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Trummer G, Benk C, Pooth JS, Wengenmayer T, Supady A, Staudacher DL, Damjanovic D, Lunz D, Wiest C, Aubin H, Lichtenberg A, Dünser MW, Szasz J, Dos Reis Miranda D, van Thiel RJ, Gummert J, Kirschning T, Tigges E, Willems S, Beyersdorf F. Treatment of Refractory Cardiac Arrest by Controlled Reperfusion of the Whole Body: A Multicenter, Prospective Observational Study. J Clin Med 2023; 13:56. [PMID: 38202063 PMCID: PMC10780178 DOI: 10.3390/jcm13010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Background: Survival following cardiac arrest (CA) remains poor after conventional cardiopulmonary resuscitation (CCPR) (6-26%), and the outcomes after extracorporeal cardiopulmonary resuscitation (ECPR) are often inconsistent. Poor survival is a consequence of CA, low-flow states during CCPR, multi-organ injury, insufficient monitoring, and delayed treatment of the causative condition. We developed a new strategy to address these issues. Methods: This all-comers, multicenter, prospective observational study (69 patients with in- and out-of-hospital CA (IHCA and OHCA) after prolonged refractory CCPR) focused on extracorporeal cardiopulmonary support, comprehensive monitoring, multi-organ repair, and the potential for out-of-hospital cannulation and treatment. Result: The overall survival rate at hospital discharge was 42.0%, and a favorable neurological outcome (CPC 1+2) at 90 days was achieved for 79.3% of survivors (CPC 1+2 survival 33%). IHCA survival was very favorable (51.7%), as was CPC 1+2 survival at 90 days (41%). Survival of OHCA patients was 35% and CPC 1+2 survival at 90 days was 28%. The subgroup of OHCA patients with pre-hospital cannulation showed a superior survival rate of 57.1%. Conclusions: This new strategy focusing on repairing damage to multiple organs appears to improve outcomes after CA, and these findings should provide a sound basis for further research in this area.
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Affiliation(s)
- Georg Trummer
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Jan-Steffen Pooth
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Department of Emergency Medicine, Medical Center—University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
| | - Tobias Wengenmayer
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Alexander Supady
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Dawid L. Staudacher
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
- Interdisciplinary Medical Intensive Care, Medical Center—University of Freiburg, 79106 Freiburg, Germany
| | - Domagoj Damjanovic
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center, 93042 Regensburg, Germany;
| | - Clemens Wiest
- Department of Internal Medicine II, University Medical Center, 93042 Regensburg, Germany
| | - Hug Aubin
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Artur Lichtenberg
- Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany (A.L.)
| | - Martin W. Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Johannes Szasz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020 Linz, Austria
| | - Dinis Dos Reis Miranda
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Robert J. van Thiel
- Department of Adult Intensive Care, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jan Gummert
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Thomas Kirschning
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr University Bochum, 44791 Bad Oeynhausen, Germany
| | - Eike Tigges
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Stephan Willems
- Asklepios Klinik St. Georg, Heart and Vascular Center, Department of Cardiology and Intensive Care Medicine, 20099 Hamburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Center Freiburg, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; (G.T.)
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Breisacherstr. 153, 79110 Freiburg, Germany
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2
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Sezer M, Escaned J, Broyd CJ, Umman B, Bugra Z, Ozcan I, Sonsoz MR, Ozcan A, Atici A, Aslanger E, Sezer ZI, Davies JE, van Royen N, Umman S. Gradual Versus Abrupt Reperfusion During Primary Percutaneous Coronary Interventions in ST‐Segment–Elevation Myocardial Infarction (GUARD). J Am Heart Assoc 2022; 11:e024172. [PMID: 35574948 PMCID: PMC9238546 DOI: 10.1161/jaha.121.024172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background
Intramyocardial edema and hemorrhage are key pathological mechanisms in the development of reperfusion‐related microvascular damage in ST‐segment–elevation myocardial infarction. These processes may be facilitated by abrupt restoration of intracoronary pressure and flow triggered by primary percutaneous coronary intervention. We investigated whether pressure‐controlled reperfusion via gradual reopening of the infarct‐related artery may limit microvascular injury in patients undergoing primary percutaneous coronary intervention.
Methods and Results
A total of 83 patients with ST‐segment–elevation myocardial infarction were assessed for eligibility and 53 who did not meet inclusion criteria were excluded. The remaining 30 patients with totally occluded infarct‐related artery were randomized to the pressure‐controlled reperfusion with delayed stenting (PCRDS) group (n=15) or standard primary percutaneous coronary intervention with immediate stenting (IS) group (n=15) (intention‐to‐treat population). Data from 5 patients in each arm were unsuitable to be included in the final analysis. Finally, 20 patients undergoing primary percutaneous coronary intervention who were randomly assigned to either IS (n=10) or PCRDS (n=10) were included. In the PCRDS arm, a 1.5‐mm balloon was used to achieve initial reperfusion with thrombolysis in myocardial infarction grade 3 flow and, subsequently, to control distal intracoronary pressure over a 30‐minute monitoring period (MP) until stenting was performed. In both study groups, continuous assessment of coronary hemodynamics with intracoronary pressure and Doppler flow velocity was performed, with a final measurement of zero flow pressure (primary end point of the study) at the end of a 60‐minute MP. There were no complications associated with IS or PCRDS. PCRDS effectively led to lower distal intracoronary pressures than IS over 30 minutes after reperfusion (71.2±9.37 mm Hg versus 90.13±12.09 mm Hg,
P
=0.001). Significant differences were noted between study arms in the microcirculatory response over MP. Microvascular perfusion progressively deteriorated in the IS group and at the end of MP, and hyperemic microvascular resistance was significantly higher in the IS arm as compared with the PCDRS arm (2.83±0.56 mm Hg.s.cm
−1
versus 1.83±0.53 mm Hg.s.cm
−1
,
P
=0.001). The primary end point (zero flow pressure) was significantly lower in the PCRDS group than in the IS group (41.46±17.85 mm Hg versus 76.87±21.34 mm Hg,
P
=0.001). In the whole study group (n=20), reperfusion pressures measured at predefined stages in the early reperfusion period showed robust associations with zero flow pressure values measured at the end of the 1‐hour MP (immediately after reperfusion:
r
=0.782,
P
<0.001; at the 10th minute:
r
=0.796,
P
<0.001; and at the 20th minute:
r
=0.702,
P
=0.001) and peak creatine kinase MB level (immediately after reperfusion:
r
=0.653,
P
=0.002; at the 10th minute:
r
=0.597,
P
=0.007; and at the 20th minute:
r
=0.538,
P
=0.017). Enzymatic myocardial infarction size was lower in the PCRDS group than in the IS group with peak troponin T (5395±2991 ng/mL versus 8874±1927 ng/mL,
P
=0.006) and creatine kinase MB (163.6±93.4 IU/L versus 542.2±227.4 IU/L,
P
<0.001).
Conclusions
In patients with ST‐segment–elevation myocardial infarction, pressure‐controlled reperfusion of the culprit vessel by means of gradual reopening of the occluded infarct‐related artery (PCRDS) led to better‐preserved coronary microvascular integrity and smaller myocardial infarction size, without an increase in procedural complications, compared with IS.
Registration
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02732080.
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Affiliation(s)
- Murat Sezer
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
- Acibadem International Hospital Istanbul Turkey
| | - Javier Escaned
- Hospital Clínico San CarlosInstituto de Investigación Sanitaria San CarlosUniversidad Complutense de Madrid Madrid Spain
| | | | - Berrin Umman
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Zehra Bugra
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Ilke Ozcan
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Mehmet Rasih Sonsoz
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Alp Ozcan
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Adem Atici
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Emre Aslanger
- Marmara UniversitySchool of Medicine Istanbul Turkey
| | | | - Justin E. Davies
- Hammersmith Hospital Imperial College London London United Kingdom
| | | | - Sabahattin Umman
- Department of Cardiology Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
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Trummer G, Foerster K, Buckberg GD, Benk C, Mader I, Heilmann C, Liakopoulos O, Beyersdorf F. Superior neurologic recovery after 15 minutes of normothermic cardiac arrest using an extracorporeal life support system for optimized blood pressure and flow. Perfusion 2013; 29:130-8. [PMID: 23885022 DOI: 10.1177/0267659113497776] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Sudden cardiac arrest is one of the leading causes of death. Conventional CPR techniques after cardiac arrest provide circulation with reduced and varying blood flow and pressure. We hypothesize that using pressure- and flow-controlled reperfusion of the whole body improves neurological recovery and survival after 15 min of normothermic cardiac arrest. METHODS Pigs were randomized in two experimental groups and exposed to 15 min of ventricular fibrillation (VF). After this period, the animals in the control group received conventional CPR with open chest compression (n=6), while circulation in the treatment group (n=6) was established with an extracorporeal life support system (ECLS) to control blood pressure and flow. Follow-up included the assessment of neurological recovery and magnetic resonance imaging (MRI) for up to 7 days. RESULTS Five of the six animals in the control group died, one animal was resuscitated successfully. In the treatment group, 1/6 could not be separated from ECLS. Five out of the six pigs survived and were transferred to the animal facility. One animal was unable to walk and had to be sacrificed 30 hours after ECLS. The remaining 4 animals of the treatment group and the surviving pig from the control group showed complete neurological recovery. Brain MRI revealed no pathological changes. CONCLUSION We were able to demonstrate a significant improvement in survival after 15 minutes of normothermic cardiac arrest. These results support our hypothesis that using an ECLS for pressure- and flow-controlled circulation after circulatory arrest is superior to conventional CPR.
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Affiliation(s)
- G Trummer
- 1Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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6
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Obal D, Rascher K, Favoccia C, Dettwiler S, Schlack W. Post-conditioning by a short administration of desflurane reduced renal reperfusion injury after differing of ischaemia times in rats. Br J Anaesth 2006; 97:783-91. [PMID: 16997839 DOI: 10.1093/bja/ael245] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND 'Anaesthetic post-conditioning', that is administration of anaesthetics during early reperfusion, is known to have positive effects on several organs. For the kidney, however, the effects of post-conditioning by volatile anaesthetics are not well researched. We examined renal function and morphology after post-conditioning by desflurane. METHODS Anaesthetized rats were subjected to 30 or 45 min of renal ischaemia 14 days after contralateral nephrectomy. Post-conditioning was achieved by administration of 1 MAC desflurane (6.7 vol%) for 15 min during early reperfusion (all groups n=8). Cystatin C (CyC), creatinine clearance (Cl(Cr)) and fractional sodium excretion (FE(Na)) were measured in the awake rats over 3 days. Cell damage was graded from 1 to 4 in histological sections. Functional variables [mean (SD)] were compared statistically by a one-way anova followed by Bonferroni's multiple comparison test and histological scores (median and range) by Kruskal-Wallis test followed by Dunn's multiple comparison test. RESULTS Pre-ischaemia function did not differ between the groups, but was markedly reduced after ischaemia. After 30 min ischaemia, the area under the curve (AUC) for Cl(Cr) was smaller in the desflurane than in the control group [21.5 (5.0) vs 31.6 (5.1) ml min(-1) h, P<0.05]. After 45 min desflurane reduced the AUC compared with the control group for both CyC [15 (4) vs 21 (3) mg litre(-1) h] and FE(Na) [1054 (221) vs 1570 (572)% h, both P<0.05). Morphological differences were greater between the 30 min groups [control: 2.75 (2.0-3.5) vs desflurane: 1.5 (1.0-2.5); P<0.05] than between the 45 min groups [control: 3.5 (3.0-4.0) vs desflurane: 3.0 (1.5-4.0)]. CONCLUSION Desflurane post-conditioning protects renal function and tissue. This protection was greater after the short episode than after the long episode of ischaemia.
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Affiliation(s)
- D Obal
- Department of Anaesthesiology, Heinrich-Heine University, Duesseldorf, Germany.
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8
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Baldwin DD, Maynes LJ, Berger KA, Desai PJ, Zuppan CW, Zimmerman GJ, Winkielman AM, Sterling TH, Tsai CK, Ruckle HC. Laparoscopic warm renal ischemia in the solitary porcine kidney model. Urology 2004; 64:592-7. [PMID: 15351615 DOI: 10.1016/j.urology.2004.04.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2004] [Accepted: 04/19/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To determine the effect of a laparoscopic approach on warm renal ischemia in the pig with a solitary kidney. Although the maximal safe duration for warm ischemia during open partial nephrectomy is commonly accepted to be 30 minutes, the maximal safe ischemic time during laparoscopic partial nephrectomy has not been previously determined. METHODS Sixteen farm pigs underwent unilateral laparoscopic right nephrectomy. Two weeks later, the pigs underwent complete laparoscopic mobilization of the remaining left kidney and were randomized to complete hilar clamp times of 0, 30, 60, or 90 minutes. Serum creatinine was evaluated before right nephrectomy and at days 0, 2, 4, 7, 14, and 30 after renal ischemia during laparoscopy. All renal specimens were evaluated by an experienced nephropathologist in a blinded fashion. RESULTS The serum creatinine remained stable at all points in the control and 30-minute ischemia groups. The serum creatinine level rose initially on days 2 and 4 in the 60-minute and 90-minute ischemia groups but returned to baseline by day 7. At harvest, no statistically significant difference was found among the groups in serum creatinine or histologic features. CONCLUSIONS Renal ischemic times up to 90 minutes during laparoscopy were well tolerated by the solitary porcine kidney. Possible explanations for this finding include the protective effect of a solitary kidney and the potential protective effect of relative ischemic preconditioning provided by the pneumoperitoneum.
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Affiliation(s)
- D Duane Baldwin
- Division of Urology, Loma Linda University School of Medicine, Loma Linda, California 92354, USA
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9
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Onen A, Cigdem MK, Deveci E, Kaya S, Turhanoğlu S, Yaldiz M. Effects of whole blood, crystalloid, and colloid resuscitation of hemorrhagic shock on renal damage in rats: an ultrastructural study. J Pediatr Surg 2003; 38:1642-9. [PMID: 14614716 DOI: 10.1016/s0022-3468(03)00572-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE The aim of this study was to determine the effects of whole blood, crystalloid, and colloid treatment on histopathologic damage of kidney induced by hemorrhagic shock in rats. METHODS Fifty-six male Sprague Dawley rats were divided into 8 groups. The carotid artery was cannulated, and systolic arterial pressure (SAP), diastolic arterial pressure (DAP), heart rate (HR), and rectal temperature (RT) were observed during the procedure. The jugular vein also was cannulated, and the SAP was decreased by aspiration of 75% of blood through the jugular vein in the control (nonresuscitated) and study (resuscitated) groups, whereas blood was not diminished in the sham group. The hemorrhagic shock was permitted to last 45 minutes; then, the study group rats were resuscitated with heparinized shed autologous whole blood (WB), normal saline (NS), Lactated Ringer's solution (LR), hydroxyethyl starch 6% (HES6), hydroxyethyl starch 10% (HES10), or dextran 40 (D40). Histopathologic evaluation was performed under light and electron microscope. RESULTS The RT, SAP, and DAP decreased, and HR increased significantly in the control and study groups during the shock period compared with those of sham group. After volume resuscitation, these parameters changed to preshock levels. Electron and light microscopic examinations of kidneys showed severe proximal tubular degeneration with moderate glomerular damage in the control group; moderate proximal tubular degeneration with mild glomerular damage in the NS, LR, HES6, and HES10 groups; and mild proximal tubular degeneration with no evidence of glomerular damage in the WB and D-40 groups. CONCLUSIONS The characteristic ultrastructural features of hemorrhagic shock appear to be severe tubular degeneration and mild to moderate changes in glomeruli. Resuscitation of hemorrhagic shock with whole blood or dextran 40 solution appears to be most favorable therapy in preventing ultrastructural renal damage in rats.
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Affiliation(s)
- Abdurrahman Onen
- Department of Pediatric Surgery, Dicle University School of Medicine, Diyarbakir, Turkey
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