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Should we emergently revascularize occluded coronaries for cardiac arrest?: rapid-response extracorporeal membrane oxygenation and intra-arrest percutaneous coronary intervention.

Circulation. 2012; 126(13):1605-13 (ISSN: 1524-4539)

Kagawa E; Dote K; Kato M; Sasaki S; Nakano Y; Kajikawa M; Higashi A; Itakura K; Sera A; Inoue I; Kawagoe T; Ishihara M; Shimatani Y; Kurisu S
Department of Cardiology, Hiroshima City Asa Hospital, 2-1-1, Kabeminami, Asakita-ku, Hiroshima, 731-0293 Japan

"CONCLUSIONS: Rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional cardiopulmonary resuscitation. On the basis of these findings, randomized studies of intra-arrest PCI are needed."
 
Here is a podcast about a hospital that uses ed ECMO for the refractory cardiac arrest patients. Dont know about PCI in arrest patients but what about throbolysis in that group?
 
d_miracle36 said:
Here is a podcast about a hospital that uses ed ECMO for the refractory cardiac arrest patients. Dont know about PCI in arrest patients but what about throbolysis in that group?
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I do not think systemic thrombolytics will have anywhere near the effect of direct revascularization.

They don't seem to work very well for stokes, why would they work any better in a different part of the body?

Direct arterial thrombolysis to the affected artery might produce better results than systemic, but that doesn't solve the problem and subsequent thrombosis is highly likely.
 
I have seen studies showing they may not be effective for strokes but have not seen any for MI. Would it be possible to do pci during a resucitation?
 
d_miracle36 said:
I have seen studies showing they may not be effective for strokes but have not seen any for MI. Would it be possible to do pci during a resucitation?
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Possible? Technically.

Doubt it is very effective. The pubmed search I did on it cites multiple studies of high mortality from arrest in the cath lab.

I would venture that arrest prior to it would be worse.
 
Japan's interventional cards is just crazy right now. They also have been trialing retrograde PCI of chronic total occlusions through collaterals.

I had a case kinda similar to this. We were working on a guy who was going into vfib every 5 mins for a 1 min for hours in our lab. He was going in an out for a couple of hours before hand as well. We were PCIing, placing an Icy cath, and put in an IABP. His blood gases and pH were shot. So we called the CT surg team. They came, brought their CPB pump and were debating about putting him on ECMO. Pump was already being primed, just in case. I really wanted to see it. However, they didn't perform it. Patient left the lab "alive..."
 
Japan has lots of incredible minimally invasive surgery.
 
d_miracle36 said:
Would it be possible to do pci during a resucitation?
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I believe it would be possible but it is generally not done. At least were I work if they code on the cath lab table they work them until they get ROSC then proceed with the PCI. If they can not get ROSC after a reasonable time they will call it.

I saw on the Lucas website that they have a carbon fiber back plate that is radiotransulcent specifically designed for the cath lab. Maybe that would make it more effective to do PCI during resuscitation.


Sounds like an interesting concept however I am not sure how many places in the US could actually accomplishment.
 
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ChaseZ33 said:
I believe it would be possible but it is generally not done. At least were I work if they code on the cath lab table they work work them until they get ROSC then proceed with the PCI. If they can not get ROSC after a reasonable time they will call it.

I saw on the Lucas website that they have a carbon fiber back plate that is radiotransulcent specifically designed for the cath lab. Maybe that would make it more effective to do PCI during resuscitation.
Click to expand...

So how do you use the intravascular tools without tearing up the arteries while this machine pumps away?
 
I've been involved in active CPR/resuscitation during PCI. These were folks who coded on the table during PCI so usually there was a culprit lesion or dissection the interventionalist was actively trying to fix. CPR seemed to make things a little more difficult and maybe for a couple seconds CPR was held so the stent placement could be visualized a little better but for the most part it wasn't an issue. In normal cases the heart is beating/moving anyway....

Cardiac arrest ED/EMS pts aren't brought to the lab unless there's ROSC. Adult ECMO is even more sparse in the US. Besides maybe one tertiary center, I don't know of any places around here that do it right now.
 
We are currently running a pilot study to get this going from ems point of contact. Basically we take any young, healthy arrests with a presumed primary cardiac cause, run a basic code then auto-CPR-machine them to hospital where ECMO is started and off to cath lab. No idea how it is going.
 
FLdoc2011 said:
I've been involved in active CPR/resuscitation during PCI. These were folks who coded on the table during PCI so usually there was a culprit lesion or dissection the interventionalist was actively trying to fix. CPR seemed to make things a little more difficult and maybe for a couple seconds CPR was held so the stent placement could be visualized a little better but for the most part it wasn't an issue. In normal cases the heart is beating/moving anyway....

Cardiac arrest ED/EMS pts aren't brought to the lab unless there's ROSC. Adult ECMO is even more sparse in the US. Besides maybe one tertiary center, I don't know of any places around here that do it right now.
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So they are blind advancing the wire and catheter as someone is doing compressions? There is no way you could fluoro while doing CPR based on the C arm of the x-ray. Additionally, any tech, nurse, physician would be foolish to put themselves in harms way then.

I do want to reiterate what you said though in regards to ROSC. I think this is why they are trying to see if ECLS would actually work in very extreme cases.

Edit: I guess I stand corrected with Vene's article. I still am unsure how you could fluoro through that though. Unless you are doing lateral shots, but I don't know many physicians who would be able to do that.
 
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Most views they use are not "straight on" and so if they're shooting one of their usual views, LAO, RAO, cranial/caudal, etc, there's usually room for someone to do CPR without the c-arm in the way. Certainly not ideal, but doable. And the ones I've been involved with have been fairly short codes where ROSC was obtained quickly once perfusion was restored or CPR was given while an IABP could be inserted.

The only times I've seen this is when there was known lesion being fixed or known complication (coronary dissection, acute stent thrombosis) that was actively trying to be fixed at that time.
 
FLdoc2011 said:
Most views they use are not "straight on" and so if they're shooting one of their usual views, LAO, RAO, cranial/caudal, etc, there's usually room for someone to do CPR without the c-arm in the way. Certainly not ideal, but doable. And the ones I've been involved with have been fairly short codes where ROSC was obtained quickly once perfusion was restored or CPR was given while an IABP could be inserted.

The only times I've seen this is when there was known lesion being fixed or known complication (coronary dissection, acute stent thrombosis) that was actively trying to be fixed at that time.
Click to expand...

Obviously not straight on shots. Regardless, you'd be giving crappy CPR. Especially because LAO/RAO will throw out the detector or emitter into where the person should be standing. Reducing the effectiveness.

I would totally stop, and give good CPR. Additionally, I think being behind protection (on top of an apron) it would be selfish for the physician to say oh go stand up by the fluoro for 2 mins. During the time I worked in a lab, we never continued, but extensive CPR wasn't often needed.
 
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