External pressure circulatory assistance: No light on the shadow

The eminent T.S. Eliot wrote: “. . . between the idea and the reality; between the motion and the act: falls the shadow.” The unhappy reality and the heretofore impenetrable shadow for cardiologists treating acute myocardial infarction has been pump failure manifested by shock and advanced left ventricular failure. For this reason, attention is commanded by any study suggesting that a procedure can reduce mortality in acute myocardial infarction either by more effectively treating severe left ventricular failure and shock (the principal causes of mortality) or, preferably, by preventing their development. The cooperative study on clinical assessment of external pressure circulatory assistance published in this Journal1 is one such study. It claims that this mechanical technique reduces mortality and morbidity in subsets of patients with acute myocardial infarction. Its publication was accompanied by an aggressive advertising campaign to the profession, and was preceded by vigorous efforts to obtain national exposure on the major television networks. Use of this apparently trendy technique-in which putative medical advances are announced to the public before they can be considered carefully by the physicians who are to judge and apply them-should, of course, be accompanied by the responsibility of having a study that is relatively flawless and that reports a truly significant advance. After several years of the use of intraaortic balloon counterpulsation to treat patients with acute myocardial infarction and shock, the mortality rate of patients with the shock syndrome remains very high, although different studies indicate some variation in efficacy of the technique,2-7 probably owing to different criteria in patient selection. In addition, the intraaortic balloon