Percutaneous Coronary Intervention During Cardiac Arrest and Ongoing Chest Compressions Figure 7: An Actual Registration of the Arterial Blood Pressure in a Patient with Cardiac Arrest Arterial Pressure 120 100 80 60 40 20 0 8,500 9,000 9,500 10,000 10,500 23 seconds The arrow illustrates the point where mechanical chest compressions are initiated with the LUCAS device. Wagner et al.26 Conclusion
In summary none of the devices provides perfect circulation or perfect fluoroscopic images. Sustainable circulation is easily achieved, however, and a continued PCI can still be performed by an experienced operator and often lead to a life-saving procedure despite prolonged cardiac arrest.
Discussion
Chest compressions in the cath lab during cardiac arrest have traditionally been performed by manual compressions. The recent introduction of mechanical chest compression devices may offer advantages compared to manual chest compression in cases of prolonged cardiac arrest. This is due to better fluoroscopic imaging during the procedure, better compressions due to an improved aortic pressure waveform and better ergonomics for the cath lab staff. Mechanical chest compressors also allow for a continued, uninterrupted interventional procedure during a potentially life-saving procedure. In light of the numerous reports of successful use of mechanical chest compressions in the cath lab, which have been noted in the recent 2010 Resuscitation guidelines,18
a case could be
made that mechanical chest compression devices should be available to all cath labs. Data are currently severely lacking on the use of manual chest compression in the cath lab in cases with prolonged cardiac arrest. Experience among cardiologists is that it is exceedingly difficult to maintain circulation with manual compressions while continuing the interventional procedure that may be life-saving.7
In
these circumstances, mechanical chest compressions may be of benefit. The use of mechanical chest compressions has resulted in more published case reports than were previously available. The devices offer a much better working environment for the cath lab staff and very likely better quality compressions compared to manual efforts, specifically in the cath lab.25,26
It has also been the experience
of the authors that with a machine performing the compressions and stabilising the circulation of the patient, a large burden of stress is relieved in an otherwise tension-ridden situation. A common feeling is that this tension relief allows for an improved, continued intervention where the operator can better concentrate on the task at hand. In
INTERVENTIONAL CARDIOLOGY
which patients should a mechanical device be used in the cath lab? In published case series it appears that patients already in cardiac arrest when brought into the cath lab with ongoing mechanical chest compressions have extremely high mortality rates.14
In contrast,
Patients in cardiac arrest with re-established circulation only through ongoing mechanical chest compressions should therefore be carefully selected before being brought to the cath lab. The alternative to the use of mechanical chest compression devices as a means to improve survival during prolonged cardiac arrest in the cath lab may be through the use of portable extra corporal membrane oxygenator (ECMO) machines. These are simple to operate and use percutaneously inserted arterial and venous access. ECMO machines may thus hold real promise, not as an alternative to mechanical chest compressions, but rather as a complement. Mechanical chest compression devices have the advantage of being initiated very quickly to stabilise circulation. If required, the patient can then be placed on an ECMO. This may be useful in patients who are difficult to ventilate, such as in cases of pulmonary oedema or in patients still in cardiac arrest following the end of a technically successful intervention.12
patients who initially arrive alive to the cath lab and then suffer a severe prolonged cardiac arrest may have survival rates of up to 30%.17
11,000 11,500 12,000
ECMO, PCPB and PLVADs seem to be effective but are usually time-consuming to initiate and can require extra staff with special skills, such as a cardiovascular surgeon and a perfusionist.
Conclusion
In conclusion, the use of mechanical chest compressions to maintain circulation during prolonged cardiac arrest in the cath lab may be superior to the use of manual chest compressions. The use of mechanical chest compressions can facilitate a potentially lifesaving continued coronary intervention and may also be used as a bridge to ECMO or other means of cardiopulmonary bypass. n
15
Percutaneous cardio pulmonary bypass (PCPB) or percutaneous left ventricular assist devices (PLVADs), such as Impella (Abiomed) or TandemHeart (CardiacAssist), may also be used as an alternative to an ECMO. Several small studies using PCPB and an ECMO in intractable cardiac arrest have reported promising results.8–10,31
mmHg
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