Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest

Abstract

Background— Targeted temperature management is recommended after out-of-hospital cardiac arrest. Whether advanced internal cooling is superior to basic external cooling remains unknown. The aim of this multicenter, controlled trial was to evaluate the benefit of endovascular versus basic surface cooling. Methods and Results— Inclusion criteria were the following: age of 18 to 79 years, out-of-hospital cardiac arrest related to a presumed cardiac cause, time to return of spontaneous circulation <60 minutes, delay between return of spontaneous circulation and inclusion <240 minutes, and unconscious patient after return of spontaneous circulation and before the start of cooling. Exclusion criteria were terminal disease, pregnancy, known coagulopathy, uncontrolled bleeding, temperature on admission <30°C, in-hospital cardiac arrest, immediate need for extracorporeal life support or hemodialysis. Patients were randomized between 2 cooling strategies: endovascular femoral devices (Icy catheter, Coolgard, Zoll, formerly Alsius; n=203) or basic external cooling using fans, a homemade tent, and ice packs (n=197). The primary end point, that is, favorable outcome evaluated by survival without major neurological damage (Cerebral Performance Categories 1–2) at day 28, was not significantly different between groups (odds ratio, 1.41; 95% confidence interval, 0.93–2.16; P =0.107). Improvement in favorable outcome at day 90 in favor of the endovascular group did not reach significance (odds ratio, 1.51; 95% confidence interval, 0.96–2.35; P =0.07). Time to target temperature (33°C) was significantly shorter and target hypothermia was more strictly maintained in the endovascular than in the surface group ( P <0.001). Minor side effects directly related to the cooling method were observed more frequently in the endovascular group ( P =0.009). Conclusion— Despite better hypothermia induction and maintenance, endovascular cooling was not significantly superior to basic external cooling in terms of favorable outcome. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00392639.

Implementation of targeted temperature management after cardiac arrest in Polish intensive care units. What has changed in the last five years?

“…Similar to the Italian study [17], 36% of our respondents cited lack of equipment as the reason for not using TTM. There is no contraindication for using TTM without specific equipment; despite more precise temperature control, reduced latency in reaching the target temperature (when 32-34°C is chosen as the target), and less nursing staff workload, there is no evidence of better patient outcomes when using dedicated equipment [22,23].…”

Emergency Neurological Life Support: Resuscitation Following Cardiac Arrest

“…One study found good neurological outcomes of 35.4 versus 25.6 % for endovascular versus surface cooling [46]; another, of 45 versus 38 % [47]. Recently, the results of a prospective multicenter RCT in 400 patients comparing endovascular to basic surface cooling methods have been published [48]. The authors observed significantly shorter time to target temperature, fewer cases of overshoot, more effective temperature control during maintenance and re-warming, reduced nursing workload, and a trend to better outcome at 90 days (34.6 vs. 26.0 %, OR 1.51 [0.96-2.35], p = 0.07) with endovascular cooling [48].…”

“…Recently, the results of a prospective multicenter RCT in 400 patients comparing endovascular to basic surface cooling methods have been published [48]. The authors observed significantly shorter time to target temperature, fewer cases of overshoot, more effective temperature control during maintenance and re-warming, reduced nursing workload, and a trend to better outcome at 90 days (34.6 vs. 26.0 %, OR 1.51 [0.96-2.35], p = 0.07) with endovascular cooling [48]. It is unclear whether these differences were due to the specific cooling technologies used, or (more likely) to greater efficacy and accuracy of temperature control, especially during maintenance and re-warming [49].…”

How to Stay Cool in the Intensive Care Unit?

“…Now there is compelling new evidence on this issue from a study by Deye and coworkers, 20 who compared endovascular with surface cooling in a prospective, multicenter RCT, the results of which are published in this issue of Circulation. The authors enrolled 400 patients; 203 were treated with endovascular cooling (using Zoll femoral Icy catheters) and 197 were treated with external cooling (ice packs, fans, and a homemade tent).…”

“…The main findings were as follows: significantly shorter time to target temperature (33.0°C), greater stability of temperature (defined as time within target ±1°C) in the maintenance phase, and reduced nursing workload (10 versus 38 minutes, P<0.001) in the endovascular group; more minor side effects (likely attributable to more effective cooling) in the endovascular group (P=0.009); a nonsignificant trend toward more favorable outcome at 28 days (36.0 versus 28.4%, odds ratio 1.41 [0.93-2.16], P=0.107; for shockable rhythm 53.7% versus 37.1%, odds ratio 1.97 [0.99-3.9], P=0.269) and at 90 days (34.6% versus 26.0%, odds ratio 1.51 [0.96-2.35], P=0.07) in the endovascular group; and fewer cases of severe overshoot (below 30°C) in the endovascular group (n=0 versus n=3). 20 Of note, strict fever control was maintained for a minimum of 3 days following rewarming in both groups. This is the first major study to directly compare the 2 fundamental cooling methodologies, ie, surface versus core cooling, in a prospective RCT; the authors are to be congratulated.…”