1. EECP: Pushing forward Gregory W Barsness, MD Director, EECP Program Mayo Clinic Rochester, MN

2. The process EECP:Pushing forward Cuffs inflate sequentially to milk blood up to the heart in diastole. (click to view animation)

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

4. EECP:Pushing forward Pre-EECPPost-EECP Mean PAMP* (mW/cm 4 )4.2 ± 1.65.4 ± 2.0 Mean EF25 ± 1029 ± 8 Mean heart rate (min -1 )73 ± 565 ± 5 *preload-adjust maximal power Dr John Gorcsan, 49th Annual Scientific Session of the American College of Cardiology 8 patients received 35 separate EECP sessions, each lasting for 1 h, over 7 weeks Pilot study

5. EECP:Pushing forward Change post- treatment Exercise duration (s) Time to ST depression (s) Inactive EECP+32 (p <0.03)+4 (p <0.74) Active EECP+44 (p <.001)+42 (p <.002) Between-group p value <0.31=0.01 139 patients randomized to either active or inactive EECP (double-blind) MUST-EECP Arora RR, et.al. J Am Coll Cardiol 1999; 33:1833-1840

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

7. Mechanism EECP:Pushing forward 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)

8. Hurdles to acceptance EECP:Pushing forward “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

9. When to use ECP EECP:Pushing forward 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.

10. Long term follow up EECP:Pushing forward 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.

11. Cost of treatment EECP:Pushing forward 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.