Targeted Delivery of Electrical Shocks and Epinephrine, Guided by Ventricular Fibrillation Amplitude Spectral Area, Reduces Electrical and Adrenergic Myocardial Burden, Improving Survival in Swine

Abstract

Background We previously reported that resuscitation delivering electrical shocks guided by real‐time ventricular fibrillation amplitude spectral area (AMSA) enabled return of spontaneous circulation (ROSC) with fewer shocks, resulting in less myocardial dysfunction. We now hypothesized that AMSA could also guide delivery of epinephrine, expecting further outcome improvement consequent to less electrical and adrenergic burdens. Methods and Results A swine model of ventricular fibrillation was used to compare after 10 minutes of untreated ventricular fibrillation a guidelines‐driven (n=8) resuscitation protocol, delivering shocks every 2 minutes and epinephrine every 4 minutes, with an AMSA‐driven shocks (n=8) protocol, delivering epinephrine every 4 minutes, and with an AMSA‐driven shocks and epinephrine (ADSE; n=8) protocol. For guidelines‐driven, AMSA‐driven shocks, and ADSE protocols, the time to ROSC (mean±SD) was 569±164, 410±111, and 400±80 seconds ( P =0.045); the number of shocks (mean±SD) was 5±2, 3±1, and 3±2 ( P =0.024) with ADSE fewer than guidelines‐driven ( P =0.03); and the doses of epinephrine (median [interquartile range]) were 2.0 (1.3–3.0), 1.0 (1.0–2.8), and 1.0 (0.3–3.0) ( P =0.419). The ROSC rate was similar, yet survival after ROSC favored AMSA‐driven protocols (guidelines‐driven, 3/6; AMSA‐driven shocks, 6/6; and ADSE, 7/7; P =0.019 by log‐rank test). Left ventricular function and survival after ROSC correlated inversely with electrical burden (ie, cumulative unsuccessful shocks, J/kg; P =0.020 and P =0.046) and adrenergic burden (ie, total epinephrine doses, mg/kg; P =0.042 and P =0.002). Conclusions Despite similar ROSC rates achieved with all 3 protocols, AMSA‐driven shocks and ADSE resulted in less postresuscitation myocardial dysfunction and better survival, attributed to attaining ROSC with less electrical and adrenergic myocardial burdens.

Mapping the research trends and hot topics of ventricular arrhythmia: A bibliometric analysis from 2001 to 2020

“…An excellent paradigm for this is the recent work by Salvatore R. Aiello et al, whose experimental design and protocol were ingenious and clinically meaningful. This comparative study combined a large animal experiment with a clinical guideline-driven resuscitation protocol, and positive results were obtained, although the research topic was focused but not novel (i.e., AMSA) ( 39 ). More importantly, the starting point of this experimental design offers a significant benefit and valuable reference to researchers in this field.…”

Feature tracking strain analysis detects the onset of regional diastolic dysfunction in territories with acute myocardial injury induced by transthoracic electrical interventions

“…To the best of our knowledge this is the first published investigation about the onset of regional changes in systolic and diastolic biventricular function after transthoracic shocks. Previous imaging investigations have focused on global volumetric changes, while other non-invasive techniques have utilized serology markers 3 , 6 , 22 , 23 . Yet, the electrical pathway from transthoracic shocks can vary across the heart and these global techniques cannot identify the unique distributions of myocardial injury that occur as a result.…”

“…However, myocardial injury follows unique pathways through the thorax in each individual and it is unknown how it impacts regional ventricular function. In swine, Aeillo et al demonstrated that increased electrical burden, defined by the cumulative energy of unsuccessful shocks, was linked to reduced LV function and survival 6 . Common functional measures such as ejection fraction (EF) and volumes are limited in that they represent only global ventricular function and the effects of transthoracic shocks on regional myocardial function have yet not been systematically assessed.…”

Prediction of Shock-Refractory Ventricular Fibrillation During Resuscitation of Out-of-Hospital Cardiac Arrest

“…The use of AI to automate a more patient-specific approach to resuscitation care using real-time signals such as the ECG is a promising area of investigation. 30,[35][36][37][38] However, clinician adoption of AI to inform medical decisions can be challenged by the "black box" nature of many classification algorithms (eg, deep neural networks). 39,40 This is especially salient for AI applications that might modify guideline care in real time during OHCA resuscitation.…”