Catheterization and Cardiovascular Diagnosis 20:120-122 (1990)
Case Reports Successful Resuscitation of a Patient With Critical Aortic Stenosis and Cardiac Arrest by Peripheral Cardiopulmonary Support System Gregory S. Pavlides, MD, John Cieszkowski, MD, Gerald C. Timmis, MD, and William O’Neill, MD Patients with critical aortic stenosis have an increased risk of complications during diagnostic cardiac catheterization, and those who arrest are particularly difficult to resuscitate. Recent advances in therapeutictechniques may change this unfavorableprognosis, as it is illustrated in the presented case. A 68 year-old women with critical aortic stenosis sustained a cardiac arrest during diagnostic cardiac catheterization. Conventional cardiopulmonaryresuscitationfor 45 minutes failed to restore cardiac function and rhythm, which had degeneratedto ventricularfibrillation, electromechanicaldissociation, and asystole. Peripheral cardiopulmonarysupport system restored cardiac rhythm and blood pressure, with a subsequent successful aortic valve replacement. Key words: cardiac catheterization, valvular heart disease, cardiopulmonary bypass
It is well documented that patients with critical aortic base. A 12 lead electrocardiogram showed left ventricstenosis have an increased risk of complications during ular hypertrophy. An echocardiographic examination cardiac catheterization [l], and in case of cardiac arrest with Doppler revealed left ventricular hypertrophy with they are particularly difficult to resuscitate. To lower the normal contractility, a calcified aortic valve with a peak risk, contrast ventriculography is generally avoided and instantaneous pressure gradient of 125 mm Hg, and modperformed only when concomitant mitral regurgitation is erate mitral regurgitation. Cardiac catheterization was present [2]. Recent advances in therapeutic techniques performed 2 days after admission. The hemodynamic may change this unfavorable prognosis. Successful findings are shown in Table I. To assess the mitral reemergency aortic balloon valvuloplasty has been em- gurgitation, contrast ventriculography was performed at ployed for patients who became hypotensive during car- 30 RAO projection, using 30 cc of Omnipaque (iohexol, diac catheterization [3,4]. However, in cardiac arrest re- Winthrop Pharmaceudicals, New York, NY). Shortly afquiring chest compressions, it is not technically possible ter ventriculography the arterial pressure fell to 30 systo perform balloon valvuloplasty. We report a case of a tolic, the patient became unresponsive, was intubated, patient with critical aortic stenosis who sustained a car- and chest compressions started. The sinus rhythm degendiac arrest during catheterization and required conven- erated to ventricular flutter-fibrillation that required multional cardiopulmonary resuscitation for 45 minutes, be- tiple defibrillating capacitor discharges. Brief episodes fore a more definitive support was achieved by of asystole were managed with a transvenous pacemaker percutaneous femoral-femoral cardiopulmonary support but despite good capture no effective systolic pressure (CPS) system, followed by successful aortic valve re- was generated. Intravenous epinephrine ( 1 mg), atropine placement. A 68 year-old white female was admitted with dys- From the Division of Cardiovascular Diseases, William Beaumont pnea over a 2 week period. She had experienced two Hospital, Royal Oak, Michigan. syncopal episodes within the last 6 months and described angina for 1 year. The physical examination on admis- Received October 2, 1989; revision accepted January 20, 1990 sion was suggestive of significant aortic stenosis with an Address reprint requests to Gregory Pavlides, M.D., Division of Caranacrotic carotid pulse, diminished aortic heart sound, diovascular Diseases, William Beaumont Hospital, 3601 West Thirand a IIINI harsh late peaking systolic murmur at the teen Mile Road, Royal Oak, MI 48072. 0 1990 Wiley-Liss, Inc.
Peripheral Cardiopulmonary Support System
was not performed. Figure 1 shows the electrocardiogram and pressure recordings, throughout the resuscitation. The patient was transferred to the operating room while on the CPS system, when a blood pressure of 88/26 mm Hg was recorded. The heart was approached by medial sternotomy . It displayed left ventricular hypertrophy and poor myocardial contractility. Full cardiopulmonary bypass was established by standard surgical technique and the CPS system was turned off. A heavily calcified bicuspid aortic valve with a very small outlet was excised and replaced with a 19 mm St. Jude prosthesis. The epicardial coronary arteries were palpated and no disease was identified. The patient was weaned from cardiopulmonary bypass with the assistance of epinephrine. The right groin was then cut down, the CPS cannulae were removed, and both femoral artery and vein were surgically repaired. Subsequent recovery of the patient was slow due to limited anoxic encephalopathy. There were no right groin complications. Postop-
TABLE 1. Cardiac Catheterization Data 4 mm Hg 3510 mm Hg 48/24 rnm Hg 25 mrn Hg 128167 m m Hg 274115 mm Hg 5.8 litershin 0.4 cm'
Right atrial pressure (mean) Right ventricular pressure Pulmonary artery pressure Pulmonary capillary wedge pressure Aortic pressure Left ventricular pressure Cardiac output Aortic valve area
(2 mg cumulative dose), lidocaine (100 mg bolus initially and 50 mg thereafter), and bretylium (700 mg total) were used as needed. After 45 min of cardiopulmonary resuscitation, a peripheral CPS system (BARD Inc.), was introduced percutaneously into the right femoral vein and artery; a flow of 4 literdmin was achieved. No arterial pressure was recorded immediately, but the patients rhythm reverted to normal sinus and the chest compressions were stopped. Selective coronary angiography
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Fig. 1. Electrocardiographic and hemodynamic recordings during sequential stages of the cardiac catheterization and resuscitation. A: Electrocardiogram and blood pressure (130/60 mm Hg), on baseline. B: Electrocardiogram and simultaneous left ventricular (270/15 mm Hg) and peripheral (120/60 mm Hg) blood pressure prior to angiography. C: Electrocardiogram and blood pressure (25 mm Hg), immediately post angiography. D:
Wide QRS idioventricular rhythm (1st and 3rd recordings from top), and blood pressure (2nd and 4th recordings from top) during chest compressions. E: Coarse ventricular fibrillation and blood pressure during chest compressions. F: Restored normal sinus rhythm with narrow QRS, after the introduction of peripheral cardiopulmonary bypass system.
122
Pavlides et al.
erative cardiac function was assessed by three serial achieved with manual compression for 30-45 minutes, echocardiograms; they consistently showed well pre- without complications. In our case, it is unlikely that served contractility (left ventricular fractional shortening prosthetic replacement of a severely stenotic aortic valve of 41%), and a normally functioning prosthetic aortic could have been achieved without emergency percutanevalve. The patient was discharged from the hospital in 3 ous cardiopulmonary support offsetting profound ventricular disfunction complicating cardiac catheterization. weeks. The use of venoarterial pumping for relief of intractable cardiac failure was first reported three decades ago, but the system did not gain wide acceptance at the time REFERENCES [ 5 ] . A portable venoarterial CPS system has been developed recently using two 20 French cannulae that can be I . Kennedy JW: Complications associated with cardiac catheterization and angiography. Cathet Cardiovasc Diagn 8:5-11, 1982. introduced percutaneously into the femoral vein and ar2. Grossman W: “Cardiac Catheterization and Angiography. Philtery; the venous cannula is advanced to the right atrium adelphia: Lea & Febiger Editors. 1986. and the arterial cannula placed in the iliac artery. The 3. Losordo DW, Ramaswamy K, Rosenfield K, Isner JM: Use of emergency dilation to reverse acute hemodynamic decompensation procedure is simple; it involves standard percutaneous developing during diagnostic catheterization for aortic stenosis. technique for introducing 8 F sheaths into femoral artery Am J Cardiol 63:388-389, 1989. and vein, and then sequential dilation with larger diala4. Friedman HZ, Cragg DR, O’Neill WW: Cardiac resuscitation ustors up to 14 F until the actual cannulae are inserted. It ing emergency aortic balloon valvuloplasty. Am J Cardiol 63: takes on average ten minutes from the beginning of the 387,388, 1989. procedure until extracorporeal flow is established. The 5 . Dickson JF, Hamer NA, Dowe JW: Veno-arterial pumping for relief of intractable cardiac failure in man. Arch Surg 78:418-421, system can generate flows up to 6 liters/min. It has been 1959. used for supporting patients during high risk coronary 6. Vogel RA, Tommaso CL, Gundry SR: Initial experience with corangioplasty [ 6 ] .In this case the CPS cannulae were suronary angioplasty and aortic valvuloplasty using elective semipergically removed but in our experience they can be recutaneous cardiopulmonary support. Am J Cardiol 62:811-813, 1988. moved without surgical incision and hemostasis can be ”
Case Reports Successful Resuscitation of a Patient With Critical Aortic Stenosis and Cardiac Arrest by Peripheral Cardiopulmonary Support System Gregory S. Pavlides, MD, John Cieszkowski, MD, Gerald C. Timmis, MD, and William O’Neill, MD Patients with critical aortic stenosis have an increased risk of complications during diagnostic cardiac catheterization, and those who arrest are particularly difficult to resuscitate. Recent advances in therapeutictechniques may change this unfavorableprognosis, as it is illustrated in the presented case. A 68 year-old women with critical aortic stenosis sustained a cardiac arrest during diagnostic cardiac catheterization. Conventional cardiopulmonaryresuscitationfor 45 minutes failed to restore cardiac function and rhythm, which had degeneratedto ventricularfibrillation, electromechanicaldissociation, and asystole. Peripheral cardiopulmonarysupport system restored cardiac rhythm and blood pressure, with a subsequent successful aortic valve replacement. Key words: cardiac catheterization, valvular heart disease, cardiopulmonary bypass
It is well documented that patients with critical aortic base. A 12 lead electrocardiogram showed left ventricstenosis have an increased risk of complications during ular hypertrophy. An echocardiographic examination cardiac catheterization [l], and in case of cardiac arrest with Doppler revealed left ventricular hypertrophy with they are particularly difficult to resuscitate. To lower the normal contractility, a calcified aortic valve with a peak risk, contrast ventriculography is generally avoided and instantaneous pressure gradient of 125 mm Hg, and modperformed only when concomitant mitral regurgitation is erate mitral regurgitation. Cardiac catheterization was present [2]. Recent advances in therapeutic techniques performed 2 days after admission. The hemodynamic may change this unfavorable prognosis. Successful findings are shown in Table I. To assess the mitral reemergency aortic balloon valvuloplasty has been em- gurgitation, contrast ventriculography was performed at ployed for patients who became hypotensive during car- 30 RAO projection, using 30 cc of Omnipaque (iohexol, diac catheterization [3,4]. However, in cardiac arrest re- Winthrop Pharmaceudicals, New York, NY). Shortly afquiring chest compressions, it is not technically possible ter ventriculography the arterial pressure fell to 30 systo perform balloon valvuloplasty. We report a case of a tolic, the patient became unresponsive, was intubated, patient with critical aortic stenosis who sustained a car- and chest compressions started. The sinus rhythm degendiac arrest during catheterization and required conven- erated to ventricular flutter-fibrillation that required multional cardiopulmonary resuscitation for 45 minutes, be- tiple defibrillating capacitor discharges. Brief episodes fore a more definitive support was achieved by of asystole were managed with a transvenous pacemaker percutaneous femoral-femoral cardiopulmonary support but despite good capture no effective systolic pressure (CPS) system, followed by successful aortic valve re- was generated. Intravenous epinephrine ( 1 mg), atropine placement. A 68 year-old white female was admitted with dys- From the Division of Cardiovascular Diseases, William Beaumont pnea over a 2 week period. She had experienced two Hospital, Royal Oak, Michigan. syncopal episodes within the last 6 months and described angina for 1 year. The physical examination on admis- Received October 2, 1989; revision accepted January 20, 1990 sion was suggestive of significant aortic stenosis with an Address reprint requests to Gregory Pavlides, M.D., Division of Caranacrotic carotid pulse, diminished aortic heart sound, diovascular Diseases, William Beaumont Hospital, 3601 West Thirand a IIINI harsh late peaking systolic murmur at the teen Mile Road, Royal Oak, MI 48072. 0 1990 Wiley-Liss, Inc.
Peripheral Cardiopulmonary Support System
was not performed. Figure 1 shows the electrocardiogram and pressure recordings, throughout the resuscitation. The patient was transferred to the operating room while on the CPS system, when a blood pressure of 88/26 mm Hg was recorded. The heart was approached by medial sternotomy . It displayed left ventricular hypertrophy and poor myocardial contractility. Full cardiopulmonary bypass was established by standard surgical technique and the CPS system was turned off. A heavily calcified bicuspid aortic valve with a very small outlet was excised and replaced with a 19 mm St. Jude prosthesis. The epicardial coronary arteries were palpated and no disease was identified. The patient was weaned from cardiopulmonary bypass with the assistance of epinephrine. The right groin was then cut down, the CPS cannulae were removed, and both femoral artery and vein were surgically repaired. Subsequent recovery of the patient was slow due to limited anoxic encephalopathy. There were no right groin complications. Postop-
TABLE 1. Cardiac Catheterization Data 4 mm Hg 3510 mm Hg 48/24 rnm Hg 25 mrn Hg 128167 m m Hg 274115 mm Hg 5.8 litershin 0.4 cm'
Right atrial pressure (mean) Right ventricular pressure Pulmonary artery pressure Pulmonary capillary wedge pressure Aortic pressure Left ventricular pressure Cardiac output Aortic valve area
(2 mg cumulative dose), lidocaine (100 mg bolus initially and 50 mg thereafter), and bretylium (700 mg total) were used as needed. After 45 min of cardiopulmonary resuscitation, a peripheral CPS system (BARD Inc.), was introduced percutaneously into the right femoral vein and artery; a flow of 4 literdmin was achieved. No arterial pressure was recorded immediately, but the patients rhythm reverted to normal sinus and the chest compressions were stopped. Selective coronary angiography
--
_ _ -
- -
--
___
- --
.
__ -- _- -- -
- - -_-
-
-
- - _.-
-- -
-__- __ ~
--_-A-.
__
-
_.
-
.
. -
121
&
&-__
-
_-
__
.
__
-
.
.
Fig. 1. Electrocardiographic and hemodynamic recordings during sequential stages of the cardiac catheterization and resuscitation. A: Electrocardiogram and blood pressure (130/60 mm Hg), on baseline. B: Electrocardiogram and simultaneous left ventricular (270/15 mm Hg) and peripheral (120/60 mm Hg) blood pressure prior to angiography. C: Electrocardiogram and blood pressure (25 mm Hg), immediately post angiography. D:
Wide QRS idioventricular rhythm (1st and 3rd recordings from top), and blood pressure (2nd and 4th recordings from top) during chest compressions. E: Coarse ventricular fibrillation and blood pressure during chest compressions. F: Restored normal sinus rhythm with narrow QRS, after the introduction of peripheral cardiopulmonary bypass system.
122
Pavlides et al.
erative cardiac function was assessed by three serial achieved with manual compression for 30-45 minutes, echocardiograms; they consistently showed well pre- without complications. In our case, it is unlikely that served contractility (left ventricular fractional shortening prosthetic replacement of a severely stenotic aortic valve of 41%), and a normally functioning prosthetic aortic could have been achieved without emergency percutanevalve. The patient was discharged from the hospital in 3 ous cardiopulmonary support offsetting profound ventricular disfunction complicating cardiac catheterization. weeks. The use of venoarterial pumping for relief of intractable cardiac failure was first reported three decades ago, but the system did not gain wide acceptance at the time REFERENCES [ 5 ] . A portable venoarterial CPS system has been developed recently using two 20 French cannulae that can be I . Kennedy JW: Complications associated with cardiac catheterization and angiography. Cathet Cardiovasc Diagn 8:5-11, 1982. introduced percutaneously into the femoral vein and ar2. Grossman W: “Cardiac Catheterization and Angiography. Philtery; the venous cannula is advanced to the right atrium adelphia: Lea & Febiger Editors. 1986. and the arterial cannula placed in the iliac artery. The 3. Losordo DW, Ramaswamy K, Rosenfield K, Isner JM: Use of emergency dilation to reverse acute hemodynamic decompensation procedure is simple; it involves standard percutaneous developing during diagnostic catheterization for aortic stenosis. technique for introducing 8 F sheaths into femoral artery Am J Cardiol 63:388-389, 1989. and vein, and then sequential dilation with larger diala4. Friedman HZ, Cragg DR, O’Neill WW: Cardiac resuscitation ustors up to 14 F until the actual cannulae are inserted. It ing emergency aortic balloon valvuloplasty. Am J Cardiol 63: takes on average ten minutes from the beginning of the 387,388, 1989. procedure until extracorporeal flow is established. The 5 . Dickson JF, Hamer NA, Dowe JW: Veno-arterial pumping for relief of intractable cardiac failure in man. Arch Surg 78:418-421, system can generate flows up to 6 liters/min. It has been 1959. used for supporting patients during high risk coronary 6. Vogel RA, Tommaso CL, Gundry SR: Initial experience with corangioplasty [ 6 ] .In this case the CPS cannulae were suronary angioplasty and aortic valvuloplasty using elective semipergically removed but in our experience they can be recutaneous cardiopulmonary support. Am J Cardiol 62:811-813, 1988. moved without surgical incision and hemostasis can be ”
