Early Coronary Reperfusion Facilitates Return of Spontaneous Circulation and Improves Cardiovascular Outcomes After Ischemic Cardiac Arrest and Extracorporeal Resuscitation in Pigs

Abstract

BackgroundExtracorporeal cardiopulmonary resuscitation (ECPR) is widely proposed for the treatment of refractory cardiac arrest. It should be associated with coronary angiography if coronary artery disease is suspected. However, the prioritization of care remains unclear in this situation. Our goal was to determine whether coronary reperfusion should be instituted as soon as possible in such situations in a pig model.Methods and ResultsAnesthetized pigs were instrumented and submitted to coronary artery occlusion and ventricular fibrillation. After 5 minutes of untreated cardiac arrest, conventional cardiopulmonary resuscitation (CPR) was started. Fifteen minutes later, ECPR was initiated for a total duration of 240 minutes. Animals randomly underwent either early or late coronary reperfusion at 20 or 120 minutes of ECPR, respectively. This timing was adapted to the kinetic of infarct extension in pigs. Return of spontaneous circulation was determined as organized electrocardiogram rhythm with systolic arterial pressure above 80 mm Hg. During conventional CPR, hemodynamic parameters were not different between groups. Carotid blood flow then increased by 70% after the onset of ECPR in both groups. No animal (0 of 7) elicited return of spontaneous circulation after late reperfusion versus 4 of 7 after early reperfusion (P=0.025). The hemodynamic parameters, such as carotid blood flow, were also improved in early versus late reperfusion groups (113±20 vs 43±17 mL/min after 240 minutes of ECPR, respectively; P=0.030), along with infarct size decrease (71±4% vs 84±2% of the risk zone, respectively; P=0.013).ConclusionsEarly reperfusion improved hemodynamic status and facilitated return of spontaneous circulation in a porcine model of ischemic cardiac arrest treated by ECPR.

Effects of Prolonged Serum Calcium Suppression during Extracorporeal Cardiopulmonary Resuscitation in Pigs

“…The animals in the intervention group showed a significantly lower mean coronary perfusion pressure than those in the control group (Figure 4B). Early and adequate coronary reperfusion is important for functional recovery and for preventing myocardial damage after cardiac arrest [41][42][43]. Accordingly, the presented study found an increase in arrhythmias in the intervention group, which, on the one hand, could be interpreted as a direct effect of the proarrhythmogenic effects of hypocalcemia, and, on the other hand, as a consequence of the lower CPP, as already assumed in preliminary studies.…”

A Pre-Hospital Extracorporeal Cardio Pulmonary Resuscitation (ECPR) strategy for treatment of refractory out hospital cardiac arrest: An observational study and propensity analysis

“…This etiologic research strategy allows identification of the cause of OHCA in 59% of cases [31]. Several registries or animal studies have shown that immediate or emergent coronary angiography may improve survival of OHCA [32,33]. The overall invasive strategy implemented may therefore have contributed to the higher survival rate, although improved survival with Period 2 was still observed after several types of adjustments for the use of myocardial revascularization procedures were made.…”

ECMO in Cardiac Arrest: A Narrative Review of the Literature

“…In this specific group of patients, studies have demonstrated that coronary lesions are frequently multiple and proximal [ 68 , 69 ]. Moreover, it has been shown that the delay between CA and PCI is associated with survival [ 70 ]. If a pulmonary embolism is the origin of the CA, an injected pulmonary CT-scan should be considered to confirm the diagnosis [ 71 ].…”