The History of Counterpulsation

In 1953, Kantrowitz and Kantrowitz initially described the concept of diastolic augmentation as a technique to improve coronary flow which had been known to be primarily diastolic. Early work by Birtwell and others showed that the ECG QRS complex could be utilized to time an external pumping device that provided a synchronous pulse wave thereby increasing the development of coronary collaterals in experimental models. In the 1960's, Dr. S.D. Malopoulis at the Cleveland Clinic developed an experimental protocol of the intra-aortic balloon pump where a pulse wave was delivered via intra-aortic balloon device timed to the cardiac cycle to increase diastolic pressure and flow. Soroff and colleagues then described how these types of assist devices could not only produce increased coronary flow, but also reduce left ventricular work and oxygen demand




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Gorlin first coined the term "counterpulsation" to describe the two-fold effect of the rapid displacement and reduced resistant of volume in the lower arterial circuit. The principle thought to be in effect is that via persistent augmentation of diastolic flow, stimulation of collaterals to ischemic territories occurs with improvement in symptoms and clinical measures of ischemia. It has been shown that external counterpulsation improves ischemic physiology by increasing myocardial oxygen supply (with increased diastolic perfusion pressure) and reducing cardiac workload by decreasing left-ventricular afterload

Adrian Kantrowitz began initial clinical work with an internal system in 1968 with a 15 French device which was employed via a surgical approach using a chimney graft on the femoral artery This technique developed into the modern intra-aortic balloon pump which is part of the standard armamentarium of cardiologists and cardiovascular surgeons today . The present day intra-aortic balloon pump is available in 8 French and 9 French sizes and can be placed via a transfemoral approach in 90-95% of patients where coronary perfusion or cardiac assist is needed.

Soroff and Birtwell first described how the application of a positive pressure pulse to the lower extremities during diastole could raise diastolic pressures by 40 to 50% and lower systolic pressures by up to 30% (5, 6). By the early 1960's, three groups (Birtwell and Soroff, Dennis, and Osborn) independently developed hydraulically activated external counterpulsation devices. They found that the technique was effective in improving survival after myocardial infarction complicated by cardiogenic shock (5, 6). Initial experience with a crude external counterpulsation device used in stable angina saw relief of angina symptoms with angiographic evidence of increased vascularity (7). In a large randomized trial, 258 acute myocardial infarction patients were assigned to treatment with external counterpulsation for three hours within 24 hours of presentation reduced mortality significantly in patients over 46 years of age (8.3% vs. 17.5%, p < 0.05) (8). Despite some of these very positive early findings, other studies showed no benefit with external counterpulsation as it was studied in the 1970's and 1980's. The great variability in the clinical benefit found seemed to correlate with the level of diastolic augmentation achieved.

In the early 1980's, a Chinese group lead by Z.S. Zheng began reporting a large experience using a sequential three-cuff external counterpulsation system which provided a pressure wave by sequentially inflating from calf to thigh to buttock (Figure 1) (9, 10). Their clinical experience led to the installation of more than 1,500 external counterpulsation units in China during the past 15 years leading to the development and refinement of the EECP technique and device.

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