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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 51  |  Issue : 4  |  Page : 148-152

The result of emergency cardiac intervention in resuscitated out-of-hospital cardiac arrest patients


1 Department of Surgery, Chung Shan Medical University Hospital; Department of Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
2 Department of Surgery, Chung Shan Medical University Hospital; College of Medicine, Chung Shan Medical University, Taichung, Taiwan
3 College of Medicine, Chung Shan Medical University, Taichung, Taiwan
4 College of Medicine, Chung Shan Medical University; Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
5 Department of Institute of Medicine, Chung Shan Medical University; Division of Cardiovascular Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
6 Department of Institute of Medicine, Chung Shan Medical University; Division of Cardiology, Chung Shan Medical University Hospital, Taichung, Taiwan
7 Division of Cardiovascular Surgery, Tzu Chi Hospital, Taichung; College of Medicine, Tzu Chi University, Hualien, Taiwan

Date of Submission21-May-2017
Date of Decision06-Sep-2017
Date of Acceptance08-Jan-2018
Date of Web Publication22-Aug-2018

Correspondence Address:
Prof. Tsung-Po Tsai
Division of Cardiovascular Surgery, College of Medicine, Chung Shan Medical University Hospital, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Rd., Taichung City 40201
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_84_17

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  Abstract 

Background: Arrhythmia and sudden cardiac decompensation (acute myocardial infarct or acute heart failure) are the most often causes of out-of-hospital cardiac arrest (OHCA). Emergency cardiac catheterization followed by coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting surgery [CABG]) or valvular surgery is a lifesaving procedure. However, the result of this emergency room resuscitated OHCA patients underwent cardiac invasive procedure was not well defined before.
Materials and Methods: One hundred and seventy (including 23 traumatic and stroke, etc.,) out of 705 OHCA patients were resuscitated and achieved a return of spontaneous circulation (ROSC) at Emergency Room of Chung Shan Medical University Hospital from January 1, 2011, to March 31, 2015. Only 23 (M/F = 25/8) out of 147 medically resuscitated OHCA patient with one or more cardiac risk factors were transferred for emergency cardiac catheterization (33/147). Thirty-one of them (31/33) underwent PCI (either balloon angioplasty or stent deployment) with coronary culprit stenotic lesions (>70%) of right coronary artery (15), left anterior descending artery (12), circumflex branch of left coronary artery (5), and left main coronary artery (1). One of the rest two patients with aortic valvular stenosis who underwent aortic valve replacement; and another with triple vessel disease of coronary artery received CABG.
Results: All 33 patients (22.4%) survived the catheterization procedures and were sent to intensive care units. 31 patients were in comatose state and 24 eventually deceased due to cardiogenic shock (16), septic shock (4), ventricular tachycardia and ventricular fibrillation (2), hyperkalemia (1) and multiple organ failure (1). Nine patients (27.3%) survived to hospital discharge and were followed up at OPD periodically (1.3–43 months, mean 30.4 months). Four OHCA patients required extra-corporeal membrane oxygenation support, but only one out of four underwent PCI and survived.
Conclusions: The resuscitated OHCA (ROSC) patients with any cardiac disease in the past should undergo emergency cardiac catheterization and possible intervention procedure with an acceptable result (survival to hospital discharge rate of 27.3%).

Keywords: Cardiac catheterization, out-of-hospital cardiac arrest, percutaneous coronary intervention, return of spontaneous circulation


How to cite this article:
Ming-Yu H, Liao HH, Tsai SC, Teng YH, Chen PY, Tsao SC, Tsai CF, Chan KC, Yu JM, Wu YL, Tsai TP. The result of emergency cardiac intervention in resuscitated out-of-hospital cardiac arrest patients. Formos J Surg 2018;51:148-52

How to cite this URL:
Ming-Yu H, Liao HH, Tsai SC, Teng YH, Chen PY, Tsao SC, Tsai CF, Chan KC, Yu JM, Wu YL, Tsai TP. The result of emergency cardiac intervention in resuscitated out-of-hospital cardiac arrest patients. Formos J Surg [serial online] 2018 [cited 2018 Nov 17];51:148-52. Available from: http://www.e-fjs.org/text.asp?2018/51/4/148/239555


  Introduction Top


Sudden cardiac arrest is a major cause of unexpected death, as well as a major clinical issue.[1],[2] The survival rate after out-of-hospital cardiac arrest (OHCA) is estimated to be below 5% from most reports throughout the world. The procedures and strategies that may improve the outcomes of cardiac arrest patients include cardiopulmonary resuscitation (CPR), defibrillation, the use of automated external defibrillators, and therapeutic hypothermia.[3],[4],[5],[6],[7],[8] However, the survival rate after OHCA continues to be poor even though treatments for coronary heart disease and the practice of CPR have been improving for decades.

There are approximately 2.7 million inhabitants lived in Taichung area of Taiwan, which is served by a comprehensive centrally coordinated ambulance system. The Chung Shan Medical University Hospital is one of the large tertiary-care referral centers that provide 24-h emergency coronary and cardiac surgical interventions for patients with acute coronary syndromes (ACSs).

ACS is one of the major causes of sudden death according to autopsies and coronary angiograms.[9],[10] Many clinical trials among ST-elevation myocardial infarction (STEMI) patients and selected patients with non-ST-elevation ACS demonstrated that early cardiac catheterization and coronary revascularization (percutaneous coronary intervention [PCI] or coronary artery bypass grafting surgery [CABG]) improved outcomes, and primary PCI is currently the standard care for patients with STEMI in general clinical settings.[11] However, most patients who were included in the clinical trials mentioned above were not all cardiac arrest patients, and the meaning of revascularization for resuscitated patients remains unclear. Recent studies have reported that using emergency PCI to resuscitate patients has the potential to improve their outcomes.[12],[13] Stær-Jensen, et al. also reported that initial EKG findings are not reliable. Even in the absence of EKG changes indicating myocardial ischemia, an acute culprit lesion may be present and patients may benefit from emergent revascularization.[14] The purpose of this one single-center experience is to elucidate the patients' characteristics in relating to the effects of emergent cardiac intervention among resuscitated patients in a large tertiary-care referral center.


  Materials and Methods Top


In this retrospective analysis, we evaluated clinical characteristics and outcomes of all patients who had an OHCA with sustained return of spontaneous circulation (ROSC) at Chung Shan Medical University Hospital from January 1, 2011, to March 31, 2015. The study was performed in accordance with the Chung Shan Medical University Hospital Ethics Committee guidelines. The primary outcome was survival to hospital discharge. Interrogation of the hospital database identified 705 patients with presumed OHCA. Among them, 170 patients were successfully resuscitated. Twenty-three patients were excluded secondary to noncardiac causes such as trauma, stroke, cancer, and drug overdose. The study population, therefore, consisted of 147 medically resuscitated OHCA patients.

In this period, the decision regarding the need for cardiac catheterization was made according to patients with history of the risk factors of coronary artery disease (CAD) or electrocardiogram showing ST-T change after resuscitation [Table 1]. Intensive care including target hemodynamic and metabolic parameters and even choice of inotropic agents or support of extracorporeal membrane oxygenation (ECMO) were decided according to general critical care study cohort [Figure 1].
Table 1: Risk factors of 33 patients underwent emergency cardiac catheterization (n=33/147)

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Figure 1: Study cohort of early cardiac intervention in cardiac arrest

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  Results Top


One hundred and seventy patients out of 705 resuscitated OHCA patients (24.1%) were successfully resuscitated and achieved ROSC at the emergency department of Chung Shan Medical University Hospital. There were only 33 nontraumatic medically resuscitated patients (33/147 = 22.4%). Among them, 25 were males and 8 were females with two or more cardiac risk factors were transferred for emergency cardiac catheterization. There were 31 patients in comatose state with Glasgow coma scale (GCS) E1M1VT and 2 patients in GCS E2M5VT immediately after the resuscitation.

All 33 patients were referred for emergency cardiac catheterization. Thirty-two patients had culprit stenotic coronary artery lesion (>70%) at RCA (17), LAD (14), LCX (7), LM (1) coronary arteries, and 1 with insignificant lesions. There were 31 patients with CAD underwent PCI (either with plain old balloon angioplasty or stent deployment). None of them had documented contraindications to cardiac catheterization, nor did any patients or their surrogates refuse the procedure when it was offered. Moreover for the rest two patients, one with aortic valvular heart disease underwent aortic valve replacement and one with triple-vessels CAD was transferred for CABG. These two patients survived.

The hospital stay for these 33 resuscitated patients was from 1 day to 57 days with a mean of 10.2 days. The Intensive Care Unit stay was from 1 day to 34 days with a mean of 7.8 days. Veno-arterial extracorporeal membrane oxygenation was applied to 4 patients with cardiogenic shock in association with ventricular tachycardia ventricular fibrillation arrhythmia after CPR. The duration of ECMO applied in those four patients was from 3 to 9 days with a mean of 6.3 days. Among them, only one was weaned from ECMO and was transferred to respiratory care ward.

All 33 resuscitated patients underwent endotracheal intubation and in ventilator use. The duration of intubation period was from 1 day to 34 days with a mean of 8.2 days. While the duration of endotracheal intubation for 9 survived patients was from 5 days to 48 days (one with tracheostomy) with a mean of 13.3 days. Regarding about 12 patients with acute renal injuries, only 5 patients received continuous venovenous hemodialysis and two of them converted to regular hemodialysis. Among those, three patients receiving regular hemodialysis, one had had chronic kidney disease with regular hemodialysis before cardiac arrest.

24 out of 31 comatose patients (74%) eventually deceased because of a variety of reasons [Table 2]. As the rest two clear conscious patients (2/33; 6%) were transferred to respiratory care ward or further respiratory care and one survived. All these 31 patients received palliative and spiritual care program during their stay in the intensive care unit or respiratory care ward.
Table 2: Causes of mortality in 24 out of 31 survived comatose patients (n=24/31)

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Nine patients (9/33; 27.3%) survived to hospital discharge without any complications (including neurologic deficit, paralysis/paresia or renal impairment etc.,) and were followed up at our outpatient department periodically (1.3–43 months, mean 30.4 m) [Table 2].


  Discussion Top


There were several observational reports regarding PCI for cardiac arrest patients, and proved that PCI may improve the outcomes of resuscitated cardiac arrest patients. However, the OHCA patients' risk factors and the efficacy of emergency cardiac intervention for resuscitated cardiac arrest patients remain unclear.[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] In our study, 33 patients with cardiac risk factor of all 147 ROCS patient received emergent catheterization had survival rate of 27.3% (9/33), which higher than average rate in the past reports. Our result indicated the value of emergent catheterization in resuscitated OHCA patient with cardiac risk factor.

Stær-Jensen, et al. had reported that initial EKG findings are not reliable to identify if patient's cardiac arrest is secondary to ischemia event, which indicates the possibility of false negative. Therefore, we exclude EKG findings as our risk factors are listed in [Table 1]. However if ischemia findings appear in EKG, I believe that it should be an indicator to do PCI in resuscitated OHCA patient.

Kagawa et al. reported that alternative CPR using venoarterial extracorporeal membrane oxygenation (ECMO) has the potential to improve the outcomes of cardiac arrest patients.[24] Though his study is observational and has potential biases, the combination of ECMO, PCI, and therapeutic hypothermia could be one solution for refractory cardiac arrest patients.[26],[27],[28] In our study, four of our OHCA patients required veno-arterial ECMO (ECMO V-A type) support. However, only two out of the four underwent PCI and one survived. PCI seems to have a better survival rate in ECMO group (50% vs. 0%). However, it is a retrospective study; and the case number is too small to prove it.

Hypothermia therapy in OHCA patient had been reported and discussed well before.[6],[7],[8] We can increase the survival rate by decreasing the consumption of heart by low temperature. However, the patency of coronary artery is still the priority to save the heart. In our study, we had no patient received hypothermia therapy, but we still had an acceptable result by doing PCI after resuscitated OHCA. If we combine these two therapies in the future, we believe the result could be better.

Although 24 of 31 comatose patients were still deceased, basing on ethical and legal principles (Palliative Care and Spiritual Care Recommendation for End-of-Life Care) had been given to those comatose patients and their families to support them through the process of dying and bereavement period through an interdisciplinary approach.[29]

Our study demonstrates that emergency cardiac catheterization for resuscitated OHCA patients with two or more cardiac risk factors followed by coronary revascularization (PCI or CABG) or surgical procedure (aortic valve replacement) may improve the outcomes, and also support the combination usage of ECMO and PCI is a life-saving procedure for refractory cardiac arrest patients. However, our limitations are small case numbers in sub-categories and not introducing hypothermia therapy. Its our goal in the future.


  Conclusions Top


The resuscitated OHCA (ROSC) patients with history of the risk factors of CAD or electrocardiogram showing ST-T wave change after resuscitation should undergo emergency cardiac catheterization and possible intervention procedure associated with therapeutic hypothermia to achieve an acceptable result (survival to hospital discharge rate of 27.3%).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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