTIVE RESULTS AND INTEND TO
IMPROVE THE QUALITY OF LIFE.