Ricciardi MD Mauro Moscucci MD Bradley P Knight MD Adam Zivin MD Robert H Bartlett MD and Eric R Bates MD We describe two cases of refractory ventricular 731brillation complicating transcatheter interventional procedures Extracorporeal membrane ID: 88335
Download Pdf The PPT/PDF document "Emergency Extracorporeal Membrane Oxygen..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
EmergencyExtracorporealMembraneOxygenation(ECMO)-SupportedPercutaneousCoronaryInterventionsintheFibrillatingHeartMarkJ.Ricciardi,,MauroMoscucci,,BradleyP.Knight,,AdamZivin,RobertH.Bartlett, ostiumandmidsegments,wasthoughttoberesponsibleforhisanginaandappearedamenabletopercutaneousThedecisionwasmadetoproceedwithpercutaneouscoronaryangioplasty(315mmNCBandit,ScimedLifeSystems,MapleGrove,MN)oftheostialandmidLADlesions.Thisresultedinanimprovedbutsubopti-mallumenwithnoevidenceofdissection.Soonthereaf-ter,thepatientdevelopedventricular®brillationunrespon-sivetoremovaloftheguidingcatheterfromtheleftcoronaryarteryandimmediateexternalde®brillation.Aggressiveexternalcardiaccompressionwasperformedandendotrachealintubationestablished.Repeatangiogra-physhowedostialLADocclusionwithlossofwirepositionfromthedistalartery.Resuscitativeeffortswereresumed.Multipleattemptsatexternalde®brillationwith360Joulesusingastandardmonophasicde®brillatorandananteroposteriorpatchcon®gurationprovedineffectivedespiteintravenousloadingwithlidocaine,bretyllium,andamiodarone.De®brillationwasthensuccessfullyperformedbyaddingasecondexternalmonophasicde®brillatorwithasternum-to-apexcon®guration,anddelivering720Joulesbysimultaneousmanualdelivery.Transientpostconversionasystolewastreatedwithrightventricularpacing.Despitemultiplesuccessfulde®brilla-tionsusing720Joules,ventricular®brillationrepeatedlyrecurredandsinusrhythmcouldnotbemaintained.WhileprolongedCPRandadvancedcardiaclifesupportmeasuresmaintainedexcellentperfusionpressureandoxygenation,severeacidemiadevelopedandonlybriefepisodesoforganizedventriculartachycardiacouldbeachievedwithhigh-energyshocks.Thedecisionwasmadetoplacefemoralarterialandvenouscannulae(21and23Fr,respectively)forECMOsupport.Thepatientwassuccessfullyplacedoncirculatorysupportafter45minofCPR,buttheelectricalstormcontinuedunabateddespitecontinuedeffortsandimprove-mentsinhemodynamicsandacid-basedisturbance.Atten-tionwasthenredirectedtorevascularization,approxi-mately1hraftercommencingcardiopulmonaryresuscitation.Whilethepatientremainedinventricular®brillation,theproximalandmidLADsegmentsweresuccessfullydilatedandstentedwiththree315mmPalmaz-Schatzstents(JohnsonandJohnsonInterven-tionalSystems,Warren,NJ).Thrombolysisinmyocardialinfarction(TIMI)grade3¯owwasrestoredandnoresidualstenosiswasevidentinthestentedareas.Onthe®rstattemptafterrevascularization,thepatientwassuccessfullyde®brillatedwith720Joulesandreturnedtosinusrhythm.HewastransferredtothecoronarycareunitandsupportedwithIVamiodarone,mechanicalventilation,andECMO.IntactbrainfunctionwasevidentfromthetimeofinitialresuscitativeeffortsandthepatientwasrespondingtocommandsbythetimeofhisarrivalintheCCU.Surfaceechocardiographyinitiallyshowed``stun-ning''oftheanteriorwallwithgradualimprovementinsystolicfunctionovertheensuingdays.Beforedistalperfusioncouldbeestablished,theleftlegbecameischemicandnecrotic,requiringabove-the-kneeamputa-tion.HewasweanedfromamiodaroneandECMOsupportwithin5days.Hesufferednofurthermyocardialischemiaorventriculararrhythmias.Aprolongedhospitalcoursewascomplicatedbypneumoniaand®nallynecro-tizingpancreatitis,whichdeveloped30dayspostangio-plasty.Thepatientdiedduringhissecondexploratorylaparotomy.Case2A60-year-oldmanwithahistoryofischemiccardiomy-opathy(ejectionfraction25%),successfulstentingofthemidrightcoronaryartery(RCA)4monthspreviously,heartfailure,ventriculartachycardia(VT),implantablecardioverterde®brillator(ICD)therapy,andrecentnonischemicadenosinethalliumscanpresentedforVTablationbecauseoffrequentICDdischarges.Duringtheablationprocedure,hedevelopedintractableVFrefrac-torytomultipleattemptsatpharmacologicandelectricalde®brillation.AggressiveCPRwasperformedandECMOwasinstitutedwithin30minusing23Frrightfemoralveinand21Frrightfemoralarterycannulae.VFpersistedandthepatientunderwentemergencycoronaryangiogra-phy,whichshowed20%leftmaindisease,subtotalnarrowingoftheproximalandmidLAD,70%and90%stenosesofthe®rstobtusemarginalartery,occlusionofthesecondobtusemarginalartery,andintervalocclusionofthemidRCAatthesiteofthepreviousstentimplantation.Therewereleft-to-rightandright-to-rightHeparinandabciximab(ReoPro,CentocorBV,theNetherlands)weregivenandtheRCAocclusionwascrossedanddilated(3.0-mmBandit),resultingina10%residualdiameterstenosis.The®rstobtusemarginalarterywasalsosuccessfullydilatedwiththesameballooncatheter.Immediatelythereafter,thepatientwassuccess-fullyde®brillatedwithone360-Jouleshock.Withthepreservationofbrain,lung,andkidneybutcontinuedpoorcardiacfunctionovertheensuing3days,thepatientwasthoughttobeasuitablecardiacassistdeviceandhearttransplantcandidate.Accordingly,leftandrightventricularassistdevices(HeartMate,Thermo-Cardiosystems,Woburn,MA)wereimplantedandECMOdiscontinued.Thepatientwassuccessfullyextubatedafter10days,waslaterweanedfromrightventricularsupport,remainedonleftventricularsupportfor6months,andthenunderwentsuccessfulorthotopiccar-diactransplantation.Heisalive9monthslater.PTCAintheFibrillatingHeart403 Whilepercutaneouscoronaryinterventionsandinva-siveelectrophysiologicproceduresareoccasionallycom-plicatedbyventricular®brillation[11±13],theseeventsarerarelyunresponsivetorapidelectricalde®brillation.Previouslyreportedistheuseofemergencycardiopulmo-narysupporttoestablishamorefavorablemilieuforsuccessfulde®brillation(i.e.,improvedoxygenation,per-fusion,andacid-basebalance).Inpreviousreportsofemergencybypasssupport[3,14±17],allpatientswithVFweresuccessfullyconvertedtosinusrhythmwiththeinstitutionofCPSbutpriortorevascularization.Thepatientsdescribedhereinrepresentsituationsinwhichextracorporealsupport(andresultantcorrectionsinhemo-dynamicandacid-basedisturbance)alonewasinsuffi-cientforreestablishingsinusrhythmanddictatedtheneedforaddressingthepresumedischemicetiologyfortherefractoryelectricalstorm.Thesetwocasesthereforerepresentthe®rstreportsofpercutaneouscoronaryinterventionsinthe®brillatingheartmadepossiblebytheemergentinstitutionofECMOsupport.Incase1,effortsatrecanalizationoftheoccludedarterycouldnotbeachievedwithoutprolongedperiodsofpulselessnessandbrainanoxia.Incase2,itwasassumedthatonlyreliefoftheischemicburdenwouldmakede®brillationpossible.Giventheoptionsofintra-aorticballoonpumping,CPS,orECMOas``bailout''supportmeasures,thelatterwaschosenbecauseofananticipatedneedforprolongedcirculatorysupport(i.e.,longerthantheusual6-hrlimitationwithCPS).Atourinstitution,ECMOsupportcanbeachievedwithinminutes,especiallyinthecardiaccatheterizationlaboratorywherearterialandvenousaccessiseitheralreadyestablishedoreasilyattained.Onceplaced``oncircuit,''patientsareconstantlymoni-toredbyateamofphysicians,nurses,andtechniciansdedicatedtothecareofECMOpatients.Thisteamaccountsfortheabilitytoinstituterapidlyandcontinuesupportforprolongedperiodsoftime(sometimesupto30to40days).Survivalinthetwopatientsdescribed,despitepro-longedventricular®brillation,stemmedfromveryeffec-tiveinitialexternalcardiacmassageefforts,whichal-lowedtheoperatorstimetode®netheincitingproblemandbegincirculatorysupport.Inthe®rstcase,lossofwirepositionduringCPRprecludedimmediaterecanali-zationoftheculpritvesselanddictatedtheneedtostabilizethepatientbyextracorporealmeans.Multipleattemptsatde®brillationwereunsuccessfulinpartbe-causeofanischemicsubstrateandsevere,uncorrectableacidemia.Inthesecondcase,ECMOsupportallowedtimetotransportthepatienttothecatheterizationlabora-torywhererevascularizationcouldbeperformed.Inbothcases,maintenanceofsinusrhythmwasachievedonlyaftersuccessfulrevascularizationwasperformedwiththeheartstill®brillating.TheECMOtechniques,contrastedtothoseofCPS,thatcontributedtothesuccessinthesepatientswere:heparinanticoagulationbycontinuousinfusion,titratedtomaintainwholebloodactivatedclottingtime(ACT)at10sec;venousdrainagebysiphon,ratherthansuction,toeliminatehemolysis;theexclusionofreser-voirsorstagnantareaswithinthecircuit;platelettransfu-siontomaintainplateletcountgreaterthan100,000/mmandadedicatedteamofcaregiversusingprotocolsdesignedforextendedcontinuousperfusionintheICU.Ourreportdemonstratesthe®rstsuccessfuluseofextracorporealmembraneoxygenation-supportedpercuta-neouscoronaryrevascularizationinthe®brillatingheart.Successfulrevascularizationfacilitatedrestorationofsinusrhythminwhatwasotherwiserefractoryventricular®brillationandrepresentsdramaticevidenceforanischemicsubstrateinintractableventricular®brillation.1.GibbonJHJr.Applicationofamechanicalheartandlungapparatustocardiacsurgery.MinnMed1954;37:171.2.PhillipsSJ,ZeffRH,KongtohwornC,SkinnerJR,ToonRS,GrignonA,WickemeyerW,IannoneLA.Percutaneouscardiopul-monarybypass:applicationandindicationforuse.AnnThoracSurg1989;47:121±123.3.ShawlFA,DomanskiMJ,WishMH,DavisM,PunjaS,HernandezTJ.Emergencycardiopulmonarybypasssupportinpatientswithcardiacarrestinthecatheterizationlaboratory.CathetCardiovascDiagn1990;19:8±12.4.GrambowDW,DeebGM,PavlidesGS,MargulisA,O'NeillWW,BatesER.Emergentpercutaneouscardiopulmonarybypassinpatientshavingcardiovascularcollapseinthecardiaccatheteriza-tionlaboratory.AmJCardiol1994;73:872±875.5.BartlettRH,GazzanigaAB,JeffriesMR,HuxtableRF,HaiducNJ,FongSW.Extracorporealmembraneoxygenation(ECMO)cardio-pulmonarysupportininfancy.TransAmSocArtifInternOrgans6.BartlettRH,AndrewsAF,ToomasianJM,HaiducNJ,GassanigaAB.Extracorporealmembraneoxygenationfornewbornrespira-toryfailure:forty-®vecases.Surgery1982;92:425±433.7.AndersonHIII,SteimleC,ShapiroM,DeliusR,ChapmanR,HirschlR,BartlettR.Extracorporeallifesupportforadultcardiorespiratoryfailure.Surgery1993;114:161±172.8.PenningtonDG,McBrideLR,KanterKR,MillerLW,RuzevichSA,NaunheimK,SwartzMT,TermuhlenD.Bridgingtohearttransplantationwithcirculatorysupportdevices.JHeartTransplan-tation1989;8:116±1239.DeliusRE,ZwischenbergerJB,CilleyR,BehrendtDM,BoveEL,DeebGM,CrowleyD,HeidelbergerKP,BartlettRH.Prolongedextracorporeallifesupportofpediatricandadolescentcardiactransplantpatients.AnnThoracSurg1990;50:791±795.10.ReedyJE,SwartzMT,RaithelSC,SzukalskiEA,PenningtonDG.Mechanicalcardiopulmonarysupportforrefractorycardiogenicshock.HeartLung1990;19:514±523.11.DorrosG,CowleyMJ,SimpsonJ,BentivogilioLG,BlockLG,BourassaM,DetreK,GosselinAJ,KelseySF,KentKM,MockMB,MullinSM,MylerRK,PassamaniER,StertzerSH,Williams404Ricciardietal. DO.Percutaneoustransluminalcoronaryangioplasty:reportofcomplicationsfromtheNationalHeart,LingandBloodInstitutePTCAregistry.Circulation1983;67:723±730.12.SteffeninoG,MeierB,FinciL,VelebitV,vonSegesserL,FaiduttiB,RutishauserW.Acutecomplicationsofelectivecoronaryangioplasty:areviewof500consecutiveprocedures.BrHeartJ13.BrendanE,MahrerPR,AharonianVJ.Incidenceandpresumedetiologyofventricular®brillationduringcoronaryangioplasty.AmJCardiol1991;67:769±770.14.ShawlFA,BaxleyWA.Roleofpercutaneouscardiopulmonarybypassandothersupportdevicesininterventionalcardiology.CardiolClin1994;12:543±557.15.RaithelSC,SwartzMT,BraunPR,DakeSB,TaubJO,ZambieMA,MillerLW,DeligonulU,McBrideLR,PenningtonDG.Experiencewithanemergencyresuscitationsystem.ASAIOTrans16.MoriY,UenoK,HattoriA,KimT,AoyamaT,SegawaT,MimotoH,TomitaR,TanakaT,MoriN.Emergencycardiopulmonarybypasssupportinpatientswithcardiacarrestcausedbymyocar-dialinfarction.ArtifOrgans1994;18:698±701.17.OverliePA,WalterPD,HurdHPII,WellsGA,SegerJJ,ZiasJ,WeyRJ,JensenJB,ShoukfehMF,LevineMJ,etal.Emergencycardiopulmonarysupportwithcirculatorysupportdevices.Cardi-ology1994;84:231±237.PTCAintheFibrillatingHeart405