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Lüsebrink E, Binzenhöfer L, Hering D, Villegas Sierra L, Schrage B, Scherer C, Speidl WS, Uribarri A, Sabate M, Noc M, Sandoval E, Erglis A, Pappalardo F, De Roeck F, Tavazzi G, Riera J, Roncon-Albuquerque R, Meder B, Luedike P, Rassaf T, Hausleiter J, Hagl C, Zimmer S, Westermann D, Combes A, Zeymer U, Massberg S, Schäfer A, Orban M, Thiele H. Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence? Circulation 2024; 149:1033-1052. [PMID: 38527130 DOI: 10.1161/circulationaha.123.067087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.
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Affiliation(s)
- Enzo Lüsebrink
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Leonhard Binzenhöfer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Daniel Hering
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Laura Villegas Sierra
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany (B.S.)
| | - Clemens Scherer
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria (W.S.S.)
| | - Aitor Uribarri
- Cardiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain. CIBER-CV (A.U.)
| | - Manel Sabate
- Interventional Cardiology Department, Hospital Clinic, Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain (M.S.)
| | - Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia (M.N.)
| | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clínic, Barcelona, Spain (E.S.)
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia (A.E.)
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, AO SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (F.P.)
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, Edegem, Belgium (F.D.R.)
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia Intensive Care, Fondazione IRCCS Policlinico San Matteo, Italy (G.T.)
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, and SODIR, Vall d'Hebron Research Institute, Barcelona, Spain (J.R.)
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, São João University Hospital Center, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, Portugal (R.R.-A.)
| | - Benjamin Meder
- Department of Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Germany (B.M.)
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen (P.L., T.R.)
| | - Jörg Hausleiter
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (C.H.)
| | - Sebastian Zimmer
- Department of Internal Medicine II, Heart Center Bonn, University Hospital Bonn, Venusberg-Campus 1, Germany (S.Z.)
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Germany (D.W.)
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France (A.C.)
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany (U.Z.)
| | - Steffen Massberg
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany (A.S.)
| | - Martin Orban
- Department of Medicine I, LMU University Hospital, LMU Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance (E.L., L.B., D.H., L.V.S., C.S., J.H., S.M., M.O.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Science, Germany (H.T.)
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Tanaka S, Tachibana S, Toyohara T, Sonoda H, Yamakage M. Venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation: A retrospective study comparing the outcomes of fluoroscopy. Heliyon 2024; 10:e24565. [PMID: 38304838 PMCID: PMC10831723 DOI: 10.1016/j.heliyon.2024.e24565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/21/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Background Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation is performed for out-of-hospital cardiac arrest; however, it is associated with a risk of several complications. Objective To investigate whether the fluoroscopy equipment was removed from the emergency department (ED) and whether it would be beneficial to transport the patient to the fluoroscopy room to reduce vascular complications without affecting the induction time. Methods This single-center, retrospective, before-and-after analysis was conducted at a tertiary emergency medical center and included 59 patients who underwent ECPR for out-of-hospital cardiac arrest between May 2017 and March 2022. The patients were divided into two groups: those who underwent cannulation in the ED without fluoroscopy (ED-ECPR group) and those who were transferred directly from the ED to the cardiac angiography room (ECPR call group). Results The rate of vascular complications associated with ECPR was significantly lower in the ECPR group than in the ED-ECPR group (40.6 % [14/32] vs. 10 % [2/20], respectively; p = 0.014). The duration from ED arrival to venoarterial extracorporeal membrane oxygenation initiation was similar in the two groups (median: 23.0 min in the ED-ECPR group vs. 25.5 min in the ECPR call group, p = 0.71). Results adjusted for confounding factors showed that performing ECPR under fluoroscopy was a consistent and independent element of vascular complication rates (adjusted odds ratio: 9.92, 95 % confidence interval: 2.04 to 81.2, p = 0.011). Conclusions Fluoroscopy-guided ECPR can significantly reduce the incidence of vascular complications even if the ED and fluoroscopy room are far apart. However, no significant difference was observed in the time required to establish ECPR in the cardiac catheterization laboratories.
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Affiliation(s)
- Soichi Tanaka
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
- Department of Anesthesiology, Kushiro City General Hospital, Japan
| | - Shunsuke Tachibana
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
| | - Takashi Toyohara
- Department of Emergency Medicine, Kushiro City General Hospital, Japan
| | - Hajime Sonoda
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
- Department of Anesthesiology, Kushiro City General Hospital, Japan
| | - Michiaki Yamakage
- Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan
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Jones D, Daglish FM, Tanner BM, Wilkie FJM. A review of pre-hospital extracorporeal cardiopulmonary resuscitation and its potential application in the North East of England. Int J Emerg Med 2024; 17:7. [PMID: 38191285 PMCID: PMC10773118 DOI: 10.1186/s12245-023-00581-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 12/25/2023] [Indexed: 01/10/2024] Open
Abstract
Patients in the UK who suffer an out-of-hospital cardiac arrest are treated with cardiopulmonary resuscitation in the pre-hospital environment. Current survival outcomes are low in out-of-hospital cardiac arrest. Extracorporeal cardiopulmonary resuscitation is a technique which is offered to patients in specialised centres which provides better blood flow and oxygen delivery than conventional chest compressions. Shortening the interval between cardiac arrest and restoration of circulation is associated with improved outcomes in extracorporeal cardiopulmonary resuscitation. Delivering extracorporeal cardiopulmonary resuscitation in the pre-hospital environment can shorten this interval, improving outcomes in out-of-hospital cardiac arrest. This article will review recently published studies and summarise studies currently being undertaken in pre-hospital extracorporeal cardiopulmonary resuscitation. It will also discuss the potential application of a pre-hospital extracorporeal cardiopulmonary resuscitation programme in the North East of England.
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Affiliation(s)
- Dominic Jones
- Emergency Department, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington, NE23 6NZ, UK.
| | - Fiona M Daglish
- Emergency Department, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington, NE23 6NZ, UK
| | - Benjamin M Tanner
- Emergency Department, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington, NE23 6NZ, UK
| | - Fergus J M Wilkie
- Emergency Department, Northumbria Specialist Emergency Care Hospital, Northumbria Way, Cramlington, NE23 6NZ, UK
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Romain J, Marie CL, Daniel J, Stéphane T. Bolus intravenous potassium chloride for recurrent ventricular fibrillation. Am J Emerg Med 2023:S0735-6757(23)00073-6. [PMID: 36797168 DOI: 10.1016/j.ajem.2023.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
We report the feasibility and recommend the potential efficacy of a bolus intravenous potassium chloride during out-of-hospital cardiac arrest with recurrent ventricular fibrillation following an acute coronary syndrome in a man in his 40's.
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Affiliation(s)
- Jouffroy Romain
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France.
| | - Couetoux Louis Marie
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France
| | - Jost Daniel
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France
| | - Travers Stéphane
- Paris Fire Brigade, Emergency Medicine department, 1 place Jules Renard, 75017 Paris, France
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Mistraletti G, Lancioni A, Bassi G, Nespoli F, Umbrello M, Salini S, Zangrillo A, Pappalardo F, Scandroglio AM, Foti G, Avalli L, Patroniti N, Raimondi F, Costantini E, Catena E, Ottolina D, Ruffini C, Migliari M, Sesana G, Fumagalli R, Pesenti A. Mechanical chest compression and extracorporeal life support for out-of-hospital cardiac arrest. A 30-month observational study in the metropolitan area of Milan, Italy. Resuscitation 2023; 182:109659. [PMID: 36503025 DOI: 10.1016/j.resuscitation.2022.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Return of spontaneous circulation (ROSC) is achieved in 25% of out-of-hospital cardiac arrest (OHCA) patients. Mechanical chest compression (mechCPR) may maintain better perfusion during transport, allowing hospital treatments like extracorporeal circulation life support (ECLS). We aim to assess the effectiveness of a pre-hospital protocol introduction. METHODS Observational, retrospective study assessing all OHCA patients aged 12-75, with no-flow time <20 min in a metropolitan area (Milan, Italy, 2013-2016). PRIMARY OUTCOMES ROSC and Cerebral Performance Category score (CPC) ≤2 at hospital discharge. Logistic regressions with multiple comparison adjustments balanced with propensity scores calculated with inverse probability of treatment weighting were performed. RESULTS 1366 OHCA were analysed; 305 received mechCPR, 1061 manual chest compressions (manCPR), and 108 ECLS. ROSC and CPC ≤2 were associated with low-flow minutes (odds ratio [95% confidence interval] 0.90 [0.88-0.91] and 0.90 [0.87-0.93]), shockable rhythm (2.52 [1.71-3.72] and 10.68 [5.63-20.28]), defibrillations number (1.15 [1.07-1.23] and 1.15 [1.04-1.26]), and mechCPR (1.86 [1.17-2.96] and 2.06 [1.11-3.81]). With resuscitation times >13 min, mechCPR achieved more frequently ROSC compared to manCPR. Among ECLS patients, 70% had time exceeding protocol: 8 (7.5%) had CPC ≤2 (half of them with low-flow times between 45 and 90 min), 2 (1.9%) survived with severe neurological disabilities, and 13 brain-dead (12.0%) became organ donors. CONCLUSIONS MechCPR patients achieved ROSC more frequently than manual CPR patients; mechCPR was a crucial factor in an ECLS protocol for refractory OHCA. ECLS offered a chance of survival to patients who would otherwise die.
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Affiliation(s)
- Giovanni Mistraletti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Italy; UOC Anestesia e Rianimazione, Ospedale Nuovo di Legnano, ASST Ovest Milanese, Milano, Italy.
| | - Armando Lancioni
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milano, Italy; Servizio di Anestesia e Rianimazione 1, Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milano, Italy.
| | - Gabriele Bassi
- Servizio di Anestesia e Rianimazione 1, Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milano, Italy.
| | - Francesca Nespoli
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milano, Italy; Servizio di Anestesia e Rianimazione 1, Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milano, Italy.
| | - Michele Umbrello
- S.C. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST dei Santi Paolo e Carlo, Milano, Italy.
| | - Silvia Salini
- Dipartimento di Economia, Management e Metodi Quantitativi, Data Science Research Center, Università degli Studi di Milano, Italy.
| | - Alberto Zangrillo
- Dipartimento Cardio-Toraco-Vascolare, IRCCS Ospedale San Raffaele, Milano, Italy.
| | - Federico Pappalardo
- Dipartimento di Anestesia e Rianimazione Cardio-Toraco-Vascolare, AO SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy.
| | | | - Giuseppe Foti
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milano, Italy; UOC Anestesia e Rianimazione, Ospedale San Gerardo, ASST Monza, Italy.
| | - Leonello Avalli
- UOC Anestesia e Rianimazione, Ospedale San Gerardo, ASST Monza, Italy.
| | - Nicolò Patroniti
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Italy.
| | - Ferdinando Raimondi
- Dipartimento di Anestesia e Rianimazione, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy.
| | - Elena Costantini
- Dipartimento di Anestesia e Rianimazione, Humanitas Clinical and Research Center - IRCCS, Rozzano (MI), Italy.
| | - Emanuele Catena
- UOC Anestesia e Rianimazione, Ospedale Luigi Sacco, Milano, Italy.
| | - Davide Ottolina
- UOC Anestesia e Rianimazione, Ospedale Luigi Sacco, Milano, Italy.
| | - Claudia Ruffini
- UOC Anestesia e Rianimazione, Ospedale Luigi Sacco, Milano, Italy.
| | | | - Giovanni Sesana
- SOREUM Sala Operativa Emergenza Urgenza Metropolitana, AREU, Milano, Italy.
| | - Roberto Fumagalli
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Milano-Bicocca, Milano, Italy; Servizio di Anestesia e Rianimazione 1, Dipartimento di Anestesia e Rianimazione, Grande Ospedale Metropolitano Niguarda, Milano, Italy; SOREUM Sala Operativa Emergenza Urgenza Metropolitana, AREU, Milano, Italy.
| | - Antonio Pesenti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Italy; Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy.
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Cassara CM, Long MT, Dollerschell JT, Chae F, Hall DJ, Demiralp G, Stampfl MJ, Bernardoni B, McCarthy DP, Glazer JM. Extracorporeal Cardiopulmonary Resuscitation: A Narrative Review and Establishment of a Sustainable Program. Medicina (B Aires) 2022; 58:medicina58121815. [PMID: 36557017 PMCID: PMC9781756 DOI: 10.3390/medicina58121815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
The rates of survival with functional recovery for out of hospital cardiac arrest remain unacceptably low. Extracorporeal cardiopulmonary resuscitation (ECPR) quickly resolves the low-flow state of conventional cardiopulmonary resuscitation (CCPR) providing valuable perfusion to end organs. Observational studies have shown an association with the use of ECPR and improved survivability. Two recent randomized controlled studies have demonstrated improved survival with functional neurologic recovery when compared to CCPR. Substantial resources and coordination amongst different specialties and departments are crucial for the successful implementation of ECPR. Standardized protocols, simulation based training, and constant communication are invaluable to the sustainability of a program. Currently there is no standardized protocol for the post-cannulation management of these ECPR patients and, ideally, upcoming studies should aim to evaluate these protocols.
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Affiliation(s)
- Chris M. Cassara
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
- Correspondence: ; Tel.: +1-608-263-8100
| | - Micah T. Long
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - John T. Dollerschell
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Floria Chae
- Department of Anesthesiology, Ohio State University Wexner Medical Center, 370 W. 9th Ave., Columbus, OH 43210, USA
| | - David J. Hall
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Gozde Demiralp
- Department of Anesthesiology, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Matthew J. Stampfl
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Brittney Bernardoni
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Daniel P. McCarthy
- Department of Surgery, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
| | - Joshua M. Glazer
- Department of Emergency Medicine, University of Wisconsin Hospitals & Clinics, 600 Highland Ave., Madison, WI 53792, USA
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KITTNAR O. Ten years of our translational research in the field of veno-arterial extracorporeal membrane oxygenation. Physiol Res 2022; 71:S163-S178. [PMID: 36647905 PMCID: PMC9906662 DOI: 10.33549/physiolres.934999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Extracorporeal life support is a treatment modality that provides prolonged blood circulation, gas exchange and can substitute functions of heart and lungs to provide urgent cardio-respiratory stabilization in patients with severe but potentially reversible cardiopulmonary failure refractory to conventional therapy. Generally, the therapy targets blood pressure, volume status, and end-organs perfusion. As there are significant differences in hemodynamic efficacy among different percutaneous circulatory support systems, it should be carefully considered when selecting the most appropriate circulatory support for specific medical conditions in individual patients. Despite severe metabolic and hemodynamic deterioration during prolonged cardiac arrest, venoarterial extracorporeal membrane oxygenation (VA ECMO) can rapidly revert otherwise fatal prognosis, thus carrying a potential for improvement in survival rate, which can be even improved by introduction of mild therapeutic hypothermia. In order to allow a rapid transfer of knowledge to clinical medicine two porcine models were developed for studying efficiency of the VA ECMO in treatments of acute cardiogenic shock and progressive chronic heart failure. These models allowed also an intensive research of adverse events accompanying a clinical use of VA ECMO and their possible compensations. The results indicated that in order to weaken the negative effects of increased afterload on the left ventricular function the optimal VA ECMO flow in cardiogenic shock should be as low as possible to allow adequate tissue perfusion. The left ventricle can be also unloaded by an ECG-synchronized pulsatile flow if using a novel pulsatile ECMO system. Thus, pulsatility of VA ECMO flow may improve coronary perfusion even under conditions of high ECMO blood flows. And last but not least, also the percutaneous balloon atrial septostomy is a very perspective method how to passively decompress overloaded left heart.
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Affiliation(s)
- Otomar KITTNAR
- Institute of Physiology of the First Faculty of Medicine, Charles University, Prague, Czech Republic
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8
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Olson T, Anders M, Burgman C, Stephens A, Bastero P. Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience. Front Med (Lausanne) 2022; 9:935424. [PMID: 36479094 PMCID: PMC9720280 DOI: 10.3389/fmed.2022.935424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 11/04/2022] [Indexed: 09/19/2023] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.
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Affiliation(s)
- Taylor Olson
- Pediatric Critical Care Medicine, Children's National Hospital, Washington, DC, United States
| | - Marc Anders
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Pediatric Critical Care Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Cole Burgman
- ECMO, Texas Children's Hospital, Houston, TX, United States
| | - Adam Stephens
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
- Congenital Heart Surgery, Texas Children's Hospital, Houston, TX, United States
| | - Patricia Bastero
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
- Pediatric Critical Care Medicine, Texas Children's Hospital, Houston, TX, United States
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Wilhelm MJ, Inderbitzin DT, Malorgio A, Aser R, Gülmez G, Aigner T, Vogt PR, Reser D. Acute limb ischemia after femoro-femoral extracorporeal life support implantation: a comparison of surgical, percutaneous or combined vascular access in 402 patients. Artif Organs 2022; 46:2284-2292. [PMID: 35723219 DOI: 10.1111/aor.14344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/25/2022] [Accepted: 06/13/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Extracorporeal life support (ECLS) is a salvage treatment for acute circulatory failure. Our high-volume tertiary centre performs more than 100 implants annually and provides ECLS-transports. With this study, we aimed to analyse the incidence and risk factors of limb ischemia depending on the vascular access. METHODS Between January 1st 2007 and December 31st 2018, 937 patients received an ECLS. Preoperative, intraoperative, in-hospital and up to 5 years follow-up data was collected. Outcome measures were limb ischemia and survival. RESULTS In total, 402 femoro-femoral veno-arterial ECLS patients were identified. Mean age was 56±16.7years, 26.9% were female, 7.9% had a history of peripheral vascular disease. Cannulation was performed percutaneously in 82.1% (n=330), surgically in 5.7% (n=23) and combined in 12.2% (n=49). Mortality was not significantly different between the groups (51.1% percutaneous, 43.5% surgical, 44.9% combined (p=0.89)). There was no significant difference in limb ischemia either, but a trend towards an increased frequency in the percutaneous group (p=0.0501). No amputation was necessary. Limb ischemia slightly increased in-hospital mortality (54.6%) but did not affect long-term survival beyond 30 days. Univariate analysis adjusted for cannulation methods revealed younger age and female gender as risk factors of limb ischemia and younger age for limb ischemia after percutaneous cannulation. CONCLUSIONS Our study shows that percutaneous, surgical and combined vascular access techniques for ECLS implantation are associated with comparable and low incidence of limb ischemia which slightly increases in-hospital mortality. Special precaution has to be taken in young and female patients.
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Affiliation(s)
- Markus J Wilhelm
- Clinic for Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | | | - Amos Malorgio
- Clinic for Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Raed Aser
- Clinic for Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Gökhan Gülmez
- Clinic for Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Tobias Aigner
- Clinic for Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Paul Robert Vogt
- Clinic for Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Diana Reser
- Clinic for Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland.,Hirslanden Heart Clinic, Witellikerstrasse 40, 8032, Zürich, Switzerland
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10
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Kawakami S, Tahara Y, Koga H, Noguchi T, Inoue S, Yasuda S. The association between time to extracorporeal cardiopulmonary resuscitation and outcome in patients with out-of-hospital cardiac arrest. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:279-289. [PMID: 35143634 DOI: 10.1093/ehjacc/zuac010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/06/2022] [Accepted: 01/23/2022] [Indexed: 01/11/2023]
Abstract
AIMS Extracorporeal cardiopulmonary resuscitation (ECPR) is considered for potentially reversible out-of-hospital cardiac arrest (OHCA). However, the association between time to ECPR and outcome has not been well established. METHODS AND RESULTS Between June 2014 and December 2017, we enrolled 34 754 OHCA patients in a multicentre, prospective fashion [Japanese Association for Acute Medicine (JAAM)-OHCA registry]. After the application of exclusion criteria, 695 OHCA patients who underwent ECPR for cardiac causes were eligible for this study. We investigated the association between the call-to-ECPR interval and favourable neurological outcome (cerebral performance category 1 or 2) at 30 days. Seventy-seven patients (11%) had a favourable neurological outcome at 30 days. The call-to-ECPR intervals in these patients were significantly shorter than in those with an unfavourable neurological outcome [49 (41-58) vs. 58 (48-68) min, respectively, P < 0.001]. A longer call-to-ECPR interval was associated with a smaller proportion of patients undergoing percutaneous coronary intervention (PCI) (P = 0.034) or target temperature management (TTM) (P < 0.001). Stepwise multivariable logistic regression analysis revealed that the call-to-ECPR interval was an independent predictor of favourable neurological outcome [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.94-0.99, P = 0.001], as were age, male gender, initial shockable rhythm, transient return of spontaneous circulation in the prehospital setting, arterial pH at hospital arrival, PCI (OR 2.30, 95% CI 1.14-4.66, P = 0.019), and TTM (OR 2.28, 95% CI 1.13-4.62, P = 0.019). CONCLUSION A shorter call-to-ECPR interval and implementation of PCI and TTM predicted a favourable neurological outcome at 30 days in OHCA patients who underwent ECPR for cardiac causes.
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Affiliation(s)
- Shoji Kawakami
- Department of Cardiology, Aso Iizuka Hospital, 3-83, Yoshio-machi, Iizuka, Fukuoka 820-8505, Japan.,Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hidenobu Koga
- Clinical Research Support Office, Aso Iizuka Hospital, 6-1, Kishibe-shinmachi, Suita, Osaka 564-8565, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shujiro Inoue
- Department of Cardiology, Aso Iizuka Hospital, 3-83, Yoshio-machi, Iizuka, Fukuoka 820-8505, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
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11
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Yang JZ, Odish MF, Mathers H, Pebley N, Wardi G, Papamatheakis DG, Poch DS, Kim NH, Fernandes TM, Sell RE. Outcomes of Cardiopulmonary Resuscitation in Patients with Pulmonary Arterial Hypertension. Pulm Circ 2022; 12:e12066. [PMID: 35514777 PMCID: PMC9063951 DOI: 10.1002/pul2.12066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jenny Z. Yang
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Mazen F. Odish
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Hannah Mathers
- School of Medicine. University of California San DiegoLa Jolla92037
| | - Nicole Pebley
- School of Medicine. University of California San DiegoLa Jolla92037
| | - Gabriel Wardi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Demosthenes G. Papamatheakis
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - David S. Poch
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Nick H. Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Timothy M. Fernandes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
| | - Rebecca E. Sell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine. University of California San DiegoLa JollaCA92037
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12
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Podell JE, Krause EM, Rector R, Hassan M, Reddi A, Jaffa MN, Morris NA, Herr DL, Parikh GY. Neurologic Outcomes After Extracorporeal Cardiopulmonary Resuscitation: Recent Experience at a Single High-Volume Center. ASAIO J 2022; 68:247-254. [PMID: 33927083 DOI: 10.1097/mat.0000000000001448] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR)-veno-arterial extracorporeal membrane oxygenation (ECMO) for refractory cardiac arrest-has grown rapidly, but its widespread adoption has been limited by frequent neurologic complications. With individual centers developing best practices, utilization may be increasing with an uncertain effect on outcomes. This study describes the recent ECPR experience at the University of Maryland Medical Center from 2016 through 2018, with attention to neurologic outcomes and predictors thereof. The primary outcome was dichotomized Cerebral Performance Category (≤2) at hospital discharge; secondary outcomes included rates of specific neurologic complications. From 429 ECMO runs over 3 years, 57 ECPR patients were identified, representing an increase in ECPR utilization compared with 41 cases over the previous 6 years. Fifty-two (91%) suffered in-hospital cardiac arrest, and 36 (63%) had an initial nonshockable rhythm. Median low-flow time was 31 minutes. Overall, 26 (46%) survived hospitalization and 23 (88% of survivors, 40% overall) had a favorable discharge outcome. Factors independently associated with good neurologic outcome included lower peak lactate, initial shockable rhythm, and higher initial ECMO mean arterial pressure. Neurologic complications occurred in 18 patients (32%), including brain death in 6 (11%), hypoxic-ischemic brain injury in 11 (19%), ischemic stroke in 6 (11%), intracerebral hemorrhage in 1 (2%), and seizure in 4 (7%). We conclude that good neurologic outcomes are possible for well-selected ECPR patients in a high-volume program with increasing utilization and evolving practices. Markers of adequate peri-resuscitation tissue perfusion were associated with better outcomes, suggesting their importance in neuroprognostication.
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Affiliation(s)
- Jamie E Podell
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Eric M Krause
- Division of Thoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Raymond Rector
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mubariz Hassan
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashwin Reddi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Matthew N Jaffa
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nicholas A Morris
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel L Herr
- Division of Surgical Critical Care, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gunjan Y Parikh
- From the Section of Neurocritical Care and Emergency Neurology, Department of Neurology, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
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13
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Aufderheide TP, Kalra R, Kosmopoulos M, Bartos JA, Yannopoulos D. Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death. Ann N Y Acad Sci 2022; 1507:37-48. [PMID: 33609316 PMCID: PMC8377067 DOI: 10.1111/nyas.14580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 01/03/2023]
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is an emerging method of cardiopulmonary resuscitation to improve outcomes from cardiac arrest. This approach targets patients with out-of-hospital cardiac arrest previously unresponsive and refractory to standard treatment, combining approximately 1 h of standard CPR followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) and coronary artery revascularization. Despite its relatively new emergence for the treatment of cardiac arrest, the approach is grounded in a vast body of preclinical and clinical data that demonstrate significantly improved survival and neurological outcomes despite unprecedented, prolonged periods of CPR. In this review, we detail the principles behind VA-ECMO-facilitated resuscitation, contemporary clinical approaches with outcomes, and address the emerging new understanding of the process of death and capability for neurological recovery.
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Affiliation(s)
- Tom P. Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Rajat Kalra
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Jason A. Bartos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
| | - Demetris Yannopoulos
- Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN,Cardiovascular Division, University of Minnesota, Minneapolis, MN
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14
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Shinar Z, Grunau B. ECPR for In- and Out-of-Hospital Cardiac Arrest: Siblings or Distant Cousins? Resuscitation 2021; 171:105-106. [PMID: 34958878 DOI: 10.1016/j.resuscitation.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Zachary Shinar
- Sharp Memorial Hospital, 7901 Frost St., San Diego, CA 92123, United States.
| | - Brian Grunau
- St. Paul's Hospital, Vancouver, British Columbia, Canada
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15
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Yeo JW, Ng ZHC, Goh AXC, Gao JF, Liu N, Lam SWS, Chia YW, Perkins GD, Ong MEH, Ho AFW. Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 11:e023806. [PMID: 34927456 PMCID: PMC9075197 DOI: 10.1161/jaha.121.023806] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background The role of cardiac arrest centers (CACs) in out‐of‐hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out‐of‐hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self‐declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta‐analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty‐six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52–2.26]), even when including high‐volume centers (aOR, 1.50 [95% CI, 1.18–1.91]) or including improved‐care centers (aOR, 2.13 [95% CI, 1.75–2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59–2.32]), even when including high‐volume centers (aOR, 1.74 [95% CI, 1.38–2.18]) or when including improved‐care centers (aOR, 1.97 [95% CI, 1.71–2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (P=0.006) and without prehospital return of spontaneous circulation (P=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out‐of‐hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.
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Affiliation(s)
- Jun Wei Yeo
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | - Zi Hui Celeste Ng
- Yong Loo Lin School of Medicine National University of Singapore Singapore
| | | | | | - Nan Liu
- Centre for Quantitative Medicine Duke-NUS Medical SchoolNational University of Singapore Singapore
| | - Shao Wei Sean Lam
- Health Services Research Centre SingHealth Duke-NUS Academic Medical Centre Singapore
| | - Yew Woon Chia
- Department of Cardiology Tan Tock Seng Hospital Singapore
| | - Gavin D Perkins
- Warwick Medical School University of Warwick Coventry United Kingdom
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine Singapore General Hospital Singapore.,Health Services & Systems Research Duke-NUS Medical School Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine Singapore General Hospital Singapore.,Pre-Hospital and Emergency Research Centre Health Services and Systems Research Duke-NUS Medical School Singapore
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16
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How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis. Am J Emerg Med 2021; 51:127-138. [PMID: 34735971 DOI: 10.1016/j.ajem.2021.08.072] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/17/2021] [Accepted: 08/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA. METHODS We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity. RESULTS We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies. CONCLUSIONS Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.
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17
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Kuroki N, Nagao K, Otsuka T, Kuwabara M, Nakata J, Takayama T, Hosokawa Y, Ashida T, Suzuki K, Yamamoto T, Takayama M. Combined use of venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump after cardiac arrest. Resuscitation 2021; 167:345-354. [PMID: 34314778 DOI: 10.1016/j.resuscitation.2021.07.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 07/02/2021] [Accepted: 07/15/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVES We investigated whether intra-aortic balloon pump (IABP) combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO) was associated with favourable neurological outcomes for patients after the return of spontaneous circulation (ROSC). Moreover, we evaluated the aetiology of cardiac arrest on the effectiveness of this therapy in a sub-study. BACKGROUND There is insufficient research on the optimal combination of machines for patients after ROSC is not established. METHODS This is a large-scale, multicentre, 30-day cohort study. Among 80,716 patients who delivered to the emergency room, 935 patients treated with VA-ECMO after ROSC were included using the data from the Tokyo Cardiovascular Care Unit Network Registry between 2010 and 2017. The study patients were stratified according to the use of IABP [the ECMO + IABP group (n = 762) vs. the ECMO-alone group (n = 173)]. We also evaluated the cause of cardiac arrest [acute coronary syndrome (ACS) and non-ACS] in the sub-study. To adjust the patients' backgrounds, we used the propensity score matching for additional analyses. The endpoint was 30-day favourable neurological outcome. RESULTS The ECMO + IABP group showed significantly better neurological outcomes than the ECMO-alone group (crude; 35% vs. 25%; log-lank P < 0.001). In the ACS subgroup, the ECMO + IABP group showed significantly better neurological outcome (crude; 34% vs. 18%; log-lank P < 0.001), but not in the non-ACS subgroup (crude; 38% vs. 32%; log-lank P = 0.11). These results are similar after adjustments to their backgrounds using propensity matching. CONCLUSIONS Compared to VA-ECMO alone, the combined use of VA-ECMO and IABP is associated with better neurological outcomes after ROSC, especially in complicated ACS.
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Affiliation(s)
- Norihiro Kuroki
- Tokyo CCU Network, Scientific Committee, Tokyo, Japan; Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan.
| | - Ken Nagao
- Tokyo CCU Network, Scientific Committee, Tokyo, Japan
| | - Toshiaki Otsuka
- Tokyo CCU Network, Scientific Committee, Tokyo, Japan; Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
| | | | - Jun Nakata
- Tokyo CCU Network, Scientific Committee, Tokyo, Japan
| | | | | | | | - Kou Suzuki
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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18
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Guru PK, Seelhammer TG, Singh TD, Sanghavi DK, Chaudhary S, Riley JB, Friedrich T, Stulak JM, Haile DT, Kashyap R, Schears GJ. Outcomes of adult patients supported by extracorporeal membrane oxygenation (ECMO) following cardiopulmonary arrest. The Mayo Clinic experience. J Card Surg 2021; 36:3528-3539. [PMID: 34250642 DOI: 10.1111/jocs.15804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/24/2021] [Accepted: 06/03/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION To describe our experience in use of extracorporeal life support (ECLS) as a rescue strategy in patients following cardiopulmonary resuscitation. METHODS A retrospective analysis was performed for patients (n = 101) who received ECLS after cardiorespiratory arrest between May 2001 and December 2014. The primary outcome was survival to hospital discharge. RESULTS In this cohort median (IQR) age was 56 (37-67) years, 53 (53%) were male, and 90 (89%) were Caucasian. Ventricular tachycardia or ventricular fibrillations were the initial cardiac rhythm in 49 (48.5%) and asystole/pulseless electrical activity in 37 (36.8%). Median (IQR) time to initiation of extracorporeal support from arrest time was 72 (43-170) min. The median (IQR) duration of support was 100 (47-157) hours. Renal failure (66%) and bleeding (66%) were the two most commonly observed complications during ECLS support. The survival to hospital discharge was seen in 47 (47%) patients, and good neurologic outcome (mRs 0-3) was seen in 29%. Acidosis, lactate and continuous renal replacement therapy were independent predictors of mortality. The median (IQR) intensive care unit stay was 14 (4-28) days and hospital stay was 17 (4-35) days. CONCLUSION Our institutional experience with ECLS as a rescue measure following cardiac arrest is associated with improvement in mortality, and favorable neurologic status at hospital discharge.
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Affiliation(s)
- Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Florida, USA
| | - Troy G Seelhammer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tarun D Singh
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Jeffrey B Riley
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Tammy Friedrich
- Department of Nursing, Mayo Clinic, Rochester, Minnesota, USA
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dawit T Haile
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Gregory J Schears
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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19
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A. Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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20
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Huang M, Shoskes A, Migdady I, Amin M, Hasan L, Price C, Uchino K, Choi CW, Hernandez AV, Cho SM. Does Targeted Temperature Management Improve Neurological Outcome in Extracorporeal Cardiopulmonary Resuscitation (ECPR)? J Intensive Care Med 2021; 37:157-167. [PMID: 34114481 DOI: 10.1177/08850666211018982] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE Targeted temperature management (TTM) is a standard of care in patients after cardiac arrest for neuroprotection. Currently, the effectiveness and efficacy of TTM after extracorporeal cardiopulmonary resuscitation (ECPR) is unknown. We aimed to compare neurological and survival outcomes between TTM vs non-TTM in patients undergoing ECPR for refractory cardiac arrest. METHODS We searched PubMed and 5 other databases for randomized controlled trials and observational studies reporting neurological outcomes or survival in adult patients undergoing ECPR with or without TTM. Good neurological outcome was defined as cerebral performance category <3. Two independent reviewers extracted the data. Random-effects meta-analyses were used to pool data. RESULTS We included 35 studies (n = 2,643) with the median age of 56 years (interquartile range [IQR]: 52-59). The median time from collapse to ECMO cannulation was 58 minutes (IQR: 49-82) and the median ECMO duration was 3 days (IQR: 2.0-4.1). Of 2,643, 1,329 (50.3%) patients received TTM and 1,314 (49.7%) did not. There was no difference in the frequency of good neurological outcome at any time between TTM (29%, 95% confidence interval [CI]: 23%-36%) vs. without TTM (19%, 95% CI: 9%-31%) in patients with ECPR (P = 0.09). Similarly, there was no difference in overall survival between patients with TTM (30%, 95% CI: 22%-39%) vs. without TTM (24%, 95% CI: 14%-34%) (P = 0.31). A cumulative meta-analysis by publication year showed improved neurological and survival outcomes over time. CONCLUSIONS Among ECPR patients, survival and neurological outcome were not different between those with TTM vs. without TTM. Our study suggests that neurological and survival outcome are improving over time as ECPR therapy is more widely used. Our results were limited by the heterogeneity of included studies and further research with granular temperature data is necessary to assess the benefit and risk of TTM in ECPR population.
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Affiliation(s)
- Merry Huang
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Aaron Shoskes
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Ibrahim Migdady
- Division of Neurocritical Care, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Moein Amin
- Department of Neurology, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Leen Hasan
- 7712University of Connecticut, Medicine Institute, Farmington, CT, USA
| | - Carrie Price
- Albert S. Cook Library, 1492Towson University, Towson, MD, USA
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Chun Woo Choi
- Division of Cardiac Surgery, 1500Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, 15504University of Connecticut School of Pharmacy, Storrs, CT, USA.,Vicerrectorado de Investigación, Universidad San Ignacio de Loyola (USIL), Lima, Peru, USA
| | - Sung-Min Cho
- Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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21
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Pozzi M, Grinberg D, Armoiry X, Flagiello M, Hayek A, Ferraris A, Koffel C, Fellahi JL, Jacquet-Lagrèze M, Obadia JF. Impact of a Modified Institutional Protocol on Outcomes After Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-Of-Hospital Cardiac Arrest. J Cardiothorac Vasc Anesth 2021; 36:1670-1677. [PMID: 34130897 DOI: 10.1053/j.jvca.2021.05.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/03/2021] [Accepted: 05/13/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To analyze the impact of the modification of the authors' institutional protocol on outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). DESIGN An observational analysis. The protocol complied with national recommendations. A further eligibility criterion was added since January 2015: the presence of sustained shockable rhythm at extracorporeal life support (ECLS) implantation. To assess the impact of this change, patients were divided into two groups: (1) from January 2010 to December 2014 (group A) and (2) from January 2015 to December 2019 (group B). The primary endpoint was survival to hospital discharge with good neurologic outcome. Predictors of survival were searched with multivariate analyses. SETTING University hospital. PARTICIPANTS Adult patients supported with ECPR for refractory OHCA. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From January 2010 to December 2019, 85 patients had ECLS for OHCA (group A, n = 68, 80%; group B, n = 17, 20%). The mean age was 42.4 years, 78.8% were male. The rate of implantation of ECLS was significantly lower in group B (p = 0.01). Mortality during ECLS support was significantly lower (58.8 v 86.8%; p = 0.008), and the weaning rate was significantly higher (41.2 v 13.2%; p = 0.008) in group B. Survival to discharge with good neurologic outcome was significantly improved (23.5 v 4.4%; p = 0.027) in group B. A sustained shockable rhythm was the only independent predictor of survival to hospital discharge with good neurologic outcome. CONCLUSIONS The modification of the authors' institutional protocol throughout the further criterion of sustained shockable rhythm yielded a favorable impact on outcomes after ECPR for OHCA.
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Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France.
| | - Daniel Grinberg
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Xavier Armoiry
- University of Lyon, School of Pharmacy (ISPB) / UMR CNRS 5510 MATEIS / "Edouard Herriot" Hospital, Pharmacy Department, Lyon, France
| | - Michele Flagiello
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Ahmad Hayek
- Department of Cardiology, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Arnaud Ferraris
- Department of Anaesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Catherine Koffel
- Department of Anaesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Jean Luc Fellahi
- Department of Anaesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | | | - Jean Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
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22
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Brain Injury and Neurologic Outcome in Patients Undergoing Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 48:e611-e619. [PMID: 32332280 DOI: 10.1097/ccm.0000000000004377] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation has shown survival benefit in select patients with refractory cardiac arrest but there is insufficient data on the frequency of different types of brain injury. We aimed to systematically review the prevalence, predictors of and survival from neurologic complications in patients who have undergone extracorporeal cardiopulmonary resuscitation. DATA SOURCES MEDLINE (PubMed) and six other databases (EMBASE, Cochrane Library, CINAHL Plus, Web of Science, and Scopus) from inception to August 2019. STUDY SELECTION Randomized controlled trials and observational studies in patients greater than 18 years old. DATA EXTRACTION Two independent reviewers extracted the data. Study quality was assessed by the Cochrane Risk of Bias tool for randomized controlled trials, the Newcastle-Ottawa Scale for cohort and case-control studies, and the Murad tool for case series. Random-effects meta-analyses were used to pool data. DATA SYNTHESIS The 78 studies included in our analysis encompassed 50,049 patients, of which 6,261 (12.5%) received extracorporeal cardiopulmonary resuscitation. Among extracorporeal cardiopulmonary resuscitation patients, the median age was 56 years (interquartile range, 52-59 yr), 3,933 were male (63%), 3,019 had out-of-hospital cardiac arrest (48%), and 2,289 had initial shockable heart rhythm (37%). The most common etiology of cardiac arrest was acute coronary syndrome (n = 1,657, 50% of reported). The median extracorporeal cardiopulmonary resuscitation duration was 3.2 days (interquartile range, 2.1-4.9 d). Overall, 27% (95% CI, 0.17-0.39%) had at least one neurologic complication, 23% (95% CI, 0.14-0.32%) hypoxic-ischemic brain injury, 6% (95% CI, 0.02-0.11%) ischemic stroke, 6% (95% CI, 0.01-0.16%) seizures, and 4% (95% CI, 0.01-0.1%) intracerebral hemorrhage. Seventeen percent (95% CI, 0.12-0.23%) developed brain death. The overall survival rate after extracorporeal cardiopulmonary resuscitation was 29% (95% CI, 0.26-0.33%) and good neurologic outcome was achieved in 24% (95% CI, 0.21-0.28%). CONCLUSIONS One in four patients developed acute brain injury after extracorporeal cardiopulmonary resuscitation and the most common type was hypoxic-ischemic brain injury. One in four extracorporeal cardiopulmonary resuscitation patients achieved good neurologic outcome. Further research on assessing predictors of extracorporeal cardiopulmonary resuscitation-associated brain injury is necessary.
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23
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Grunau B, Dainty K, MacRedmond R, McDonald K, Sasaki A, Sarti AJ, Shemie SD, Cheung A, Gill J. A qualitative exploratory case series of patient and family experiences with ECPR for out-of-hospital cardiac arrest. Resusc Plus 2021; 6:100129. [PMID: 34223386 PMCID: PMC8244414 DOI: 10.1016/j.resplu.2021.100129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Abstract
Objective There is currently no existing data examining the opinions of patients and families after treatment with extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). We sought to interview family members and patients to learn from their experiences and satisfaction with treatment. Methods We contacted family members and survivors for all cases treated with ECPR for refractory OHCA at St. Paul’s Hospital between January 2014 and July 2018. We performed semi-structured interviews with participants, specifically within the topics of: information sharing (including impressions of an ECPR informational pamphlet), prognostication, organ donation, and perceived value of ECPR. Due to low participant enrolment, we described all interviews in a narrative approach. Results Within the study period, there were 23 OHCAs treated with ECPR; two survivors and three family members agreed to participate. Participants were satisfied with the treatment provided, including information sharing and prognostication. There were mixed opinions about the best method of information-sharing (verbal vs written), as well as the timing of organ donation conversations. All participants believed ECPR for OHCA to be of high value. Conclusion Patient’s conveyed satisfaction with ECPR treatment, with mixed views on the best information sharing strategy. Further study is needed to define the optimal methods and timing for discussions of organ donation, especially for treatments of with a relatively low likelihood success.
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Affiliation(s)
- Brian Grunau
- Department of Emergency Medicine, University of British Columbia, Canada.,Centre for Health Evaluation & Outcome Sciences, Vancouver, B.C., Canada.,St. Paul's Hospital, Vancouver, B.C., Canada
| | - Katie Dainty
- North York General Hospital, Canada.,University of Toronto, Canada
| | - Ruth MacRedmond
- St. Paul's Hospital, Vancouver, B.C., Canada.,Division of Critical Care, University of British Columbia, Canada
| | - Ken McDonald
- St. Paul's Hospital, Vancouver, B.C., Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Canada
| | - Ayumi Sasaki
- Divison of Nephrology, University of British Columbia, Canada
| | - Aimee J Sarti
- Department of Critical Care, The Ottawa Hospital, General Campus, Ottawa, Ontario, Canada
| | - Sam D Shemie
- Division of Pediatric Critical Care, McGill University, Canada
| | - Anson Cheung
- St. Paul's Hospital, Vancouver, B.C., Canada.,Division of Cardiac Surgery, University of British Columbia, Canada
| | - John Gill
- Centre for Health Evaluation & Outcome Sciences, Vancouver, B.C., Canada.,St. Paul's Hospital, Vancouver, B.C., Canada.,Divison of Nephrology, University of British Columbia, Canada
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24
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Miyamoto Y, Matsuyama T, Goto T, Ohbe H, Kitamura T, Yasunaga H, Ohta B. Association between age and neurological outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: a nationwide multicentre observational study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 11:35-42. [PMID: 33880567 DOI: 10.1093/ehjacc/zuab021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 11/14/2022]
Abstract
AIMS Little is known about the difference in outcomes between young and old patients who received extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). Therefore, we aimed to investigate the differences in outcomes between those aged ≥75 years and <75 years who experienced OHCA and were resuscitated with ECPR. METHODS AND RESULTS We performed a secondary analysis of a nationwide prospective cohort study using the Japanese Association for Acute Medicine OHCA registry. We identified patients aged ≥18 years with OHCA who received ECPR. The patients were classified into three age groups (18-59 years, 60-74 years, and ≥75 years). The primary outcome was a 1-month neurological outcome. To examine the association between age and 1-month neurological outcome, we performed logistic regression analyses fitted with generalized estimating equations. From 2014 to 2017, we identified 875 OHCA patients aged ≥18 years who received ECPR. The proportion of patients who survived with favourable neurological outcome in the patients aged 18-59 years, 60-74 years, and ≥75 years were 15% (64/434), 8.9% (29/326), and 1.7% (2/115), respectively. In the multivariable analysis, compared with the age of 18-59 years, the proportions of favourable neurological outcomes were significantly lower in patients aged 60-74 years [adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.32-0.61] and those aged ≥75 years (adjusted OR, 0.26; 95% CI, 0.11-0.59). CONCLUSION Advanced age (age ≥75 years in particular) was significantly associated with poor neurological outcomes in patients with OHCA who received ECPR.
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Affiliation(s)
- Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan.,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 1130033, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 1130033, Japan.,TXP Medical Co. Ltd., Hongo 7-3-1, Bunkyo-ku, Tokyo 1138485, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 1130033, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University, 2-2 Yamada-Oka, Suita 5650871, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 1130033, Japan
| | - Bon Ohta
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kaji-cho 465, Kamigyo-ku, Kyoto 6028566, Japan
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25
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Grunau B, Shemie SD, Wilson LC, Dainty KN, Nagpal D, Hornby L, Lamarche Y, van Diepen S, Kanji HD, Gould J, Saczkowski R, Brooks SC. Current Use, Capacity, and Perceived Barriers to the Use of Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Canada. CJC Open 2021; 3:327-336. [PMID: 33778449 PMCID: PMC7985000 DOI: 10.1016/j.cjco.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/04/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Extracorporeal cardiopulmonary resuscitation (ECPR) is a therapeutic option for refractory cardiac arrest. We sought to perform an environmental scan to describe ECPR utilization in Canada and perceived barriers for application to out-of-hospital cardiac arrest (OHCA). METHODS This was a national cross-sectional study. We identified all cardiovascular surgery- and extracorporeal membrane oxygenation (ECMO)-capable hospitals in Canada and emergency medical services (EMS) agencies delivering patients to those centres. We requested the medical lead from each hospital's ECMO service and each EMS agency to submit data regarding ECMO and ECPR utilization, as well as perceived barriers to ECPR provision for OHCA. RESULTS We identified and received survey data from 39 of 39 Canadian hospital institutions and 21 of 22 EMS agencies. Of hospitals, 38 (97%) perform ECMO and 27 (69%) perform ECPR (74% of which perform ≤5 cases per year). Of the 18 (46%) sites offering ECPR for OHCA, 8 apply a formal protocol for eligibility and initiation procedures. EMS agencies demonstrate heterogeneity with intra-arrest transport practices. The primary rationale for nontransport of refractory OHCA is that hospital-based care offers no additional therapies. Perceived barriers to the use of ECPR for OHCA were primarily related to limited evidence supporting its use, rather than resources required. CONCLUSION Many Canadian cardiovascular surgery- or ECMO-equipped hospitals use ECPR; roughly half employ ECPR for OHCAs. Low case volumes and few formal protocols indicate that this is not a standardized therapy option in most centres. Increased application may be dependent on a stronger evidence base including data from randomized clinical trials currently underway.
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Affiliation(s)
- Brian Grunau
- Department of Emergency Medicine and Centre for Health Evaluation and Outcome Sciences, University of British Columbia and St Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Sam D. Shemie
- Division of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
- Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada
| | | | - Katie N. Dainty
- Patient-Centred Outcomes, North York General Hospital, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dave Nagpal
- Divisions of Cardiac Surgery and Critical Care Medicine, Western University, London, Ontario, Canada
| | - Laura Hornby
- Deceased Donation, Canadian Blood Services, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Yoan Lamarche
- Divisions of Cardiac Surgery and Critical Care Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Hussein D. Kanji
- Division of Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Gould
- Department of Emergency Medicine, Dalhousie University, Saint John, New Brunswick, Canada
| | - Richard Saczkowski
- Division of Cardiac Surgery, Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - Steven C. Brooks
- Department of Emergency Medicine, Queen’s University, Kingston, Ontario, Canada
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26
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Miraglia D, Ayala JE. Extracorporeal cardiopulmonary resuscitation for adults with shock-refractory cardiac arrest. J Am Coll Emerg Physicians Open 2021; 2:e12361. [PMID: 33506232 PMCID: PMC7813516 DOI: 10.1002/emp2.12361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/28/2020] [Accepted: 12/23/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation has increasingly emerged as a feasible treatment to mitigate the progressive multiorgan dysfunction that occurs during cardiac arrest, in support of further resuscitation efforts. OBJECTIVES Because the recent systematic review commissioned in 2018 by the International Liaison Committee on Resuscitation Advanced Life Support task did not include studies without a control group, our objective was to conduct a review incorporating these studies to increase available evidence supporting the use of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest patients, while waiting for high-quality evidence from randomized controlled trials (RCTs). METHODS MEDLINE, Embase, and Science Citation Index (Web of Science) were searched for eligible studies from database inception to July 20, 2020. The population of interest was adult patients who had suffered cardiac arrest in any setting. We included all cohort studies with 1 exposure/1 group and descriptive studies (ie, case series studies). We excluded RCTs, non-RCTs, and observational analytic studies with a control group. Outcomes included short-term survival and favorable neurological outcome. Short-term outcomes (ie, hospital discharge, 30 days, and 1 month) were combined into a single category. RESULTS Our searches of databases and other sources yielded a total of 4302 citations. Sixty-two eligible studies were included (including a combined total of 3638 participants). Six studies were of in-hospital cardiac arrest, 34 studies were of out-of-hospital cardiac arrest, and 22 studies included both in-hospital and out-of-hospital cardiac arrest. Seven hundred and sixty-eight patients of 3352 (23%) had short-term survival; whereas, 602 of 3366 (18%) survived with favorable neurological outcome, defined as a cerebral performance category score of 1 or 2. CONCLUSIONS Current clinical evidence is mostly drawn from observational studies, with their potential for confounding selection bias. Although studies without controls cannot supplant case-control or cohort studies, several ECPR studies without a control group show successful resuscitation with impressive results that may provide valuable information to inform a comparison.
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Affiliation(s)
- Dennis Miraglia
- Department of Emergency MedicineSan Francisco HospitalSan JuanPuerto RicoUSA
| | - Jonathan E. Ayala
- Department of Emergency MedicineGood Samaritan HospitalAguadillaPuerto RicoUSA
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27
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Miraglia D, Miguel LA, Alonso W. Long-term neurologically intact survival after extracorporeal cardiopulmonary resuscitation for in-hospital or out-of-hospital cardiac arrest: A systematic review and meta-analysis. Resusc Plus 2020; 4:100045. [PMID: 34223320 PMCID: PMC8244502 DOI: 10.1016/j.resplu.2020.100045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used as extracorporeal cardiopulmonary resuscitation (ECPR) to support further resuscitation efforts in patients with cardiac arrest, yet its clinical effectiveness remains uncertain. OBJECTIVES This study reviews the role of ECPR in contemporary resuscitation care compared to no ECPR and/or standard care, e.g. conventional CPR, and quantitatively summarize the rates of long-term neurologically intact survival after adult in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA). METHODS We searched the following databases on January 31 st, 2020: CENTRAL, MEDLINE, Embase, and Web of Science. We followed PRISMA guidelines and used PICO format to summarize the research questions. Risk of bias was assessed using the ROBINS-I tool. Pooled risk ratios (RRs) for each outcome of interest were calculated. Quality of evidence was evaluated according to GRADE guidelines. RESULTS Six cohort studies were included, totaling 1750 patients. Of these, 530 (30.3%) received the intervention, and 91 (17.2%) survived with long-term neurologically intact survival. ECPR compared to no ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest in any setting (risk ratio [RR] 3.11, 95% confidence interval [CI] 2.06-4.69; p < 0.00001) (GRADE: Very low quality). Similar results were found for long-term neurologically intact survival after IHCA (RR 3.21, 95% CI 1.74-5.94; p < 0.0002) (GRADE: Very low quality) and OHCA (RR 3.11, 95% CI 1.50-6.47; p < 0.002) (GRADE: Very low quality). Long-term time frames for neurologically intact survival (three months to two years) were combined into a single category, defined a priori as a Glasgow-Pittsburgh cerebral performance category (CPC) of 1 or 2. CONCLUSIONS VA-ECMO used as ECPR is likely associated with improved long-term neurologically intact survival after cardiac arrest. Future evidence from randomized trials is very likely to have an important impact on the estimated effect of this intervention and will further define optimal clinical practice. Review registration: PROSPERO CRD42020171945.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Lourdes A. Miguel
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Wilfredo Alonso
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
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28
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Outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation for In-Hospital Cardiac Arrest. Cardiol Rev 2020; 30:75-79. [PMID: 33165089 DOI: 10.1097/crd.0000000000000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used in cardiac arrest. Currently, public registries report the outcomes of cardiac arrest regardless of the setting (out-of-hospital versus in-hospital). Meanwhile, in-hospital cardiac arrest represents a more favorable setting for ECMO-assisted cardiopulmonary resuscitation than out-of-hospital cardiac arrest. Survival to discharge varies, but looks promising overall, ranging from 18.9 to 65%, with the bulk of the studies reporting survival to discharge between 30% and 50%, with about one-third to half of the patients discharged with no or minimal neurologic deficit. Based on the reported outcomes, in-hospital cardiac arrests can become a next focus for studies on successful implementation of VA ECMO.
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29
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Hryniewicz K, Hart M, Raile D, Wang Y, Mooney M, Mudy K, Eckman PM, Samara MA, Traverse J, Sun B, Williams DM, Wilson KJ, Pavlovec M, Kunz M, Lyon D, Chavez I. Multidisciplinary shock team is associated with improved outcomes in patients undergoing ECPR. Int J Artif Organs 2020; 44:310-317. [PMID: 33028139 DOI: 10.1177/0391398820962807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Veno-arterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly used in cardiopulmonary resuscitation (ECPR) in select patients. Few centers have published their experience or outcomes with ECPR. The aim of our study was to evaluate outcomes of adult patients in cardiac arrest placed on VA ECMO in the catheterization laboratory. METHODS We performed a retrospective analysis of adult patients in refractory cardiac arrest who underwent ECPR at the Minneapolis Heart Institute (MHI) at Abbott Northwestern Hospital from January 2012 to December 2017. Relevant data were obtained from electronic medical records, including arrest to ECMO flow time, total ECMO support time, and outcomes. RESULTS Twenty-six adult patients underwent ECPR at the study site during the defined time period. Seven patients (27%) sustained cardiac arrest out of hospital, 19 patients arrested in-hospital with eight of those occurring in the catheterization laboratory. Seventeen (65%) patients had initial rhythm of ventricular fibrillation or tachycardia (VF/VT). All patients underwent mechanical CPR with LUCAS device. Overall 30 day and 6 month survival was 69%. Median time from arrest to ECMO flow was 46 mins (21,68) vs 61 mins (36,71) in survivors and non-survivors, respectively. Sixteen of 18 survivors discharged with a CPC score of 1 or 2. CONCLUSIONS We demonstrate that adult patients in cardiac arrest initiated on VA ECMO in the cardiac catheterization laboratory and cared for by a multidisciplinary shock team in the critical care unit have superior long-term survival and functionally favorable neurologic recovery when compared to current literature.
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Affiliation(s)
- Katarzyna Hryniewicz
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Michael Hart
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - David Raile
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Yale Wang
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Michael Mooney
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Karol Mudy
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Peter M Eckman
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Michael A Samara
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Jay Traverse
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Benjamin Sun
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | | | - Kelly J Wilson
- Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Matthew Pavlovec
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Miranda Kunz
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Danielle Lyon
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Ivan Chavez
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, USA
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Gravesteijn BY, Schluep M, Disli M, Garkhail P, Dos Reis Miranda D, Stolker RJ, Endeman H, Hoeks SE. Neurological outcome after extracorporeal cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis. Crit Care 2020; 24:505. [PMID: 32807207 PMCID: PMC7430015 DOI: 10.1186/s13054-020-03201-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 07/26/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In-hospital cardiac arrest (IHCA) is a major adverse event with a high mortality rate if not treated appropriately. Extracorporeal cardiopulmonary resuscitation (ECPR), as adjunct to conventional cardiopulmonary resuscitation (CCPR), is a promising technique for IHCA treatment. Evidence pertaining to neurological outcomes after ECPR is still scarce. METHODS We performed a comprehensive systematic search of all studies up to December 20, 2019. Our primary outcome was neurological outcome after ECPR at any moment after hospital discharge, defined by the Cerebral Performance Category (CPC) score. A score of 1 or 2 was defined as favourable outcome. Our secondary outcome was post-discharge mortality. A fixed-effects meta-analysis was performed. RESULTS Our search yielded 1215 results, of which 19 studies were included in this systematic review. The average survival rate was 30% (95% CI 28-33%, I2 = 0%, p = 0.24). In the surviving patients, the pooled percentage of favourable neurological outcome was 84% (95% CI 80-88%, I2 = 24%, p = 0.90). CONCLUSION ECPR as treatment for in-hospital cardiac arrest is associated with a large proportion of patients with good neurological outcome. The large proportion of favourable outcome could potentially be explained by the selection of patients for treatment using ECPR. Moreover, survival is higher than described in the conventional CPR literature. As indications for ECPR might extend to older or more fragile patient populations in the future, research should focus on increasing survival, while maintaining optimal neurological outcome.
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Affiliation(s)
- Benjamin Yaël Gravesteijn
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands.
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands.
| | - Marc Schluep
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | - Maksud Disli
- Erasmus University Medical Centre School of Medicine, Rotterdam, The Netherlands
| | - Prakriti Garkhail
- Erasmus University Medical Centre School of Medicine, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Robert-Jan Stolker
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sanne Elisabeth Hoeks
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Miraglia D, Miguel LA, Alonso W. Extracorporeal cardiopulmonary resuscitation for in- and out-of-hospital cardiac arrest: systematic review and meta-analysis of propensity score-matched cohort studies. J Am Coll Emerg Physicians Open 2020; 1:342-361. [PMID: 33000057 PMCID: PMC7493557 DOI: 10.1002/emp2.12091] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/25/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION In this systematic review and meta-analysis of propensity score-matched cohort studies, we quantitatively summarize whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) used as extracorporeal cardiopulmonary resuscitation (ECPR), compared with conventional cardiopulmonary resuscitation (CCPR), is associated with improved rates of 30-day and long-term favorable neurological outcomes and survival in patients resuscitated from in- and out-of-hospital cardiac arrest. METHODS We searched MEDLINE via PubMed, Embase, Scopus, and Google Scholar for eligible studies on January 14, 2019. All searches were limited to studies published between January 2000 and January 2019. Two investigators independently evaluated the quality (or certainty) of evidence according to GRADE guidelines. Pooled results are presented as relative risks (RRs) with 95% confidence intervals (CIs). RESULTS Six cohort studies using propensity score-matched analysis were included, totaling 1108 matched patients. Pooled analyses showed that ECPR was likely associated with improved 30-day and long-term favorable neurological outcome in adults compared to CCPR for in- and out-of-hospital cardiac arrest (RR = 2.02, 95% CI = 1.29-3.16; I2 = 20%, P = 0.002; very low-quality evidence) and (RR = 2.86, 95% CI = 1.64-5.01; I2 = 0%, P = 0.0002; moderate-quality evidence), respectively. When we analyzed in- and out-of-hospital cardiac arrest separately, ECPR was likely associated with improved 30-day favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.18, 95% CI = 1.24-3.81; I2 = 9%, P = 0.006; very low-quality evidence), but not for out-of-hospital cardiac arrest (RR = 2.61, 95% CI = 0.56-12.20; I2 = 59%, P = 0.22; very low-quality evidence). ECPR was also likely associated with improved long-term favorable neurological outcome compared to CCPR for in-hospital cardiac arrest (RR = 2.50, 95% CI = 1.33-4.71; I2 = 0%, P = 0.005; moderate-quality evidence) and out-of-hospital cardiac arrest (RR = 4.64, 95% CI = 1.41-15.25; I2 = 0%, P = 0.01; moderate-quality evidence). CONCLUSIONS Our analysis suggests that VA-ECMO used as ECPR may improve long-term favorable neurological outcomes and survival when compared to the best standard of care in a selected patient population. Therefore, it is imperative for well-designed randomized clinical trials to obtain a higher level of scientific evidence to ensure optimal outcomes for cardiac arrest patients.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Lourdes A Miguel
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
| | - Wilfredo Alonso
- Department of Internal Medicine Good Samaritan Hospital Aguadilla Puerto Rico USA
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Murakami N, Kokubu N, Nagano N, Nishida J, Nishikawa R, Nakata J, Suzuki Y, Tsuchihashi K, Narimatsu E, Miura T. Prognostic Impact of No-Flow Time on 30-Day Neurological Outcomes in Patients With Out-of-Hospital Cardiac Arrest Who Received Extracorporeal Cardiopulmonary Resuscitation. Circ J 2020; 84:1097-1104. [DOI: 10.1253/circj.cj-19-1177] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Naoto Murakami
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Nobuaki Kokubu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Nobutaka Nagano
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | | | - Ryo Nishikawa
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Jun Nakata
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Yohei Suzuki
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Kazufumi Tsuchihashi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
- Division of Health Care Administration and Management, Sapporo Medical University School of Medicine
| | - Eichi Narimatsu
- Department of Emergency Medicine and Advanced Critical Care and Emergency Center, Sapporo Medical University School of Medicine
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
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Extracorporeal membrane oxygenation for refractory cardiac arrest: a retrospective multicenter study. Intensive Care Med 2020; 46:973-982. [DOI: 10.1007/s00134-020-05926-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 01/08/2020] [Indexed: 11/26/2022]
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Chen X, Zhen Z, Na J, Wang Q, Gao L, Yuan Y. Associations of therapeutic hypothermia with clinical outcomes in patients receiving ECPR after cardiac arrest: systematic review with meta-analysis. Scand J Trauma Resusc Emerg Med 2020; 28:3. [PMID: 31937354 PMCID: PMC6961259 DOI: 10.1186/s13049-019-0698-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 12/30/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia has been recommended for eligible patients after cardiac arrest (CA) in order to improve outcomes. Up to now, several comparative observational studies have evaluated the combined use of extracorporeal cardiopulmonary resuscitation (ECPR) and therapeutic hypothermia in adult patients with CA. However, the effects of therapeutic hypothermia in adult CA patients receiving ECPR are inconsistent. METHODS Relevant studies in English databases (PubMed, ISI web of science, OVID, and Embase) were systematically searched up to September 2019. Odds ratios (ORs) from eligible studies were extracted and pooled to summarize the associations of therapeutic hypothermia with favorable neurological outcomes and survival in adult CA patients receiving ECPR. RESULTS 13 articles were included in the present meta-analysis study. There were nine studies with a total of 806 cases reporting the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Pooling analysis suggested that therapeutic hypothermia was significantly associated with favorable neurological outcomes in overall (N = 9, OR = 3.507, 95%CI = 2.194-5.607, P < 0.001, fixed-effects model) and in all subgroups according to control type, regions, sample size, CA location, ORs obtained methods, follow-up period, and modified Newcastle Ottawa Scale (mNOS) scores. There were nine studies with a total of 806 cases assessing the association of therapeutic hypothermia with survival in CA patients receiving ECPR. After pooling the ORs, therapeutic hypothermia was found to be significantly associated with survival in overall (N = 9, OR = 2.540, 95%CI = 1.245-5.180, P = 0.010, random-effects model) and in some subgroups. Publication bias was found when evaluating the association of therapeutic hypothermia with neurological outcomes in CA patients receiving ECPR. Additional trim-and-fill analysis estimated four "missing" studies, which adjusted the effect size to 2.800 (95%CI = 1.842-4.526, P < 0.001, fixed-effects model) for neurological outcomes. CONCLUSIONS Therapeutic hypothermia may be associated with favorable neurological outcomes and survival in adult CA patients undergoing ECPR. However, the result should be treated carefully because it is a synthesis of low-level evidence and other limitations exist in present study. It is necessary to perform randomized controlled trials to validate our result before considering the result in clinical practices.
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Affiliation(s)
- Xi Chen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Zhen Zhen
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Jia Na
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Qin Wang
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Lu Gao
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
| | - Yue Yuan
- Department of Cardiology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No. 56, Nanlishilu, District Xicheng, Beijing, 100045 China
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Miraglia D, Miguel LA, Alonso W. The evolving role of novel treatment techniques in the management of patients with refractory VF/pVT out-of-hospital cardiac arrest. Am J Emerg Med 2019; 38:648-654. [PMID: 31836341 DOI: 10.1016/j.ajem.2019.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/22/2019] [Accepted: 11/02/2019] [Indexed: 01/07/2023] Open
Abstract
STUDY OBJECTIVES The purpose of this review is to provide a brief overview of new life-saving interventions and novel techniques that have been proposed as viable treatment options for patients presenting with refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) out-of-hospital cardiac arrest (OHCA). METHODS We conducted a comprehensive literature search of PubMed recent, Medline and Embase databases via the Ovid interface and Google Scholar from inception to July 2019. Eligible studies were observational in nature reporting outcomes of extracorporeal membrane oxygenation (ECMO), esmolol, double sequential defibrillation (DSD), and stellate ganglion block (SGB). Two investigators conducted the literature search, study selection, and data extraction. Any disagreements were resolved by consensus. RESULTS Our database search identified 5331 records. We included in our review 23 articles that met our inclusion criteria. The selected studies included 16 observational studies on ECMO, 2 observational studies on esmolol, and 5 observational studies on DSD. CONCLUSION We would like to suggest that there is not enough evidence in the existing literature to support at large-scale the effects of these techniques in the treatment of refractory VF/pVT OHCA. Randomized studies are warranted to evaluate the significant effects of these approaches against the best current standard of care.
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Affiliation(s)
- Dennis Miraglia
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States.
| | - Lourdes A Miguel
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
| | - Wilfredo Alonso
- Department of Internal Medicine, Good Samaritan Hospital, Aguadilla, PR, United States
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Liu B, Zhang Q, Liang Y, Zhang Y, Yuan X, Ling J, Li C. Extracorporeal membrane oxygenation mitigates myocardial injury and improves survival in porcine model of ventricular fibrillation cardiac arrest. Scand J Trauma Resusc Emerg Med 2019; 27:82. [PMID: 31462264 PMCID: PMC6714103 DOI: 10.1186/s13049-019-0653-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/01/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Despite decades of improved strategy in conventional cardiopulmonary resuscitation (CCPR), survival rates of favorable neurological outcome after cardiac arrest (CA) remains poor. It is indicated that the survival rate of successful resuscitation of extracorporeal membrane oxygenation (ECMO) is superior to that of CCPR. But the effect of ECMO in heart is unclear. We aimed to investigate whether ECMO produces cardiac protection by ameliorating post-ischemia reperfusion myocardial injury and myocardial apoptosis. METHODS After undergoing 8-min untreated ventricle fibrillation (VF) and 6-min basic life support, 20 male pigs were ultimately used in this study and randomly divided into two groups: CCPR group (n = 10) and extracorporeal CPR (ECPR) group (n = 10). Hemodynamics and blood samples were obtained at baseline and 1, 2, 4, and 6 h during resuscitation. The successfully resuscitated pigs were sacrificed at 6 h after return of spontaneous circulation (ROSC), and the hearts were removed and analyzed under electron microscopy, and immunohistochemistry, quantitative real-time polymerase chain reaction, and immunofluorescence staining assay were performed to evaluate myocardial injury and myocardial apoptosis. RESULTS There were no significant differences at basic hemodynamic status between the two groups. The survival rate of ECPR was significantly higher than CCPR group (10/10 [100%] vs. 4/10 [40%], P = 0.04). Compared to CCPR group, ECPR group exhibited a better outcome in hemodynamic function. Cardiac function was significantly impaired after ROSC in both groups, but left ventricular ejection fraction (LVEF) was significantly elevated in ECPR group than CCPR group. The expression of myocardial injury biomarkers (CK-MB, cTNI, H-FABP), endothelial injury biomarker (sP-selectin), and cardiac function biomarker (BNP) were remarkably increased after ROSC in both groups, but low levels in ECPR group than in CCPR group. Cardiomyocytes injury was attenuated in ECPR group under transmission electron microscopy (TEM). Typical apoptotic nuclei of cardiomyocytes were significantly reduced and oxidative damage were attenuated in ECPR group. CONCLUSIONS During prolonged VF-induced CA, ECPR contributes to improving hemodynamics, attenuating myocardial ischemia-reperfusion injury, ameliorating myocardial ultra structure, improving cardiac function, and elevating survival rate by preventing oxidative damage, regulating energy metabolism, inhibiting cardiomyocyte apoptosis.
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Affiliation(s)
- Bo Liu
- grid.411607.5Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8# Worker’s Stadium South Road, Chao-Yang District, Beijing, 100020 China
| | - Qiang Zhang
- grid.411607.5Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8# Worker’s Stadium South Road, Chao-Yang District, Beijing, 100020 China
| | - Yong Liang
- grid.411607.5Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8# Worker’s Stadium South Road, Chao-Yang District, Beijing, 100020 China
| | - Yun Zhang
- grid.411607.5Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8# Worker’s Stadium South Road, Chao-Yang District, Beijing, 100020 China
| | - Xiaoli Yuan
- grid.411607.5Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8# Worker’s Stadium South Road, Chao-Yang District, Beijing, 100020 China
| | - Jiyang Ling
- grid.411607.5Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8# Worker’s Stadium South Road, Chao-Yang District, Beijing, 100020 China
| | - Chunsheng Li
- grid.411607.5Department of Emergency Medicine, Beijing Chao-Yang Hospital, Capital Medical University, 8# Worker’s Stadium South Road, Chao-Yang District, Beijing, 100020 China
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Lunz D, Philipp A, Müller T, Pfister K, Foltan M, Rupprecht L, Schmid C, Lubnow M, Graf B, Sinner B. Ischemia-related vascular complications of percutaneously initiated venoarterial extracorporeal membrane oxygenation: Indication setting, risk factors, manifestation and outcome. J Crit Care 2019; 52:58-62. [DOI: 10.1016/j.jcrc.2019.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/18/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
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Awwad S, Tarvade S, Piccardi M, Gattas DJ. The use of privacy-protected computer vision to measure the quality of healthcare worker hand hygiene. Int J Qual Health Care 2019; 31:36-42. [PMID: 29767747 DOI: 10.1093/intqhc/mzy099] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 03/23/2018] [Accepted: 04/20/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES (i) To demonstrate the feasibility of automated, direct observation and collection of hand hygiene data, (ii) to develop computer visual methods capable of reporting compliance with moment 1 (the performance of hand hygiene before touching a patient) and (iii) to report the diagnostic accuracy of automated, direct observation of moment 1. DESIGN Observation of simulated hand hygiene encounters between a healthcare worker and a patient. SETTING Computer laboratory in a university. PARTICIPANTS Healthy volunteers. MAIN OUTCOME MEASURES Sensitivity and specificity of automatic detection of the first moment of hand hygiene. METHODS We captured video and depth images using a Kinect camera and developed computer visual methods to automatically detect the use of alcohol-based hand rub (ABHR), rubbing together of hands and subsequent contact of the patient by the healthcare worker using depth imagery. RESULTS We acquired images from 18 different simulated hand hygiene encounters where the healthcare worker complied with the first moment of hand hygiene, and 8 encounters where they did not. The diagnostic accuracy of determining that ABHR was dispensed and that the patient was touched was excellent (sensitivity 100%, specificity 100%). The diagnostic accuracy of determining that the hands were rubbed together after dispensing ABHR was good (sensitivity 83%, specificity 88%). CONCLUSIONS We have demonstrated that it is possible to automate the direct observation of hand hygiene performance in a simulated clinical setting. We used cheap, widely available consumer technology and depth imagery which potentially increases clinical application and decreases privacy concerns.
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Affiliation(s)
- Sari Awwad
- Faculty of Engineering and IT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Sanjay Tarvade
- Intensive Care Unit, Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, Australia
| | - Massimo Piccardi
- Faculty of Engineering and IT, University of Technology Sydney, Ultimo, NSW, Australia
| | - David J Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, Australia
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Formica F, D’Alessandro S, Sangalli F, Avalli L. Distal limb perfusion cannula in peripheral extracorporeal membrane oxygenation: always a mandatory approach? Perfusion 2019; 34:528-529. [DOI: 10.1177/0267659119855846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Francesco Formica
- Cardiac Surgery Unit, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Stefano D’Alessandro
- Surgery Unit, Cardio-Thoracic-Vascular Department, San Gerardo Hospital, Monza, Italy
| | - Fabio Sangalli
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, Monza, Italy
| | - Leonello Avalli
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, Monza, Italy
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Karsan RB, Powell AG, Nanjaiah P, Mehta D, Valtzoglou V. The top 100 manuscripts in emergency cardiac surgery. Potential role in cardiothoracic training. A bibliometric analysis. Ann Med Surg (Lond) 2019; 43:5-12. [PMID: 31193454 PMCID: PMC6531840 DOI: 10.1016/j.amsu.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/29/2019] [Accepted: 05/09/2019] [Indexed: 12/15/2022] Open
Abstract
Background Emergency Cardiac Surgery (ECS) is a component of cardiothoracic training. Citations are considered to represent a papers influence. Bibliometric analyses allow us to identify the most influential work, and future research. We aim to highlight the key research themes within ECS and determine their potential impact on cardiothoracic training. Methods Thomas Reuters Web of Science was searched using terms [Emergency AND Card* AND Surg*]. Results were ranked by citation and reviewed by a panel of cardiac surgeons to identify the top 100 cited papers relevant to ECS. Papers were analysed by topic, journal and impact. Regression analysis was used to determine a link between impact factor and scientific impact. Results 3823 papers were identified. Median citations for the top 100 was 88. The paper with the highest impact was by Nashef et al. focusing on the use of EuroSCORE (2043 citations). The Annals of Thoracic Surgery published most papers (n = 18:1778 citations). The European Journal of Cardiothoracic Surgery coveted the most citations (n = 2649). The USA published most papers (n = 55).The most ubiquitous topics were; risk stratification, circulatory support and aortic surgery. A positive relationship between journal impact fact and the scientific impact of manuscripts in ECS (P = 0.043) was deduced. Conclusion This study is the first of its kind and identified the papers which are likely to the contribute most to training and understanding of ECS. A papers influence is partially determined by journal impact factor. Bibliometric analysis is a potent tool to identify surgical training needs.
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Affiliation(s)
- Rickesh B Karsan
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Arfon Gmt Powell
- Division of Cancer and Genetics, Cardiff University, Heath Park, Cardiff, CF14 4XW, UK.,Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Prakash Nanjaiah
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Dheeraj Mehta
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
| | - Vasileious Valtzoglou
- Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
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Haldenwang PL, Baumann A, Elghannam M, Schlömicher M, Buchwald D, Klak K, Strauch JT. Two-stage weaning strategy using veno-veno-arterial perfusion for patients on extracorporeal membrane oxygenation following cardiogenic shock. Perfusion 2019; 34:689-695. [DOI: 10.1177/0267659119841862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: Veno-arterial extracorporeal membrane oxygenation represents the last therapy option in refractory cardiogenic shock. Successful weaning becomes difficult if the myocardial function recovers but pulmonary impairment persists. We present our experience with a new weaning strategy, using a stepwise mode-switch from veno-arterial to veno-veno-arterial and veno-venous extracorporeal membrane oxygenation setting for patients with primary cardiogenic shock and subsequent respiratory failure. Methods: From 81 patients treated with veno-arterial extracorporeal membrane oxygenation following acute cardiogenic shock between January 2014 and April 2018, eight patients with cardiac and pulmonary failure were identified to be treated using the following protocol: patients were put on veno-arterial extracorporeal membrane oxygenation, a second inflow cannula was inserted via the right jugular vein and cardiac weaning was performed via veno-veno-arterial support. Finally, patients were pulmonary weaned via veno-venous extracorporeal membrane oxygenation mode. Results: In the mode-switch group, etiologies of cardiogenic shock were cardiac arrest (12.5%), myocardial infarction (12.5%) and post-cardiotomic heart failure (75%). Mean time between onset of cardiogenic shock and start of veno-arterial extracorporeal membrane oxygenation was 76 ± 117 min. At implantation, lactate and pH values were 9.5 ± 5.0 mmol/L and 7.2 ± 0.2. Total extracorporeal membrane oxygenation-time was 9.3 ± 4.7 days, with a mode-switch from veno-arterial to veno-veno-arterial after 3.9 ± 2.7 days. The weaning rate in the mode-switch group was 75% (vs. 41% in the entire cohort) and the 30-day survival was 50% (vs 32% in the cohort). 38% of the patients presented a favorable neurological outcome. Conclusion: Mode-switch from veno-arterial to veno-veno-arterial and weaning via veno-venous extracorporeal membrane oxygenation mode is feasible for combined cardiac and pulmonary failure, with promising results due to an optimized pre-pulmonary oxygenation.
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Affiliation(s)
- Peter Lukas Haldenwang
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Andreas Baumann
- Department of Anesthesiology, Intensive Care, Palliative Care and Pain Medicine, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Mahmoud Elghannam
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Markus Schlömicher
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Krzysztof Klak
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
| | - Justus Thomas Strauch
- Department of Cardiothoracic Surgery, BG University Hospital Bergmannsheil, Ruhr-University of Bochum, Bochum, Germany
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Yannopoulos D, Bartos JA, Aufderheide TP, Callaway CW, Deo R, Garcia S, Halperin HR, Kern KB, Kudenchuk PJ, Neumar RW, Raveendran G. The Evolving Role of the Cardiac Catheterization Laboratory in the Management of Patients With Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e530-e552. [DOI: 10.1161/cir.0000000000000630] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.
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Lactate Clearance Predicts Good Neurological Outcomes in Cardiac Arrest Patients Treated with Extracorporeal Cardiopulmonary Resuscitation. J Clin Med 2019; 8:jcm8030374. [PMID: 30889788 PMCID: PMC6462911 DOI: 10.3390/jcm8030374] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background: We evaluated critically ill patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) due to cardiac arrest (CA) with respect to baseline characteristics and laboratory assessments, including lactate and lactate clearance for prognostic relevance. Methods: The primary endpoint was 30-day mortality. The impact on 30-day mortality was assessed by uni- and multivariable Cox regression analyses. Neurological outcome assessed by Glasgow Outcome Scale (GOS) was pooled into two groups: scores of 1–3 (bad GOS score) and scores of 4–5 (good GOS score). Results: A total of 93 patients were included in the study. Serum lactate concentration (hazard ratio (HR) 1.09; 95% confidence interval (CI) 1.04–1.13; p < 0.001), hemoglobin, (Hb; HR 0.87; 95% CI 0.79–0.96; p = 0.004), and catecholamine use were associated with 30-day-mortality. In a multivariable model, only lactate clearance (after 6 h; OR 0.97; 95% CI 0.94–0.997; p = 0.03) was associated with a good GOS score. The optimal cut-off of lactate clearance at 6 h for the prediction of a bad GOS score was at ≤13%. Patients with a lactate clearance at 6 h ≤13% evidenced higher rates of bad GOS scores (97% vs. 73%; p = 0.01). Conclusions: Whereas lactate clearance does not predict mortality, it was the sole predictor of good neurological outcomes and might therefore guide clinicians when to stop ECPR.
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Pozzi M, Armoiry X, Achana F, Koffel C, Pavlakovic I, Lavigne F, Fellahi JL, Obadia JF. Extracorporeal Life Support for Refractory Cardiac Arrest: A 10-Year Comparative Analysis. Ann Thorac Surg 2019; 107:809-816. [DOI: 10.1016/j.athoracsur.2018.09.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 08/28/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Distal Perfusion Cannula in Femorofemoral ECMO: Prophylactic or Therapeutic Approach? Ann Vasc Surg 2019; 58:388-389. [PMID: 30769070 DOI: 10.1016/j.avsg.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 02/01/2019] [Indexed: 11/22/2022]
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Shapey IM, Summers A, Augustine T, van Dellen D. Systematic review to assess the possibility of return of cerebral and cardiac activity after normothermic regional perfusion for donors after circulatory death. Br J Surg 2019; 106:174-180. [PMID: 30667536 PMCID: PMC6749564 DOI: 10.1002/bjs.11046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/13/2018] [Accepted: 10/10/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Normothermic regional perfusion (NRP) is a novel technique that aids organ recovery from donors after circulatory death (DCDs). However, ethical concerns exist regarding the potential return of spontaneous cerebral and cardiac activity (ROSCCA). This study aimed to determine the likelihood of ROSCCA in NRP-DCDs of abdominal organs. METHODS Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory out-of-hospital cardiac arrest (OOHCA) was identified as a comparator for NRP-DCDs and as a validation cohort. A systematic search identified all articles relating to NRP-DCDs and ECPR-OOHCA. Rates of ROSCCA and survival outcomes (ECPR-OOHCA only) were recorded and analysed according to the duration of no perfusion. RESULTS In NRP-DCDs, 12 of 410 articles identified by database searching were eligible for inclusion. There were no instances of ROSCCA recorded among 493 donors. In ECPR-OOHCA, eight of 947 screened articles were eligible for inclusion (254 patients). Where the absence of perfusion exceeded 5 min in ECPR-OOHCA, there were no survivors with a favourable neurological outcome. CONCLUSION ROSCCA is unlikely following commencement of NRP and has not occurred to date. Strict observance of the 5-min interval following asystole provides satisfactory assurance that ROSCCA will not occur following NRP.
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Affiliation(s)
- I M Shapey
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - A Summers
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - T Augustine
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - D van Dellen
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Department of Renal and Pancreatic Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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Formica F, D'Alessandro S, Sangalli F. Arterial lactate level: A simple and effective tool during extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2019; 157:e265-e266. [PMID: 30660412 DOI: 10.1016/j.jtcvs.2018.11.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 11/29/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Francesco Formica
- Mechanical Circulatory Support Program Coordinator, Cardiac Surgery Unit, San Gerardo Hospital, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Stefano D'Alessandro
- Surgery Unit, Cardio-thoracic-vascular Department, San Gerardo Hospital, Monza, Italy
| | - Fabio Sangalli
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, Monza, Italy
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A Long-Forgotten Tale: The Management of Cardiogenic Shock in Acute Myocardial Infarction. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2018-0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Patients with acute myocardial infarction (AMI) complicated with cardiogenic shock (CS) present one of the highest mortality rates recorded in critical care. Mortality rate in this setting is reported around 45-50% even in the most experienced and well-equipped medical centers. The continuous development of ST-segment elevation acute myocardial infarction (STEMI) networks has led not only to a dramatic decrease in STEMI-related mortality, but also to an increase in the frequency of severely complicated cases who survive to be transferred to tertiary centers for life-saving treatments. The reduced effectiveness of vasoactive drugs on a severely altered hemodynamic status led to the development of new devices dedicated to advanced cardiac support. What’s more, efforts are being made to reduce time from first medical contact to initiation of mechanical support in this particular clinical context. This review aims to summarize the most recent advances in mechanical support devices, in the setting of CS-complicated AMI. At the same time, the review presents several modern concepts in the organization of complex CS centers. These specialized hubs could improve survival in this critical condition.
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Min JJ, Tay CK, Ryu DK, Wi W, Sung K, Lee YT, Cho YH, Lee JH. Extracorporeal cardiopulmonary resuscitation in refractory intra-operative cardiac arrest: an observational study of 12-year outcomes in a single tertiary hospital. Anaesthesia 2018; 73:1515-1523. [DOI: 10.1111/anae.14412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- J. J. Min
- Department of Anaesthesiology and Pain Medicine; Department of Thoracic and Cardiovascular Surgery; Samsung Medical Centre; Sungkyukwan University School of Medicine; Seoul Korea
| | - C. K. Tay
- Department of Respiratory and Critical Care; Singapore General Hospital; Singapore
| | - D. K. Ryu
- Department of Anaesthesiology and Pain Medicine; Department of Thoracic and Cardiovascular Surgery; Samsung Medical Centre; Sungkyukwan University School of Medicine; Seoul Korea
| | - W. Wi
- Department of Anaesthesiology and Pain Medicine; Department of Thoracic and Cardiovascular Surgery; Samsung Medical Centre; Sungkyukwan University School of Medicine; Seoul Korea
| | - K. Sung
- Department of Thoracic and Cardiovascular Surgery; Samsung Medical Centre; Sungkyukwan University School of Medicine; Seoul Korea
| | - Y. T. Lee
- Department of Thoracic and Cardiovascular Surgery; Samsung Medical Centre; Sungkyukwan University School of Medicine; Seoul Korea
| | - Y. H. Cho
- Department of Thoracic and Cardiovascular Surgery; Samsung Medical Centre; Sungkyukwan University School of Medicine; Seoul Korea
| | - J.-H. Lee
- Department of Anaesthesiology and Pain Medicine; Department of Thoracic and Cardiovascular Surgery; Samsung Medical Centre; Sungkyukwan University School of Medicine; Seoul Korea
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