Should We Emergently Revascularize Occluded Coronaries for Cardiac Arrest? Rapid-Response Extracorporeal Membrane Oxygenation and Intra-Arrest Percutaneous Coronary Intervention
What is the efficacy of rapid-response extracorporeal membrane oxygenation (ECMO) and intra-arrest percutaneous coronary intervention (PCI) in cardiac arrest patients who were unresponsive to conventional cardiopulmonary resuscitation (CPR) complicated with acute coronary syndrome (ACS)?
This multicenter cohort study was conducted using the database of ECMO in Hiroshima City. Between January 2004 and May 2011, rapid-response ECMO was performed in 86 patients with ACS who were unresponsive to conventional CPR. Kaplan–Meier curves, with a follow-up of up to 365 days, were plotted to show the survival trend in patients complicated with ACS.
The median age of the study patients was 63 years old, and 81% were male. Emergency coronary angiography was performed in 81 patients (94%), and intra-arrest PCI was performed in 61 patients (71%). The rates of return of spontaneous heart-beat, 30-day survival, and favorable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heart-beat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% vs. 28%, p = 0.01), the intra-arrest PCI was higher (88% vs. 70%, p = 0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 minutes [25-51 minutes] vs. 54 minutes [34-74 minutes], p = 0.002).
The authors concluded that rapid-response ECMO plus intra-arrest PCI is feasible and associated with improved outcomes in patients who are unresponsive to conventional CPR.
This retrospective study suggests that rapid-response ECMO plus intra-arrest PCI is associated with a higher survival rate in patients who are unresponsive to conventional CPR. It appears that PCI is feasible in this setting, may increase the rate of ROSB, and improve survival. Early initiation of ECMO may also improve outcomes in refractory cardiac arrest patients. Based on these findings, randomized studies of rapid-response ECMO and intra-arrest PCI in refractory cardiac arrest patients complicated with ACS may be reasonable to assess whether emergent revascularization of occluded coronary arteries for refractory cardiac arrest patients truly improves outcomes.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Follow-Up Studies, Shock, Cardiopulmonary Resuscitation, Heart Arrest, Angioplasty, Extracorporeal Membrane Oxygenation, Percutaneous Coronary Intervention, Out-of-Hospital Cardiac Arrest, Coronary Angiography, Survival Rate, Coronary Vessels, Coronary Occlusion
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