short review Wien Klin Wochenschr [Suppl] DOI 10.1007/s00508-015-0777-8
Intra-arrest percutaneous coronary intervention: a case series Igor Balevski · Andrej Markota · Darinka Purg · Matej Bernhardt · Matej Strnad · Vojko Kanic · ˇ Andreja Sinkovicˇ
Received: 28 November 2014 / Accepted: 5 March 2015 © Springer-Verlag Wien 2015
Summary In patients with refractory cardiac arrest presumably from acute coronary occlusion, primary percutaneous coronary intervention (PPCI) may provide an opportunity for revascularisation and, subsequently, return of spontaneous circulation. We present our experience from a 24/7 primary percutaneous coronary intervention centre serving a population of approximately 800,000 individuals. A retrospective analysis was performed in patients with cardiac arrest treated from July 2011 to January 2014. Inclusion criteria were cardiac arrest and emergency coronary angiography performed during on-going external cardiopulmonary resuscitation (CPR). Course of treatment was analysed to outline the reasons for poor survival. Eight patients met the inclusion criteria; six (75 %) were male, and the mean age was 63 ± 16 years. Revascularisation under continuous cardiopulmonary resuscitation was achieved in all eight patients. Sustained return of spontaneous circulation was achieved in two patients (25 %). Both patients had poor neurological outcome (cerebral performance
A. Markota, MD () · I. Balevski, MD, PhD · D. Purg, MD · M. Bernhardt, MD · V. Kanic, MD · A. Sinkovic, MD, PhD ˇ ˇ Clinic of Internal Medicine, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia e-mail: [email protected] M. Strnad, MD, PhD · I. Balevski, MD, PhD · A. Markota, MD · V. Kanic, MD · A. Sinkovic, MD, PhD ˇ ˇ Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia M. Strnad, MD, PhD Centre for Emergency Medicine, Community Health Center Maribor, Ulica talcev 9, 2000 Maribor, Slovenia
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category 4), and both died within 3 months. We identified total duration of cardiopulmonary resuscitation (90.5 ± 33.3 min), lack of prehospital mechanical cardiopulmonary resuscitation devices and lack of extracorporeal life support devices as the most likely reasons contributing to poor survival. Keywords Cardiac arrest · Ventricular fibrillation · Cardiopulmonary resuscitation · Percutaneous coronary intervention · Treatment outcome
Introduction The identification and treatment of reversible causes is important in cardiac arrest, especially when standard therapy has failed. In patients with refractory cardiac arrest presumably from acute coronary occlusion, primary percutaneous coronary intervention (PPCI) may provide an opportunity for revascularisation and, subsequently, return of spontaneous circulation (ROSC) [1]. Many authors have described successful PPCI in treatment of refractory cardiac arrest with favourable neurological outcomes [2–4]. We present our experience from a regional 24/7 PPCI centre, serving a population of approximately 800,000 individuals. In all, we treated eight patients with refractory cardiac arrest as a result of presumed coronary occlusion, in whom standard therapy was futile and PPCI was performed during an ongoing cardiopulmonary resuscitation (CPR). Only two patients survived, both with poor neurological outcome. We will attempt to outline the reasons for poor outcomes and where improvement can be achieved.
Patients, materials and methods A retrospective analysis was performed in patients with cardiac arrest treated from July 2011 to January 2014 in Intra-arrest percutaneous coronary intervention: a case series
1
short review
a regional 24/7 PPCI centre. Institutional ethics committee approval was obtained (No. 159/13). Informed consent was waived due to retrospective nature of the study. Inclusion criteria were cardiac arrest and emergency coronary angiography performed during an on-going external CPR. Catheterisation laboratory was equipped with one C-arm intended for PPCI use, elective percutaneous coronary intervention and electrophysiology. PPCI was performed by a team experienced in performing PPCI and other interventional cardiology procedures in emergency setting [5]. Extra-corporeal life support (ECLS) was not available on-site. To initiate PPCI pathway, an intensivist staffing medical intensive care unit (ICU) was contacted via telephone by emergency physicians to evaluate the indication for PPCI. PPCI team was then activated by the intensivist. Associated prehospital unit was staffed by physicians specialised in emergency medicine. All patients received advanced cardiac life support prior to emergency coronary angiography, including defibrillations, epinephrine, amiodarone and intubation, all according to current guidelines [6]. The decision when to initiate emergency coronary angiography pathway was left to the treating physicians. Patients’ medical records were used to obtain demographic data, whether the cardiac arrest was witnessed, first recorded rhythm, whether there was bystander CPR and to calculate time intervals: time from collapse to call of emergency medical team (EMT), time from collapse to arrival of EMT, duration of EMT CPR before emergency coronary angiography pathway was initiated, duration of EMT CPR before arrival to catheterisation laboratory and total duration of CPR (EMT CPR and in-hospital CPR). We also obtained data regarding coronary angiography, the rate of ROSC, neurological outcome in survivors expressed using cerebral performance category (CPC) scale, 3-month survival rate, which mechanical CPR device was used and regarding the use of intra-aortic balloon pump (IABP) and vasopressors in the peri-arrest period if ROSC was achieved. Successful PPCI was defined as
Intra-arrest percutaneous coronary intervention: a case series Igor Balevski · Andrej Markota · Darinka Purg · Matej Bernhardt · Matej Strnad · Vojko Kanic · ˇ Andreja Sinkovicˇ
Received: 28 November 2014 / Accepted: 5 March 2015 © Springer-Verlag Wien 2015
Summary In patients with refractory cardiac arrest presumably from acute coronary occlusion, primary percutaneous coronary intervention (PPCI) may provide an opportunity for revascularisation and, subsequently, return of spontaneous circulation. We present our experience from a 24/7 primary percutaneous coronary intervention centre serving a population of approximately 800,000 individuals. A retrospective analysis was performed in patients with cardiac arrest treated from July 2011 to January 2014. Inclusion criteria were cardiac arrest and emergency coronary angiography performed during on-going external cardiopulmonary resuscitation (CPR). Course of treatment was analysed to outline the reasons for poor survival. Eight patients met the inclusion criteria; six (75 %) were male, and the mean age was 63 ± 16 years. Revascularisation under continuous cardiopulmonary resuscitation was achieved in all eight patients. Sustained return of spontaneous circulation was achieved in two patients (25 %). Both patients had poor neurological outcome (cerebral performance
A. Markota, MD () · I. Balevski, MD, PhD · D. Purg, MD · M. Bernhardt, MD · V. Kanic, MD · A. Sinkovic, MD, PhD ˇ ˇ Clinic of Internal Medicine, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia e-mail: [email protected] M. Strnad, MD, PhD · I. Balevski, MD, PhD · A. Markota, MD · V. Kanic, MD · A. Sinkovic, MD, PhD ˇ ˇ Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia M. Strnad, MD, PhD Centre for Emergency Medicine, Community Health Center Maribor, Ulica talcev 9, 2000 Maribor, Slovenia
13
category 4), and both died within 3 months. We identified total duration of cardiopulmonary resuscitation (90.5 ± 33.3 min), lack of prehospital mechanical cardiopulmonary resuscitation devices and lack of extracorporeal life support devices as the most likely reasons contributing to poor survival. Keywords Cardiac arrest · Ventricular fibrillation · Cardiopulmonary resuscitation · Percutaneous coronary intervention · Treatment outcome
Introduction The identification and treatment of reversible causes is important in cardiac arrest, especially when standard therapy has failed. In patients with refractory cardiac arrest presumably from acute coronary occlusion, primary percutaneous coronary intervention (PPCI) may provide an opportunity for revascularisation and, subsequently, return of spontaneous circulation (ROSC) [1]. Many authors have described successful PPCI in treatment of refractory cardiac arrest with favourable neurological outcomes [2–4]. We present our experience from a regional 24/7 PPCI centre, serving a population of approximately 800,000 individuals. In all, we treated eight patients with refractory cardiac arrest as a result of presumed coronary occlusion, in whom standard therapy was futile and PPCI was performed during an ongoing cardiopulmonary resuscitation (CPR). Only two patients survived, both with poor neurological outcome. We will attempt to outline the reasons for poor outcomes and where improvement can be achieved.
Patients, materials and methods A retrospective analysis was performed in patients with cardiac arrest treated from July 2011 to January 2014 in Intra-arrest percutaneous coronary intervention: a case series
1
short review
a regional 24/7 PPCI centre. Institutional ethics committee approval was obtained (No. 159/13). Informed consent was waived due to retrospective nature of the study. Inclusion criteria were cardiac arrest and emergency coronary angiography performed during an on-going external CPR. Catheterisation laboratory was equipped with one C-arm intended for PPCI use, elective percutaneous coronary intervention and electrophysiology. PPCI was performed by a team experienced in performing PPCI and other interventional cardiology procedures in emergency setting [5]. Extra-corporeal life support (ECLS) was not available on-site. To initiate PPCI pathway, an intensivist staffing medical intensive care unit (ICU) was contacted via telephone by emergency physicians to evaluate the indication for PPCI. PPCI team was then activated by the intensivist. Associated prehospital unit was staffed by physicians specialised in emergency medicine. All patients received advanced cardiac life support prior to emergency coronary angiography, including defibrillations, epinephrine, amiodarone and intubation, all according to current guidelines [6]. The decision when to initiate emergency coronary angiography pathway was left to the treating physicians. Patients’ medical records were used to obtain demographic data, whether the cardiac arrest was witnessed, first recorded rhythm, whether there was bystander CPR and to calculate time intervals: time from collapse to call of emergency medical team (EMT), time from collapse to arrival of EMT, duration of EMT CPR before emergency coronary angiography pathway was initiated, duration of EMT CPR before arrival to catheterisation laboratory and total duration of CPR (EMT CPR and in-hospital CPR). We also obtained data regarding coronary angiography, the rate of ROSC, neurological outcome in survivors expressed using cerebral performance category (CPC) scale, 3-month survival rate, which mechanical CPR device was used and regarding the use of intra-aortic balloon pump (IABP) and vasopressors in the peri-arrest period if ROSC was achieved. Successful PPCI was defined as
