PMID- 9200392
OWN - NLM
STAT- MEDLINE
DCOM- 19970717
LR  - 20190626
IS  - 0002-8703 (Print)
IS  - 0002-8703 (Linking)
VI  - 133
IP  - 6
DP  - 1997 Jun
TI  - Treatment of medically and surgically refractory angina pectoris with high 
      thoracic epidural analgesia: initial clinical experience.
PG  - 648-55
AB  - Surgical sympathectomy can relieve symptoms of angina in patients with refractory 
      angina. However, in these high-risk patients this thoracic surgery may result in 
      significant morbidity and mortality rates. Similar sympathetic blockade can now 
      be produced with high thoracic epidural analgesia (HTEA). From September 1995 to 
      August 1996, we treated 10 consecutive patients with HTEA. These eight men and 
      two women, aged 58 +/- 5 years, with extensive three-vessel coronary disease and 
      ejection fractions of 40% +/- 5%, had New York Heart Association (NYHA) class IV 
      angina despite medical therapy, including nitrates, beta-blockade, calcium 
      channel blockade, and narcotics. HTEA was performed at the T1 through T4 levels 
      with a catheter placed either percutaneously or surgically, with radiographic 
      confirmation of catheter placement with an epidurogram or computed tomography 
      scan. Bupivacaine (0.25% to 0.5%), an amide local anesthetic, was given as a 
      bolus through the epidural catheter and then maintained either as a continuous 
      infusion or an intermittent rebolus. The epidural catheter remained in place for 
      7 days in four patients, 14 days in three patients, and > or =90 days in three 
      patients. Before consideration for HTEA, each patient was deemed unsuitable for 
      or refused coronary bypass surgery and percutaneous coronary angioplasty and had 
      NYHA class IV symptoms of angina. Seven of 10 patients required intravenous 
      nitroglycerin and heparin and were unable to be discharged from the intensive 
      care unit because of anginal symptoms. Two of these seven patients also required 
      an intraaortic balloon pump for symptom control. After HTEA, all 10 patients had 
      improved symptoms, with five patients improving to NYHA class II symptoms and 
      five improving to NYHA class III. All seven patients receiving intravenous 
      nitroglycerin, heparin, or intraaortic balloon pump support had these modalities 
      discontinued. Six of these seven patients were subsequently discharged from the 
      hospital. One patient died from a non-HTEA related cause. There were no 
      HTEA-related deaths. There were three catheter-related complications 
      necessitating catheter removal during 12 months of HTEA use. Local infection 
      developed in one patient, one had catheter occlusion caused by fibrosis, and one 
      patient had chronic back pain exacerbation from a paraspinous muscle spasm. No 
      patient had a myocardial infarction or a significant arrhythmia. In patients with 
      otherwise intractable angina pectoris, HTEA is an effective modality that 
      produces symptomatic relief of angina pectoris and allows increased activity 
      level.
FAU - Gramling-Babb, P
AU  - Gramling-Babb P
AD  - Department of Anesthesia and Perioperative Medicine, the Ralph H. Johnson 
      Department of Veterans Affairs Medical Center, and the Medical University of 
      South Carolina, Charleston 29425, USA. gramlipm@musc.edu
FAU - Miller, M J
AU  - Miller MJ
FAU - Reeves, S T
AU  - Reeves ST
FAU - Roy, R C
AU  - Roy RC
FAU - Zile, M R
AU  - Zile MR
LA  - eng
PT  - Journal Article
PL  - United States
TA  - Am Heart J
JT  - American heart journal
JID - 0370465
RN  - 0 (Adrenergic beta-Antagonists)
RN  - 0 (Analgesics)
RN  - 0 (Analgesics, Opioid)
RN  - 0 (Anesthetics, Local)
RN  - 0 (Anticoagulants)
RN  - 0 (Calcium Channel Blockers)
RN  - 0 (Nitrates)
RN  - 0 (Vasodilator Agents)
RN  - 9005-49-6 (Heparin)
RN  - G59M7S0WS3 (Nitroglycerin)
RN  - Y8335394RO (Bupivacaine)
SB  - IM
MH  - Adrenergic beta-Antagonists/therapeutic use
MH  - *Analgesia, Epidural/adverse effects/instrumentation
MH  - Analgesics/administration & dosage/*therapeutic use
MH  - Analgesics, Opioid/therapeutic use
MH  - Anesthetics, Local/administration & dosage/*therapeutic use
MH  - Angina Pectoris/*drug therapy/surgery
MH  - Angioplasty, Balloon, Coronary
MH  - Anticoagulants/therapeutic use
MH  - Bupivacaine/administration & dosage/*therapeutic use
MH  - Calcium Channel Blockers/therapeutic use
MH  - Cardiac Output, Low/complications
MH  - Coronary Artery Bypass
MH  - Coronary Disease/complications
MH  - Critical Care
MH  - Female
MH  - Heparin/therapeutic use
MH  - Humans
MH  - Intra-Aortic Balloon Pumping
MH  - Male
MH  - Middle Aged
MH  - Nitrates/therapeutic use
MH  - Nitroglycerin/administration & dosage/therapeutic use
MH  - Patient Discharge
MH  - Radiography, Interventional
MH  - Recurrence
MH  - Retrospective Studies
MH  - Survival Rate
MH  - Thoracic Vertebrae
MH  - Tomography, X-Ray Computed
MH  - Vasodilator Agents/administration & dosage/therapeutic use
EDAT- 1997/06/01 00:00
MHDA- 1997/06/01 00:01
CRDT- 1997/06/01 00:00
PHST- 1997/06/01 00:00 [pubmed]
PHST- 1997/06/01 00:01 [medline]
PHST- 1997/06/01 00:00 [entrez]
AID - S0002870397001919 [pii]
AID - 10.1016/s0002-8703(97)70166-2 [doi]
PST - ppublish
SO  - Am Heart J. 1997 Jun;133(6):648-55. doi: 10.1016/s0002-8703(97)70166-2.