Cardiac Arrest, Cardiogenic Shock, Therapeutic Hypothermia Timothy - - PowerPoint PPT Presentation

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Cardiac Arrest, Cardiogenic Shock, Therapeutic Hypothermia Timothy - - PowerPoint PPT Presentation

Jan 13, 2024 147 likes •504 views

Cardiac Arrest, Cardiogenic Shock, Therapeutic Hypothermia Timothy D. Henry, MD Director of Cardiology Cedars-Sinai Heart Institute Disclosures: Nothing to disclose 3 Out-of-Hospital Cardiac Arrest 48 year old male presents to ER as

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Cardiac Arrest, Cardiogenic Shock, Therapeutic Hypothermia

Timothy D. Henry, MD Director of Cardiology Cedars-Sinai Heart Institute

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Disclosures:

▪ Nothing to disclose

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  • 48 year old male presents to ER as an out of hospital

cardiac arrest: witness report seizure like activity, then slumped in his chair.

  • EMS arrival: Somnolent, then arrested, Initial rhythm

VF, multiple shocks, 4 epi and amio 300 in field.

  • Arrival to ER with ongoing CPR in PEA.
  • Risk factors, Previous History and Medications:

 None known

Out-of-Hospital Cardiac Arrest

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  • Given age and initial rhythm, CT surgery called for VA-

ECMO . Upon initiating ECMO , he was noted to have spontaneous respirations and blood pressure 140/90.

  • First EKG:

Out-of-Hospital Cardiac Arrest

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EKG#1 @ 12:20

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  • Troponin #1 11:45 0.18

 No ABG or lactate on arrival

  • Taken Emergently to Cath Lab
  • Timeline

 Arrival to ER: 11:39 AM  EKG: 12:20  Door to ECMO Initiation: 30 minutes

48 year old with OHCA

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Baseline Angiogram

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  • Aspiration: yes or no?
  • Multivessel PCI (D Cx) yes or no?
  • ECMO: yes or no Impella?
  • Therapeutic Hypothermia: yes or no,

what target, how long?

LAD culprit PCI but what else?

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  • Intervention

 Aspiration thrombectomy of the LAD.  PCI to the proximal to mid LAD using a 3.5 x 38

Xience Alpine DES.

 PCI of the distal left circumflex using a 3.0 x 15

Xience Alpine DES.

Placement of an Impella CP 4.0

  • Peak Troponin: 46

Cath Lab

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Post PCI

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EKG Post PCI

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Low normal LVEF 50 % with hypokinesis of the mid to apical septal wall otherwise normal

TTE: Hospital Day #1

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  • Therapeutic Hypothermia.

 Initiated one hour after presentation via ECMO

circuit, cooled to 33 degrees

 Rewarmed after 24 hours  No focal neurologic deficits

  • MCS

 Impella removed Hospital Day #2  Decannulated Hospital Day #4

  • Discharged Hospital Day #14
  • 3 month follow up: Doing well, returned to work, playing

soccer, on DAPT, no anginal complaints

Hospital Course

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Simple case?

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Cardiac Arrest

  • Out-of-hospital cardiac arrest (OOHCA)
  • 295,000 people annually in the US
  • 7.9% median survival rate
  • Anoxic encephalopathy and neurologic deficits
  • Therapeutic hypothermia (TH) clinical trials
  • ILCOR recommendation for TH after resuscitation

Lloyd-Jones D, Adams R, Carnethon M et al. Heart disease and stroke statistics-2009 update. Circulation 2009;119:e21-e181.

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OHCA survival to hospital discharge by 5-year time periods

Comilla Sasson et al. Circ Cardiovasc Qual Outcomes. 2010;3:63- 81

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Survival improves to 50- 60% with Favorable neurological outcomes in 86% of survivors

With hypothermia and PCI!

Rab et al. JACC 2015;66:62-73

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Early Transport to Cath Lab for ECMO and Revasc in Refractory VF (?OHCA)

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Interaction of Cardiac Arrest and Cardiogenic Shock

Cardiogenic Shock (+) Cardiogenic Shock (–) Cardiac Arrest (+) 184 Patients In-hospital Mortality: 47.3% 1 – Year Mortality: 51.6% 317 Patients In-hospital Mortality: 20.2% 1 – Year Mortality: 22.7% Cardiac Arrest (–) 259 Patients In-hospital Mortality: 25.1% 1 – Year Mortality: 33.6% 4157 Patients In-hospital Mortality: 1.7% 1 – Year Mortality: 5.5%

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Survival related to outcome of PCI

Florence Dumas et al. Circ Cardiovasc Interv. 2010;3:200-207

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Early predictors of survival in OHCA

Florence Dumas et al. Circ Cardiovasc Interv. 2010;3:200- 207

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Early Transport to Cath Lab for ECMO and Revascularization in Refractory Ventricular Fibrillation

Out of Hospital

  • VF/VT Initial rhythm
  • DCCV x3 and 300mg Amiodarone without ROSC
  • Time to CCL <30 min

Initial CCL

  • ABG and lactate
  • Stop if: ETCO2<10mmHg, PaO2<50mmHg or Lactate >18

mmol/L

  • If ROSC, immediate Cor Angio +/- IABP.
  • If no ROSC, ECLS , then Cor Angio +/- IABP.
  • Continue ACLS/ECLS for 90 minutes/PCI; if no ROSC by 90

minutes, declared dead

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Characteristics of Survivors

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Complication Rate

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  • 13% on ECMO had Vascular Complications
  • 4 with significant retroperitoneal bleeding requiring transfusion
  • 3 developed an ischemic leg after thrombosis of the distal perfusion cath
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Comparison Between the Refractory VF/VT Protocol and the Historical Comparison Group

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Cooling Outcomes

Alive at hospital discharge with favourable neurological recovery

Abbott Northwestern Hospital 53/96 55.2%

  • Survival by diagnosis

– STEMI: 33/50 66.0% – Other: 20/46 43.5%

  • Survival by initial rhythm

– VF/VT: 47/75 62.6% – PEA/Asystole: 5/19 26.3%

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Transfer Outcomes Transfer = Blue line, ANW = Red line

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Fraction surviving 1 10

7 5 4 3 2

100

60 40 20

1000

500 300

Days Arrest to Death or Last Know n Alive