EECP: Pushing forward

Gregory W Barsness, MD

Director, EECP Program Mayo Clinic Rochester, MN

EECP:Pushing forward

The process Cuffs inflate sequentially to milk blood up to the heart in diastole.

(click to view animation)

EECP:Pushing forward

Indications/contraindications INDICATIONS: Symptomatic ischemic coronary disease CONTRAINDICATIONS: Aortic insufficiency Severe valvular disease Cardiac catheterization <2 weeks Arrhythmia Severe hypertension (>180/110mmhg) History of DVT

EECP:Pushing forward

Pilot study 8 patients received 35 separate EECP sessions, each lasting for 1 h, over 7 weeks Mean PAMP* (mW/cm 4 ) Mean EF Mean heart rate (min -1 ) Pre-EECP 4.2 ± 1.6

25 ± 10 73 ± 5 *preload-adjust maximal power Post-EECP 5.4 ± 2.0 29 ± 8 65 ± 5 Dr John Gorcsan, 49th Annual Scientific Session of the American College of Cardiology

EECP:Pushing forward

MUST-EECP 139 patients randomized to either active or inactive EECP (double-blind) Change post treatment Inactive EECP Active EECP Between-group p value Exercise duration (s) +32 (p <0.03) +44 (p <.001) Time to ST depression (s) +4 (p <0.74) +42 (p <.002) <0.31

=0.01 Arora RR, et.al.

J Am Coll Cardiol

1999; 33:1833-1840

EECP:Pushing forward

What’s next Congestive Heart Failure study Approved Sept 6, 2000 by the FDA 180 patients in 18 centers across the US

EECP:Pushing forward

Mechanism Exact mechanism unknown, but possibilities include: 1) collateral development provoked through increased expression of growth factors 2) Passive exercise (blood pressure modification, sympathetic and neurohormonal changes)

EECP:Pushing forward

Hurdles to acceptance “It’s a difficult therapy to watch. It’s a lot of motion, it’s an aggressive diastolic milking of the blood centrally. On the table, patients are bouncing around and it’s a little uncomfortable for the patients to start. It’s not painful at all, but it’s a little uncomfortable.”

Gregory W Barsness, MD

Director, EECP Program Mayo Clinic Rochester, MN

EECP:Pushing forward

When to use ECP Should be used in patients unable to be revascularized a second time and those in whom medical therapy has failed.

Avoid using in patients with active deep venous thrombosis.

Doesn’t work well in people with claudication. Approximately 10% of patients cannot tolerate EECP therapy, due to leg or back pain, or leg and skin abrasions caused by the leg cuffs.

EECP:Pushing forward

Long term follow up International EECP Patient Registry (University of Pittsburgh Graduate School of Public Health) 2800 patients 3300 cases Intends to track 5000 patients with 3 year follow-up.

EECP:Pushing forward

Cost of treatment Total cost for a course of 35 1-hour sessions ranges from $5000-6000.

HCFA approved coverage of External Counterpulsation treatment for severe angina on July 1, 1999.

Reimbursement was increased to $143.85

per session on Nov 8, 2000.