Cardiac arrest in the cath lab - PowerPoint Presentation

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Cardiac arrest in the cath labCase based algorithm

Jayant Bagai, MD, FACC, FSCAI

Vanderbilt University Medical Center

VA Tennessee Valley Healthcare System

Nashville, TN

Disclosures

I have no conflicts of interest to disclose with regards to this presentation

Case presentation

58/M, unknown PMH, presented to OSH with CP

Transferred after 48 hours due to inferior STE and shock

Lactate 4.7, troponin 19, BP 91/67, HR 110, RR 27/min, rhonchi, mumbling, cold

Asystolic cardiac arrest

after induction for intubation

CPR, 4 mg epi, 4 U Vasopressin, 4 gm Ca, 300

meq

NAHCO3

ROSC after 7 min

After 5 min,

2

nd

cardiac arrest

, VT/VF, CPR, defibrillated,

Amio

300 mg, recurrent VF

ECMO initiated 7 min after 2

nd

arrest, 15F RFA, 25F RFV cannulas, V-A ECMO

Defibrillation x 2, epi and

norepi

drips, MAP 140

Case presentation

LVEDP 31 mmHg, Impella CP via LFA to vent

Pressors weaned off 2 hours after Impella

Anuric

 CRRT

Shock liver, ECHO LVEF 25%, moderate RV dysfunction

ECMO 4.3 L/min, Impella 1.8-2.6 L/min at P5, intermittent suction alarm, no pulsatility when ECMO turned down

ECMO removed after 48 hours due to some LV recovery, Impella left in place

Persistent renal failure, unresponsive off sedation, GI bleeding, severe MR on TEE due to papillary muscle dysfunction

Palliative care, DNR, Impella removed, patient expired 4 days post arrest

Who is at risk for in-lab cardiac arrest?

AMI with cardiogenic shock (CGS), or high-risk anatomy (multiple CTOs, left main)

High-risk PCI (2.2% in PROTECT-II trial)

History of cardiac arrest (CA) outside the cardiac cath lab (CCL)

Severe RV failure

Severe acute decompensation of chronic heart failure

Malignant ventricular arrhythmias (VT storm)

PCI complications- abrupt closure/no reflow of vessel supplying large territory and/or collaterals to viable myocardium, grade 3 perforation, massive air embolism

Left/right/both coronary occlusion post TAVR/

ViV

TAVR, acute severe AI

Webb JG et al. AJC. 2002;90;1252-3

O’Neil WW et al. Circulation 2012;126:1717–27

Preventative planning in patients at high risk of cardiac arrest

Understand mechanism of shock (RV, LV,

biV

) and obtain quick look ECHO to assess LV/RV/valve function to determine drug and MCS choice

Insert MCS prior to PCI if severe prolonged ischemia is anticipated/possible to maintain coronary perfusion and support patient in event of CA

If patient coming to lab on high dose pressor(s), especially epinephrine drip, notify perfusionist and anesthesia; try to determine if patient may be candidate for advanced therapies

Narrow pulse pressure and tachycardia, delay intubation if possible until vascular access/MCS in place

Challenges during cardiac arrest in cath lab

Confusion, panic due to unexpected nature and uncertainty of what to do first

Difficult balance between optimum CPR, ACLS and urgency to reverse cause (i.e. recanalize occluded vessel, seal perforation)

Airway management typically has to wait till arrival of anesthesia

Adjustments to ACLS algorithm may be required

Limited data and lack of RCTs regarding best management strategy

Objectives

1. Maintain vital organ perfusion

2. Reverse underlying cause

2. Call for anesthesia and perfusion (echo, another IC and/or cardiac surgery, if needed)

1. Assign roles to staff for immediate ACLS. Use MCD if available

Persistent cardiac arrest?

Potentially rapidly treatable/reversible cause

Not rapidly treatable/ reversible

cause

ROSC- treat underlying cause

Massive air embolism

Grade III coronary perforation

Left main dissection

Abrupt closure

Younger age, myocardial recovery possible or potential transplant candidate

Age > 75, ESRD,

malignancy,

suspected anoxic injury

ECMO available

ECMO unavailable

ECMO

ECMO consult

Impella

Grey area

Cath lab cardiac arrest management

Terminate efforts

3. Inflate balloon if perforation, 2

nd

arterial access, central venous access

Additional considerations

IC runs code initially and then designates ACLS trained provider to take over

Ensure high quality CPR; monitor efficacy by looking at arterial pressure transduced via sheath, SBP 90-100 mmHg during compressions

Having anesthesia stay in room and manage drugs/TEE/pressure frees up staff to set up MCS and get supplies

Mechanical compression devices

LUCAS-2,

Lifestat

- piston driven

Autopulse

- load distribution

MCDs for cardiac arrest

No benefit of MCDs compared with manual compression (MC) in large RCTs for OHCA

n=32, 100% in-lab CA, median duration of MCD 34 min (5-90 min), 87% underwent PCI, 25% survival with good neurological outcome

n= 43, 48% in-lab CA, MC (12) vs. MCD (31), > 70% MCS, ROSC (74%- MCD, 42%- MC, 95%- MCD + MCS, 11% MCD and no MCS), survival to hospital discharge low and NS (13%- MCD, 8%- MC)

Allows for PCI/MCS; efficacy much lower if patient brought to lab in CA

Class IIb (2015 AHA guidelines), and “strongly recommended” by European guidelines

Perkins GD et al. Lancet. 2015;385:947–955.

Wagner H et al.

Scand

J Trauma

Resusc

Emerg

Med. 2016 Jan 21;24:4

Venturini JM et al. Resuscitation. 2017;115:56-60

ECMO for cardiac arrest

Advantages

Generates high MAP, provides oxygenation

Easy and quick to place, effective in achieving ROSC

Disadvantages

Have to wait till perfusionist arrives to CCL

Poor survival unless underlying cause is treated

Increases LV afterload and wall stress which can prevent myocardial recovery unless LV is vented

Requires sufficient caliber of femoral artery, usually no time for limb perfusion

High incidence of bleeding and vascular complications

ECMO for cardiac arrest

40-50% survival to hospital discharge in patients with high percentage (84-100%) revascularization

7% survival to hospital discharge when significant proportion have OHCA, no ACS and no PCI, despite high ROSC rate (95%) and 36% survival to

decanulation

Yannopoulos

D et al. JACC. 2017;70:1109-17

Arlt

M et al. EJCS. 2012;42:858-63

Bagai J et al. JIC 2011; 23: 141-7

Venturini JM et al. Resuscitation. 2017;115:56-60

Impella for cardiac arrest

Advantages

Easy and quick to place

Do not have to wait for perfusionist in most labs

Disadvantages

Expensive

Patient may still require CPR to move blood across lungs to LV

Does not provide oxygenation; theoretically effective only for primary LV failure as cause of arrest

Requires sufficient caliber of femoral artery

Limited efficacy data (50% survival to hospital discharge in small study, n= 8)

High incidence of bleeding and vascular complications due to absent or faint pulsations (50%; 38% required surgery)

Frequent suction alarms and need for repositioning

Vase H et al.

Resuscitation. 2017 Mar;112:70-74

Prognostic considerations

2004-2013, University Hospital, Lund, Sweden

n= 35, CA arrest in-lab in 22 and 13 in CA prior to arrival

18 (51%) ROSC, 9 (26%) survived with good neurological outcome

Earlier decision to initiate ECMO if in CA on arrival, CPR time > 10-20 min, low ADP during CPR

Variable

No ROSC/Non survivor

ROSC/ Survivor

p value

In arrest coming to lab

3/13 (22%)

0/13 (0%)

0.001

CPR time

50 min

18 min, 10 min

0.001

Aortic diastolic pressure (ADP)

19 mmHg

30 mmHg

0.012

Madsen H et al. BMC Cardiovasc

Disord

. 2019 Jun 3;19(1):134.

Conclusions

CA in the cath lab is challenging to manage & associated with high mortality

Certain patient subsets are at high risk for CA in the cath lab, and labs should adequately prepare for this scenarios

ECMO, if available, will support vital organ perfusion in the setting of refractory CA, but patient survival depends on treatment of underlying cause

Impella is an alternative to ECMO, but with limited clinical data on efficacy

Mechanical compression devices, while associated with less interruption of CPR, have not translated into better outcomes when used without MCS

Questions?

jayant.Bagai@vumc.org