Coronary Disease in Out-of-Hospital Refractory Ventricular Fibrillation

Study Questions:

What is the prevalence, complexity of coronary artery disease (CAD), and survival to hospital discharge in patients experiencing refractory ventricular fibrillation/ventricular tachycardia (VF/VT) cardiac arrest treated with a novel protocol of early transport to a cardiac catheterization laboratory for extracorporeal life support (ECLS) and revascularization?

Methods:

Consecutive adult patients with refractory out-of-hospital VF/VT cardiac arrest requiring ongoing cardiopulmonary resuscitation (CPR) were transported by emergency medical services (EMS) to the cardiac catheterization laboratory. ECLS, coronary angiography, and percutaneous coronary intervention (PCI) were performed. Functionally favorable survival to hospital discharge (Cerebral Performance Category [CPC] 1 or 2) was determined. Outcomes in a historical comparison group were also evaluated.

Results:

Sixty-two of 72 (86%) transported patients met EMS transport criteria; 55 of 62 (89%) met criteria for continuing resuscitation on cardiac cath lab arrival; 5 had return of spontaneous circulation; 50 received ECLS; all 55 received coronary angiography. Forty-six of 55 (84%) had significant CAD, 35 of 55 (64%) had acute thrombotic lesions, and 46 of 55 (84%) had PCI with 2.7 ± 2.0 stents deployed per patient. The mean SYNTAX score was 29.4 ± 13.9. Twenty-six of 62 (42%) patients were discharged alive with CPC 1 or 2 versus 26 of 170 (15.3%) in the historical comparison group (odds ratio, 4.0; 95% confidence interval, 2.08-7.7; p < 0.0001).

Conclusions:

Complex, but treatable CAD was common in patients with refractory out-of-the-hospital VF/VT cardiac. A systems approach using ECLS and reperfusion appeared to improve functionally favorable survival.

Perspective:

The American Heart Association Advanced Cardiac Life Support (ACLS) guidelines recommend treating patients with refractory VF/VT at the scene of cardiac arrest for 30-45 minutes until they have return of spontaneous circulation or are declared dead. The authors of this study show that, with the use of a Lund University Cardiac Arrest System (LUCAS) automated CPR device, rapid cardiac cath lab activation, and ECLS, an impressive percentage of the cardiac arrest victims may be discharged with good functional status. This approach has limitations, as it is very resource intensive, and targets a relatively small downstream group of patients. The success of the described approach is predicated on widespread access to defibrillation and CPR in the community, where many gains are yet to materialize.

Clinical Topics: Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Advanced Cardiac Life Support, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Catheterization, Cardiopulmonary Resuscitation, Coronary Angiography, Coronary Artery Disease, Emergency Medical Service Communication Systems, Extracorporeal Membrane Oxygenation, Heart Arrest, Out-of-Hospital Cardiac Arrest, Percutaneous Coronary Intervention, Stents, Tachycardia, Ventricular, Ventricular Fibrillation


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