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Heart is almost like an engine which always need a continuous and constant fuel supply. But sometimes the fuel supply can be interrupted due to various factors results in conditions like angina and myocardial infarction,which is a cardiac emergency and a leading cause of death worldwide.Eventhough there are many sophisticated equipments and surgeries available to support the compromised heart by improving coronary perfusion,they were costly and risky.Here comes the need and importance of a simple cost effective treatment to preserve the heart, called enhanced external counter pulsation.In 1953 kantrowitz and kantrowitz initially described the concept of diastolic augmentation as a technique to improve coronary blood flow.Based on this concept adrian kantrowitz employed diastolic augmentation in 1968 through a surgically placed intravenous system.This technique later developed as modern IABP. In the mid 1960's, several scientists were involved in the evolution of counter pulsation to a noninvasive technique using externally applied pressure generated by hydraulic systems. These systems used various devices to encase the patient's lower limbs and compress the vascular bed displacing arterial and venous blood centrally.these early external counter pulsation devices were somewhat primitive. In the 1980's chinese group of researchers, led by dr. Zeng sheng zheng at the sun yat-sen , began to develop more sophisticated counter pulsation systems. They devised a system in which the pneumatic cuffs inflated sequentially, not simultaneously as they had before.studies conducted for last two decades brought evidences agreeing the positive effects of enhanced external counter pulsation (eecp) treatment.
EECP is a safe, highly beneficial, low-cost,non-invasive,non-pharmaceutical and outpatient treatment modality for patients with chest pain and heart failure.It is not an emergency treatment option but a long term process.the treatements helps in improving blood flow to the heart muscles which is deprived of adequate blood supply and reduces workload of the heart. July 2002 the FDA approved EECP as a treatment for congestive heart failure (CHF). It is FDA (USA) and NHS (UK) approved.EECP is not an alternative for coronary bypass or angioplasty instead it delays the need of these invasive risky procedures.
EECP is a computer assisted micro-processor control system. During the procedure, the patients lie down on a padded table in the treatment room. Three sets of rubber cuffs about 4 inches wide, are tied around three points of the body-the calves thighs and the hips. These connect to air hoses, which in turn are connected to valves. Three or five electrodes are applied to the chest to record a constant ECG.Record blood pressure and oxygen saturation. EECP system uses an ECG signal to electronically synchronize inflation and deflation of the cuffs.
EECP works according to Hagen poiseuille principle,as it says flow through a tube is directly proportional to the pressure difference across it and 4th power of the radius while being inversely proportional to the length and viscosity of fluid flowing through it. The system compresses the legs from the ankles through the thighs and hips sequentially by inflating three sets of flexible cuffs during the resting phase of the heart cycle (diastole). This results in the movement of blood from the legs toward the heart through both the arterial and the venous systems.This helps in improving venous return and better coronary perfusion Pressure is applied by the machine at the end of every heart beat which is sensed by the ECG connected to the machine.When the heart begins to contract again, pressure in the cuff is released instantaneously. This creates a negative pressure and lowers resistance in the blood vessels of the legs so that blood may be pumped more easily from the heart, decreases the work load of the heart muscle.In short EECP system pumps when the heart is resting and releases pressure when the heart is contracts.
EECP administered as a series of outpatient treatement.patient usually receives one hour per day, five days a week for seven weeks.A total of 35 sessions. Some patients take two hour treatments in one day in order to complete the program more quickly. Once a patient completes the 35 session treatment course, they then can continue 1-2 days per week as a maintenance dose inorder to sustain the benefits of treatment, especially in patients with the most severe CAD symptomsThe duration of treatment and interval of rest will depend on the patient's condition, how much diastolic augmentation is obtained, tolerance of patient and the indications for treatements. Most patients begin to experience beneficial results from EECP between their 15th and 25th treatments. These benefits include increased stamina, improved sleeping patterns, decreased angina, and less reliance on nitroglycerin and other medications.Pacemakers and internal defibrillators do not interfere in any way with EECP
- Angina patients who are not relieved by medicine
- patients who dont want to have bypass surgery
-patients who are contraindicated for bypass or angioplasty like kidney failure, liver failure, severe COPD cases, Diffuse diabetes disease,very old age,microvessel disease, ischaemic and dilated cardiomyopathy patients
-Severe LV dysfunction with TVD
-Diffuse TVD with poor targets
- Post CABG and angioplasty return of symptoms of ANGINA
-Severe aortic regurgitation and aortic stenosis
-Atrial fibrillation(uncontrolled and HR above 100)
-deep vein thrombosis
-very high blood pressure
-severe peripheral vascular disease
Side Effects of EECP
EECP is a safer treatment and has no side effects except little skin bruises especially when patient is not wearing proper skin cover during treatment.
Benefits of EECP
-reduces the workload of the heart
-a support to failing heart (ventricular assisting)
-increases cardiac output
-Reduces LV afterload
-increases coronary perfusion
-Improvement in endothelial function, reduction of inflammatory cytokines, EECP increases endothelial shear stress, on circulating levels of inflammatory biomarkers and adhesion molecules in patients with angina pectoris
-Promotion of collateral formation(angiogenesis)
-Reduces oxygen consumption and demand of myocardium
-Regression of atherosclerosis
-Peripheral training effects similar to exercise
- Improved quality of life
-No additional medicines required
Apart from cardiac benefits the EECP also promising invention in treating Diabetic Foot and Non Healing Vascular ulcers.,Diabetic Nephropathy & Acute Tubular Necrosis., Multi Infarct Dementia & Parkinson's Disease., Vascular Erectile Dysfunction. And End Stage Heart Disease with Stem Cell Therapy
Comparison of eecp with surgical treatments
Bypassing major vessels.Smallvessels of heart cannot be accessed
Action mainly in small vessels of heart
No collateral formation
Helps collateral formation
Many side effects
No side effects
Preparation for EECP
--It is an outpatient pocedure
--At each visit patients resting Blood pressure is measured and recorded before starting the treatment. The patients legs are examined for areas of redness, echymosis or signs of other vascular problems.
-- patient is asked to wear special skin tight pants inorder to ensure comfort and to prevent skin irritation during treatment
--The patient is instructed to inform the EECP therapist of any sensations of discomfort during therapy.
--Patient is asked to urinate before the start of each treatment session.
-- Patient is instructed to keep an angina diary and a record of nitroglycerine intake.
--It is better not to take any fluid or food before two hours of EECP session.
--Perform Echocardiography and angiography (If possible) before EECP
--If you are taking diuretic, dont take diuretic dose forÂ atleast 6 hours before EECP session.
--continue regular medication as per the doctors advice
-- Shave all chest hairs before EECP to get better ECG view. The 5-year survivals of ECP patients are 88% similar to the results seen in contemporary Bypass and angioplasty trail. (April 2000 clinical cardiology)l
Aftercare of the treatment
-monitor the vital signs and verify ECG
-No other aftercare usually needed
-Patient need to bring out some lifestyle modifications like;
Follow cardiac diet
Control body weight and obesity
Control BP,cholesterol,Diabetes,thyroid problems
Use good relaxation techniques(yoga,meditation,good IPR)
-Improvement of treatment can be verified with TMT Echo or nuclear scan
In short EECP is low cost and simple treatement.The highlight of this treatment is that it can be used as a adjuant and prophylactic treatment.This therapy is quiet effective to treat symptoms of angina,ensuring better exercise tolerance and good quality of life making EECP popular and equally competitive to other surgical measures.Apart from cardiac concern this treatment can be effectively utilized in patient with compromised renal and cerebral perfusion.In this era of increasing cardiac related mortality and morbidity EECP will be a promising elixir in medical field