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INTRA-AORTIC BALLOON PUMPING

THERAPY for cardiogenic shock remains contro-

versial, despite more than 30 years’ investigation.The advent of various " circulation-assist " systemsfurther complicates the issued In a report from theMassachusetts General Hospital, intra-aortic balloonpumping, excision of ischxmic tissue, and aorto-

coronary bypass surgery have been appraised in anexperience of 40 patients with cardiogenic shockafter acute myocardial infarction. The patients werefirst treated conservatively, with correction of hypoxia,acidosis, and arrhythmias, and with " moderate dosesof catecholamines ". Hxmodynamic monitoring wasundertaken throughout and the circulatory effects ofintra-aortic balloon pumping (i.A.B.P.) were measured.Techniques for balloon pulsation vary, but the

principle is to generate a secondary aortic pressurepulse in diastole and reduce aortic pressure in systole.Theoretically this should enhance coronary perfusionin diastole and tend to increase forward stroke-volume. In the Massachusetts General patients, acatheter-mounted balloon was passed into the aortaand triggered by the surface electrocardiogram to

inflate shortly after the peak of the T wave and deflatelate in the following P-R interval. The timing wasprecisely adjusted according to the radial pressurecurve.

The clinical status usually improved within one totwo hours of balloon pumping, with an increase incardiac output and mean arterial pressure and a de-crease in pulmonary-arterial wedge pressure. In the9 patients in whom the shock syndrome was notreversed by I.A.B.P., cardiac output did not rise sig-nificantly and renal failure continued. Of 25 patientstreated with LA.B.P. alone, 12 died during pumpingand 4 died within a week of termination of I.A.B.P.9 were successfully weaned, although 5 of these diedbefore discharge. 4 patients (16%) survived to bedischarged. 15 patients had surgical procedures aftera period of circulatory assistance. 6 of these were long-term survivors, 1 having had infarctectomy (forrefractory ventricular arrhythmias) and 5 having hadcoronary-artery bypass grafts. Dunkman et al. 2

indicate that, before 24-48 hours of LA.B.P. had elapsed,the shocked patients separated into three basic groups- those who improved to the point that LA.B.P. couldbe discontinued; those who did not improve (thesepatients had a very poor prognosis whether or notsurgery was performed); and those (the majority)who responded to i.A.B.P. but remained balloon-

dependent. The high death-rate after prolongedpumping or unsuccessful weaning has, in the past,suggested that the procedure is largely futile, butat the Massachusetts General the position seems tohave changed since February, 1970, when coronaryarteriography was started in such patients. Arterio-

graphy, it was claimed, 3 aided subdivision of patientsinto those with massive infarction and those with acombination of infarction and reversible ischæmia.

1. Am. J. Cardiol. 1971, 27, 1, 123.2. Dunkman, W. B., Leinbach, R. C., Buckley, M. J., Mundth, E. D.,

Kantrovitz, A. R., Austen, A. G., Sanders, C. A. Circulation, 1972,46, 465.

3. Leinbach, R. C., Dinsmore, R. E., Mundth, E. D., Buckley, M. J.,Dunkman, W. B., Austen, W. G., Sanders, C. A. ibid. 1972, 45,845.

In the second group emergency revascularisation byaorto-coronary bypass grafts allowed recovery in 6of 11 patients in whom the shock state had been re-versed by LA.B.P. This is a much higher success-ratethan might be expected with conservative therapy,and clearly deserves further attention.Post-mortem investigations in 21 patients (30 died)

showed necrosis of 40% or more of the left-ventricularmyocardium in all but 4. 2 of these had coincidentpneumonia and 2 had died from arrhythmias and un-successful surgery. This is consistent with otherobservations that most patients dying in cardiogenicshock have extensive myocardial necrosis. 4 There issome evidence that balloon pumping may minimisemyocardial necrosis by decreasing myocardial work 5and may increase blood-flow to the pressure-depen-dent areas of the myocardium by increasing aorticdiastolic pressures. On this basis, as well as a pre-liminary to surgery, it would seem logical to use thetechnique for a trial period in patients with severeshock syndrome. The complications are largelylimited to trauma of a severely diseased aorta, duringinsertion of the catheter rather than during pumping,and, less important, thrombocytopenia and haemolysisgiving serum-hæmoglobin values averaging 25 mg.per 100 ml. It may be argued that operative inter-ventions carry their own hazards in this extremelyprecarious clinical state; but the overall survival of 25%speaks for the aggressive approach. The more cynicaland hæmodynamically experienced will note, however,that 15 of the 40 patients had a cardiac index of 2-5litres per minute per sq.m. or above, suggesting thata proportion of patients would have survived withoutcirculation support. Some will also point out theextensive commitment in time, facilities, and speciallytrained personnel needed to save a few patients whomay well have a limited late prognosis. But onlythrough such pioneer work will a rational approach tocardiogenic shock eventually be achieved.

THE DYING PATIENT

DYING at home is generally believed to be preferableto dying anywhere else, but more people each year inEngland die in hospitals. The changing cause ofdeath partly accounts for this shift, since patients withmalignant disease form a large proportion of thoserequiring terminal care over a length of time. However,inadequacies and actual gaps in the services whichshould be available for total care at home for thedying patient are also responsible for the admissionof many terminal patients to hospital. The fact isthat concepts of terminal care in Britain are largelyunformulated and arrangements for it are consequentlyhaphazard. It was in recognition of this state ofaffairs that the Department of Health and SocialSecurity held a symposium on Nov. 29 on the careof the dying, to which representatives of over 50

organisations with an interest in some aspect ofterminal care were invited. The speakers agreedthat, while home care for the dying was usually4. Page, D. L., Caulfield, J. B., Kastor, J. A., De Sanctis, R. W.,

Sanders, C. A. New Engl. J. Med. 1971, 285, 133.5. Urschel, C. W., Eber, L., Forrester, J., Matloff, J., Carpenter, R.,

Sonnenblick, E. H. Am. J. Cardiol. 1972, 25, 546.

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preferable to hospital care, it was not always feasible,desirable, or desired by the patient, but they disagreedas to the best alternative to home care--some advo-

cating small specialist units and others accommodationin district general hospitals. The work of Dr. CicelySaunders for terminal patients at St. Christopher’sHospice was extolled by many speakers, but SirDavid Smithers warned against the proliferation ofisolated terminal-care homes. St. Christopher’s andthose like it were, he said, needed for coping with thereally difficult problems, for research and develop-ment, for teaching, and for providing a standard ofexcellence, but what was needed in abundance wasmore beds for the dying in general hospitals, so thatpatients could be cared for by the same staff throughouttheir illness, even though they could not be cured.Whether the dying patient is cared for at home or

in hospital, or for periods in both places, the generalpractitioner will usually have the most important roleto play. There was some feeling expressed during thesymposium that general practitioners were not givenenough say in the treatment of their patients oncethey had been transferred to hospital. Dr. RonaldGibson approached the problem of liaison from

another angle by suggesting that there should be

domiciliary consultations between the hospital doctorand the general practitioner in the patient’s home.He was a strong advocate of home care for the terminal

patient, but felt that it should not be attempted unlessthe general practitioner was confident that the bestcare could be provided in this way and that it waswhat patient and family wanted; an initial period inhospital for diagnosis and assessment was oftendesirable. Many of the speakers said, in fact, thatarrangements should be flexible enough to allow careto be undertaken alternately at home and in hospital,and that it was essential that general practitionerscaring for patients at home should be able to rely ona hospital bed being immediately available if necessary.Sometimes home care can be provided from the

hospital. A scheme was described whereby patientsawaiting eventual admission to St. Christopher’s,and those who were able to be discharged home for aperiod, came under the umbrella of the outpatientand home care programme, which provides a 24-hourcall system, the promise of instant admission to

hospital if necessary, and regular domiciliary visitsand outpatient clinics. Care at home is, of course,normally provided by the domiciliary team consistingideally of general practitioner, health visitor, districtnurse, home help, and social worker, with help fromthe voluntary organisations and with additionalservices such as meals-on-wheels and launderingwhere necessary. The concept of team care was

much in the minds of the speakers, and it was felt

strongly that existing inadequacies could only beremedied by imposing on the new area healthauthorities a statutory obligation to provide a certainlevel of domiciliary care. Words such as liaison,coordination, and communication were much used atthe symposium, and it was pointed out that it was

especially important, in the care of the dying, thateach member of the team should know what thepatient had been told. The separation of the socialworker and the home help from the health services

was deeply regretted by some speakers.One point that was made again and again during the

day was that people in general and doctors in particularknow too little about death and dying, and find itdifficult to understand, and indeed to contemplate,the feelings and needs of terminal patients. It was

unanimously agreed that the care of the dying patientshould form a part of the curriculum for all those inthe health team. Several people suggested that theclergy had a great, and largely unused, contributionto make to the care of the dying, both in the home andthe hospital, and not only for those with a professedreligious faith. The overall feeling of the conferencewas that the dying patient must no longer be regardedas a failure in care by those responsible for him, butas a challenge to be met with specially developed skills.

BECLOMETHASONE DIPROPIONATE AEROSOLIN ASTHMA

CORTICOSTEROIDS by mouth have been used exten-sively in chronic bronchial asthma and are of un-doubted value in both extrinsic and intrinsic varieties.There are, however, two disadvantages to treatingchronic asthma by oral corticosteroids. First, havingstarted treatment it is seldom possible to discontinueit, and severe attacks are particularly apt to followattempts at weaning from long-term treatment. 1

Second, the doses required are not without undesirableside-effects—particularly suppression of hypothalamo/pituitary/adrenal response to stress and a reduction inplasma-cortisol levels even when small doses are given,and, when larger doses are needed, moon-face, exces-sive weight gain, decreased resistance to infection,osteoporosis, and, in children, impairment of growth.It is not surprising, therefore, that attempts have beenmade to control chronic asthma with corticosteroid

drugs that can be inhaled, because, when given by thisroute, the amount of drug which is effective is manytimes less than that required by mouth. For example,100 !1-g. of the bronchodilator salbutamol by aerosol isroughly equivalent to 4 mg. of the drug by mouth.However, although symptoms improved whencortisone or hydrocortisone were administered byaerosol, there was no objective improvement seen in adouble-blind investigation using hydrocortisone hemi-succinate powder by aerosol 2 ; dexamethasone-sodium-21 phosphate by aerosol also brought about goodcontrol of respiratory symptoms, but there was

significant systemic absorption and it appeared to havelittle advantage over corticosteroids by mouth. 4 Nowa new preparation of a corticosteroid dr-ug-beclo-methasone dipropionate by aerosol-has been intro-duced which is said to have advantages over previouspreparations, in that it has greater topical activity andthat, in the recommended dose, it does not depressplasma-cortisol levels. The drug is inhaled from ametered aerosol delivering 50 1.Lg. of the drug in aliquid propellent and the recommended dose is twoinhalations 3 or 4 times a day, which is equivalent toapproximately 7 mg. of prednisone or prednisolone1. Maunsell, K., Bruce Pearson, R. S., Livingstone, J. L. Br. med. J.

1968, i, 661.2. Langlands, J. H., McNeill, R. S. Lancet, 1960, ii, 404.3. Arbesman, E. C., Bonstein, S. H., Reisman, R. E. J. Allergy,

1963, 34, 354.4. Toogood, J. H., Lefcoe, N. M. ibid. 1965, 36, 321.