New Heart Procedure Alternative To Surgery

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Col. Richard Orsini is not what you could describe as a heart-healthy guy. The 67-year-old Gainesville resident, retired from the Air Force, has a history of open-heart surgery dating back to 1984 that includes 10 coronary bypasses. Still, about three years ago Orsini found he no longer could maintain his exercise regimen without feeling angina - the pain in his chest that signaled the blood flow to his heart was once again being restricted.

Dr. James DeStephens, his cardiologist, recommended a different form of treatment, Enhanced External Counterpulsation, or EECP."The idea was that it would build other possible routes for the blood to flow in order to enhance the ability of my heart to pump blood to the rest of my body," Orsini said. "I thought it was a better alternative to another surgery, so I did it." DeStephens has been offering EECP since it was approved by the Food and Drug Administration about four years ago for treatment of ischemic heart disease, or angina patients. More recently, EECP has gotten FDA approval for treatment of congestive heart failure, which is marked by a chronic shortness of breath due to fluid accumulating in the lungs.

Doctors traditionally treat angina with medication, angioplasty or coronary bypass surgery. DeStephens believes EECP is a therapy that should be much more widely offered to heart patients, as a noninvasive alternative to surgical intervention."This is a revolutionary approach to the treatment of coronary disease that can be used for patients who do not appear to be critical and unstable," DeStephens said. "If they can walk a block or so without angina and are fairly well maintained on medications, there is time for a noninvasive approach rather than subjecting a patient to the risk of surgery."

During EECP therapy, the patient lies on a bed wearing inflatable pressure cuffs (much like blood pressure cuffs) on calves, upper and lower thighs and buttocks. Timed with the beating of the heart, the cuffs are inflated and deflated.An hour of this sequential squeezing sets up a pressure wave that forces blood from the legs to the heart.DeStephens says EECP is the only approved method of helping the heart heals itself by growing its own "natural bypasses." This collateral circulation made up of tiny blood vessels in the heart can help compensate for any lack of circulation caused by blocked arteries, he explained.

DeStephens describes the process as "squeezing the life back into you."EECP is administered in a series of five one-hour sessions each week, for seven weeks. The therapy is covered by insurance and Medicare, DeStephens added.A randomized trial with EECP, published in the Journal of the American College of Cardiology in 1999, showed that the therapy significantly improved both the symptoms of angina (which is a subjective measurement) and exercise tolerance (which is more easily measured) in patients with coronary artery disease. Most said that the treatment had improved their quality of life.That was the case for Orsini, who has had two courses of EECP. Orsini said that half way through the first round he began to feel better."I was able to go back on my three-mile walks with no real angina pain at all," he said. "After the 35th session, I had lost a little weight because I was controlling my diet, but most of all, it seemed as though my heart was not working as hard. I really felt a whole lot better and was able to do the things that I wanted to do again."

Orsini said that for a 67-year-old who had his first open heart surgery in 1984 and has had 10 bypasses, "I feel I'm doing as well as you could possible do."Dr. C. Richard Conti is the medical director of the Shands Cardiovascular Clinic and a professor of medicine in the University of Florida's College of Medicine.Conti said that Shands also is doing EECP, but added that he does not consider it the first line of therapy in coronary artery disease."Certainly drug therapy is the first thing to be tried, along with a change in diet in exercise," he said.Still, the cardiologist said, "Although I had been somewhat skeptical about EECP, I am coming around to see its benefits in some cases."DeStephens, who has treated more than 350 patients with EECP over three years, said the perfect candidate would be someone who was no longer a candidate for a surgical intervention, in the view of their cardiologist.

"In patients who are for one reason or another not candidates for revascularization procedures, I think it can help restore a more normal lifestyle, and help them regain confidence in what they can do without pain," he said.DeStephens said of those he has treated with EECP "who started off with clear angina, everyone got better to at least a certain degree." Twenty percent no longer experienced any pain, even when pushed to perform under a stress test. He emphasized that EECP will not open up blocked arteries. Nor does it stop blood clots from forming in arteries that are already partially blocked.

Rather it buys a patient time to identify and correct any of the risk factors that caused the blockages in the first place, he explained. They include high blood pressure, smoking, lack of exercise, stress, diabetes and high cholesterol, among others. Any long-term benefit is going to depend on how effectively a patient identifies and controls those risk factors. Can EECP prevent a heart attack from happening? No, DeStephens said. However, he contends that the extent of damage to the heart muscle because it is not receiving enough blood may be limited by the extra collateral circulation that the procedure has stimulated. Orsini said that he is now a believer in EECP.

"Whatever the benefits are, they have come to me," he said. "Certainly it has put off the time that I have to be concerned about going back for some other procedure. More importantly, the angina pain is gone."

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