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Lengthy resuscitations in the catheterisation laboratory carry extremely high rates of mortality because it is essentially impossible to perform effective chest compressions during percutaneous coronary intervention (PCI). The purpose of this study was to evaluate the use of a mechanical chest compression device, LUCAS, in the catheterisation labor...
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Context 1
... arrest in the catheterisation laboratory during percutaneous coronary interventions (PCIs), although a rare event, is often treated rapidly and successfully with cardiopulmonary resuscitation (CPR) and DC conversions. 1 In a minority of these patients, the initial resuscitation efforts are not immediately successful, and extended periods of manual chest compressions are needed to maintain coronary and cerebral circulation. In patients who require prolonged CPR, mortality rates are very high. Fre- quently, a continued uninterrupted PCI procedure of, for example, a suddenly occluded left main artery is often the best option for attaining return of spontaneous circulation (ROSC). However, continued cardiac compressions with simultaneous PCI, which requires fluoroscopy, is exceedingly difficult to perform effectively. A novel mechanical chest compression device, LUCAS TM (Jolife AB, Lund, Sweden), (Fig. 1), has been shown to sustain both coronary and cerebral circulation despite cardiac arrest. 3,4 The device is mostly radio translucent, enabling continued PCI with maintained circulation despite ongoing cardiac arrest, which has been docu- mented in several reports. 5–9 Although LUCAS TM has been shown to be successfully used in the catheterisation laboratory to maintain circulation, 5–9 a recent report found abysmal survival rates in patients who were brought to the catheterisation laboratory in cardiac arrest but with circulation maintained with mechanical chest compressions. 8 Our experience since 2004 with the chest compression device LUCAS TM is similar. Essentially, all patients admitted to our catheterisation laboratory already in cardiac arrest, but with circulation maintained through mechanical chest compressions, do not survive. However, patients who arrive at the catheterisation laboratory with intact circulation and who then suf- fer cardiac arrest in the catheterisation laboratory, often during the procedure of angiography or PCI, may have a benefit of LUCAS TM , especially if there is concomitant PCI performed. The study is a retrospective registry analysis of all patients who suffered a prolonged resuscitation episode while scheduled for any procedure in the coronary catheterisation laboratory at the Lund University Hospital during 2004–2008, to which the hospital’s cardiac arrest team was alerted. The database of the cardiac arrest team was used to find the patients in the study. Prolonged resuscitation was defined as an episode of cardiac arrest necessitating a period of several minutes of manual chest compressions, followed by the use of a mechanical chest compressions and then tracheal intubation. The other selection criterion was that the patients had to arrive alive to the catheterisation laboratory before the episode of cardiac arrest. We also evaluated similar patients (requiring >1 min of manual chest compressions and requiring tracheal intubation) in which no mechanical chest compression device was used in the same time span. During the period 1 January 2004 to 31 December 2007, the mechanical chest compression device used was LUCAS V1 (Euro- pean version). 3 During the period 1 January 2008 to 31 December 2008, the mechanical chest compression device used was LUCAS V2 (US version), which has the same operating parameters as LUCAS V1 except for the decompression force which is set to a maximum of 13 N. All charts and autopsy reports of our cohort of 43 patients were examined. The predefined endpoints were mortality sta- tus on departure from the catheterisation laboratory, successful PCI and discharge from hospital in the Cerebral Performance Categories (CPCs) 1 or 2, 10 representing a good neurological outcome. The use of LUCAS TM was stopped at the discretion of the attend- ing physician either because the patient achieved ROSC or because further treatment with LUCAS TM was deemed futile. During the study period, a total of 6350 PCIs were performed of which 3058 patients were treated for acute ST-elevation myocardial infarctions (STEMI). A total of 118 patients were in cardiogenic shock and 81 required defibrillations due to VF or ventricular tachycardia (VT). Mechanical chest compressions were used in 43 patients of which 31 (72%) were males. Patients were between ages 31 and 86 years (mean age: 73.3 years). The patients were admitted for STEMI, non-ST-elevation myocardial infarct (NSTEMI), elective PCI and pericardiocentesis (Table 1). The culprit artery was the left anterior descending artery (LAD) or the left main in 81% of the cases and 65% of the patients had PEA as the initial rhythm during cardiac arrest (Table 1). A total of 36 PCIs were attempted in the 42 patients with coronary disease, of which 27 PCIs were considered ‘technically successful’ procedures defined as a residual stenosis <50% at the site of the target lesion and achieving TIMI 2 or TIMI 3 blood flow with ongoing mechanical chest compressions (Table 2). 11 Rea- sons for unsuccessful PCIs were primarily complex lesions, distal embolisation or no reflow in the coronary arteries and not primarily due to the use of LUCAS TM . A total of 39 patients were treated with LUCAS TM , and mean treatment time was 28.15 min (SEM ± 3.4, range: 1–90 min). Seventeen patients were discharged from the catheterisation laboratory, one with ongoing treatment with mechanical chest compressions and 16 with ROSC. Twenty- six patients were declared dead in the catheterisation laboratory (Fig. 2). In six of the coronary patients, no PCI was performed; in five cases, the reason was undiagnosed subacute myocardial rupture that suddenly became a fulminate rupture in the catheterisation laboratory and in one case, it was global ischaemia without any obvious culprit lesion. All five patients with myocardial rupture and tamponade died. Three patients were referred for emergency cardiac surgery, of which two died during surgery ...
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Citations
... We noted, however, that patients suffering from cardiac arrest died significantly more often than those in the control group, i.e., in 19.4% and 40% of performed RA-PCI and angiography cases, respectively. In other studies, reported short-term survival rates varied greatly, from 46.7% to 75%, and equaled approximately 25% at the time of discharge [13,[16][17][18][19]. Wagner et al. reported also an 87% survival rate after one year among patients who were alive at the discharge time [17]. ...
BACKGROUND: Rotational atherectomy (RA) is traditionally administered for patients with heavily calcified lesions and is thereby characterized by a high risk of the performed intervention. However, the prevalence characteristics of cardiac arrest are poorly studied in this group of patients. We aimed to evaluate the frequency and risk factors of cardiac arrest during percutaneous coronary interventions (PCI) performed with RA and preceding coronary angiography (CA). METHODS: Based on the data collected in the Polish Registry of Invasive Cardiology Procedures (ORPKI) from 2014 to 2021, we included 6522 patients who were treated with RA-assisted PCI. We scrutinized patient and procedural characteristics, as well as periprocedural complications, subsequently comparing groups in terms of cardiac arrest incidence with the use of univariable and multivariable analyses. RESULTS: Thirty-five (0.5%) patients suffered from cardiac arrest during RA-PCI or preceding CA. They were characterized by significantly higher rates of prior stroke, acute coronary syndromes (ACS) as indications and higher Killip class (P < 0.001) at the admission time. Among the confirmed independent predictors of in-procedure cardiac arrest, the following can be noted: factors related to patients’ clinical characteristics (e.g., older age, female sex, and disease burden), periprocedural characteristics (e.g., PCI within left main coronary artery [LMCA]), and periprocedural complications (e.g., coronary artery perforation and no-reflow phenomenon). CONCLUSIONS: Severe clinical condition at baseline, expressed by ACS presence and Killip class IV, as well as RA-PCI performed within LMCA and other periprocedural complications, were the strongest predictors of cardiac arrest during RA-assisted PCI and CA.
... In pig models, the LUCAS device maintains adequate positive coronary perfu- Original Article sion pressure for 20 minutes and restores 60% of cerebral blood flow for 15 minutes [9,19]. In humans, Larsen et al. [10] and Wagner et al. [20] have shown, that LUCAS devices could achieve a mean systolic blood pressure of 70 mmHg (range 60-110 mmHg) during PCI. In this series, coronary angiography was performed in all patients, and PCI in nine while receiving adequate CPR. ...
... Only 1% of IHCAs in a large US registry were treated with ECPR [28]. Furthermore, two studies comparing ECPR with standard care did not show an increase in survival with this technique [29,30] Larsen et al. [10] Wagner et al. [20] Biondi-Zoccai et al. [31] Azadi et al. [12] Kalra et al. [32] Libungan et al. [33] Wagner et al. [34] Fishman et al. Original Article ...
... Mechanical CPR devices are attractive in this setting as they avoid radiation exposure to the team members and can ensure ongoing CPR while the underlying cause of the arrest can be promptly addressed. 17 Several mechanical CPR devices have been designed to be partially radiolucent to facilitate such interventions. 18 In recent years, there has been growing enthusiasm for extracorporeal membrane oxygenation (ECMO) for use in refractory cardiac arrest, largely based on the positive findings from the advanced reperfusion strategies for patients with outof-hospital cardiac arrest and refractory ventricular fibrillation (ARREST) trial. ...
... Thus, these systems may be beneficial as a bridge to treatment tool or as a bridge to decision on further treatment, and may be considered especially during prolonged resuscitation attempts. This might arise under specific conditions, such as, for example, sustaining ventricular fibrillation (VF) [50] or hypothermic cardiac arrest [50][51][52][53][54], patient transportation [5,[55][56][57], diagnostics, such as computed tomography (CT) [5,[58][59][60] (not chest X-rays [61]), and interventions, such as percutaneous coronary intervention (PCI) [5,58,62], fibrinolysis [60,63], dialysis [54], extra-corporeal membrane oxygenation (ECMO) [5], transcatheter aortic valve implantation (TAVI) [64], surgery [65,66], or organ preservation until retrieval [5,67]. On the other hand, after the implementation of mechanical CPR devices in a German EMS system, a dramatic increase in transportation with ongoing CPR, even for patients with unfavorable prognoses, has been observed [68]. ...
Background:
Despite numerous promising innovations, the chance of survival from sudden cardiac arrest has remained virtually unchanged for decades. Recently, technological advances have been made, user-friendly portable devices have been developed, and advanced invasive procedures have been described that could improve this unsatisfactory situation.
Methods:
A selective literature search in the core databases with a focus on randomized controlled trials and guidelines.
Results:
Technical aids, such as feedback systems or automated mechanical cardiopulmonary resuscitation (CPR) devices, can improve chest compression quality. The latter, as well as extracorporeal CPR, might serve as a bridge to treatment (with extracorporeal CPR even as a bridge to recovery). Sonography may be used to improve thoracic compressions on the one hand and to rule out potentially reversible causes of cardiac arrest on the other. Resuscitative endovascular balloon occlusion of the aorta might enhance myocardial and cerebral perfusion. Minithoracostomy, pericardiocentesis, or clamshell thoracotomy might resolve reversible causes of cardiac arrest.
Conclusions:
It is crucial to identify those patients who may benefit from an advanced or invasive procedure and make the decision to implement the intervention in a timely manner. As with all infrequently performed procedures, sound education and regular training are paramount.
... The median age (73 years), the incidence of comorbidities and the initial rhythm of SCA were close to those perceived in our patients. The main difference was also the proportion of STEMI, equal to 77%; however, it did not markedly influence overall survival compared to our analysis [12]. ...
... In their study, from 56 patients with OHCA that underwent PCI during CPR with LUCAS, only 1 survived to hospital discharge [14]. Similarly, in the case series described by Wagner, only the subjects with SCA at the CathLab survived, but not the patients with OHCA [12]. ...
... In CKD, there are numerous ion disturbances that, by affecting the membrane potential, reduce the sensitivity of cells to interstitial hyperkalemia. Since CPR conduced with LUCAS-2 provides up to 60% of physiological blood flow through the circulatory system [12], it might be enough to enable ROSC in some subjects. ...
Sudden cardiac arrest (SCA) is one of the most perilous complications of acute myocardial infarction (AMI). For years, the return of spontaneous circulation (ROSC) has had to be achieved before the patient could be treated at the catheterization laboratory, as simultaneous manual chest compression and angiography were mutually exclusive. Mechanical chest compression devices enabled simultaneous resuscitation and invasive percutaneous procedures. The aim was to characterize the poorer responders that would allow one to predict the positive outcome of such a treatment. We retrospectively analyzed the medical charts of 94 patients with SCA due to AMI, who underwent mechanical cardiopulmonary resuscitation during angiography. In total, 48 patients, 8 (17%) of which survived the event, were included in the final analysis, which revealed that 83% of the survivors had mild to moderate hyperkalemia (potassium 5.0–6.0 mmol/L), in comparison to 15% of non-survivors (p = 0.002). In the age- and sex-adjusted model, patients with serum potassium > 5.0 mmol/L had 4.61-times higher odds of survival until discharge from the hospital (95% CI: 1.41–15.05, p = 0.01). Using the highest Youden index, we identified the potassium concentration of 5.1 mmol/L to be the optimal cut-off value for prediction of survival until hospital discharge (83.3% sensitivity and 87.9% specificity). The practical implications of these findings are that patients with potassium levels between 5.0 and 6.0 mmol/L may actually benefit most from percutaneous coronary interventions with ongoing mechanical chest compressions and that they do not need immediate correction for this electrolyte abnormality.
... Class IIb, Level of Evidence C The use of mechanical CPR has been extensively investigated in at least nine randomised trials with over 12,000 patients in both out-of-hospital and in hospital arrest. Several meta-analyses exist and support the use of mechanical CPR for in hospital patients, although the evidence is less strong for use in out-of-hospital [43,46,[92][93][94] The AHA reviewed the feasibility of using mechanical CPR devices during PCI and identified papers where feasibility has been demonstrated in both animal [37], and human [38][39][40][41] studies. No comparative studies have examined the use of mechanical CPR devices compared with manual chest compressions during PCI procedures although, due to the inherent need to cease manual compressions during fluoroscopy, there is a clear benefit for mechanical CPR. ...
... A number of case reports [37,38] and case series [40,41,42,95] have reported the use of mechanical CPR devices to facilitate prolonged resuscitation in patients who have a cardiac arrest during PCI. One study demonstrated that the use of a mechanical CPR device for cardiac arrest during PCI was feasible; however, no patients survived to hospital discharge [40]. ...
More than 300 000 procedures are performed in cardiac catheter laboratories in the UK each year. The variety and complexity of percutaneous cardiovascular procedures have both increased substantially since the early days of invasive cardiology, when it was largely focused on elective coronary angiography and single chamber (right ventricular) permanent pacemaker implantation. Modern-day invasive cardiology encompasses primary percutaneous coronary intervention, cardiac resynchronisation therapy, complex arrhythmia ablation and structural heart interventions. These procedures all carry the risk of cardiac arrest.
We have developed evidence-based guidelines for the management of cardiac arrest in adult patients in the catheter laboratory. The guidelines include recommendations which were developed by collaboration between nine professional and patient societies that are involved in promoting high-quality care for patients with cardiovascular conditions. We present a set of protocols which use the skills of the whole catheter laboratory team and which are aimed at achieving the best possible outcomes for patients who suffer a cardiac arrest in this setting. We identified six roles and developed a treatment algorithm which should be adopted during cardiac arrest in the catheter laboratory. We recommend that all catheter laboratory staff undergo regular training for these emergency situations which they will inevitably face.
... Shock-resistant VF, on the other hand, is much less common, especially since the advent of biphasic defibrillation. If, however, the patient is found to have this arrhythmia, their chances of survival are even smaller, as the mortality of patients requiring prolonged cardiopulmonary resuscitation (CPR) is very high, reaching up to 95% [4]. Mechanical chest compression devices are useful in cases of prolonged cardiac arrest [4]. ...
... If, however, the patient is found to have this arrhythmia, their chances of survival are even smaller, as the mortality of patients requiring prolonged cardiopulmonary resuscitation (CPR) is very high, reaching up to 95% [4]. Mechanical chest compression devices are useful in cases of prolonged cardiac arrest [4]. Thanks to these devices, patients with OHCA refractory to standard ALS can be transported directly to the hospital while CRP is being administered. ...
Introduction:
Sudden cardiac arrest is one of the most common causes of death. In cases of shock-resistant ventricular fibrillation, immediate transport of patients to the hospital is essential and made possible with use of devices for mechanical chest compression.
Objectives:
The efficacy of AutoPulse in patients with shock-resistant ventricular fibrillation was studied.
Methods:
This is a multicentre observational study on a population of 480,000, with 192 reported cases of out-of-hospital cardiac arrest. The study included patients with shock-resistant ventricular fibrillation defined as cardiac arrest secondary to ventricular fibrillation requiring ≥3 consecutive shocks. Eventually, 18 patients met the study criteria.
Results:
The mean duration of resuscitation was 48.4±43 min, 55% of patients were handed over to the laboratory while still in cardiac arrest, 83.3% of them underwent angiography and, in 93.3% of them, infarction was confirmed. Coronary intervention was continued during mechanical resuscitation in 50.0% of patients, 60% of patients survived the procedure, and 27.8% of the patients survived.
Conclusions:
Resistant ventricular fibrillation suggests high likelihood of a coronary component to the cardiac arrest. AutoPulse is helpful in conducting resuscitation, allowing the time to arrival at hospital to be reduced.
... Outcomes for LUCAS-assisted PCI for cardiac arrest occurring in the catheterization lab seem to be less dire. For this patient population, Wagner et al. found that 11 of 43 patients in their small study survived till hospital discharge with normal neurologic status [1,7]. Despite the limited trials and studies, there are data supporting that for the right patient, LUCAS-assisted PCI can provide a means of survival. ...
We present a case of a 45-year-old female who presented to a community hospital with an anterior ST-elevation myocardial infarction (STEMI) that subsequently developed prolonged ventricular fibrillation (VF) refractory to repeated defibrillation and antiarrhythmic medications. Primary percutaneous coronary intervention was performed in the patient with VF but supported only by the Lund University Cardiac Arrest System (LUCAS). Despite a total VF time of 127 minutes, the patient was eventually discharged neurologically intact with a normal left ventricular function. For the right patient, this case illustrates the utility of the LUCAS device, especially at community hospitals without immediate venoarterial extracorporeal membrane oxygenation or ventricular assist device capability.
... 8 Studies of the Lund University Cardiopulmonary Assist System (LUCAS), a type of MPD with a vacuum head, reported improved perfusion to cerebral neurological systems and coronary arteries, achieving high PCO 2 values compared to standard manual compression. [9][10][11] The LUCAS is also amenable for use during coronary catheterization 12,13 and during Extracorporeal cardiopulmonary resuscitation (ECPR), a rescue strategy for nonresponders to CPR in cardiac arrest. 13 With the expanded distribution of ACD devices, investigations of their relative efficacy and safety in patients with OHCA have increased. ...
Objective
Survival after out-of-hospital cardiac arrest (OHCA) depends on multiple factors, mostly quality of chest compressions. Studies comparing manual compression with a mechanical active compression-depression device (ACD) have yielded controversial results in terms of outcomes and injury. The aim of the present study was to determine whether out-of-hospital ACD cardiopulmonary resuscitation (CPR) use is associated with more skeletal fractures and/or internal injuries than manual compression, with similar duration of cardiopulmonary resuscitation (CPR) between the groups.
Methods
The cohort included all patients diagnosed with out-of-hospital cardiac arrest (OHCA) at a tertiary medical center between January 2018 and June 2019 who achieved return of spontaneous circulation (ROSC). The primary outcome measure was the incidence of skeletal fractures and/or internal injuries in the two groups. Secondary outcome measures were clinical factors contributing to skeletal fracture/internal injuries and to achievement of ROSC during CPR.
Results
Of 107 patients enrolled, 45 (42%) were resuscitated with manual chest compression and 62 (58%) with a piston-based ACD device (LUCAS). The duration of chest compression was 46.0 minutes vs. 48.5 minutes, respectively (p=0.82). There were no differences in rates of ROSC (53.2% vs.50.8%, p=0.84), cardiac etiology of OHCA (48.9% vs.43.5%, p=0.3), major complications (ribs/sternum fracture, pneumothorax, hemothorax, lung parenchymal damage, major bleeding), or any complication (20.5% vs.12.1%, p=0.28). On multivariate logistic regression analysis, factors with the highest predictive value for ROSC were cardiac etiology (OR 1.94;CI 2.00–12.94) and female sex (OR 1.94;CI 2.00–12.94). Type of arrhythmia had no significant effect. Use of the LUCAS was not associated with ROSC (OR 0.73;CI 0.34–2.1).
Conclusion
This is the first study to compare mechanical and manual out-of-hospital chest compression of similar duration to ROSC. The LUCAS did not show added benefit in terms of ROSC rate, and its use did not lead to a higher risk of traumatic injury. ACD devices may be more useful in cases of delayed ambulance response times, or events in remote locations.
... [24][25][26][27] With the Lucas device, all views except for straight antero-posterior are applicable during cardiac catheterization, and the device permits free movement of the X-ray detector. 28 The force delivered does not affect the catheterization itself, although minor interruptions for coronary stent deployment may be needed. 28 On the other hand, the delay of the initial deployment has been reported as a drawback. ...
... 28 The force delivered does not affect the catheterization itself, although minor interruptions for coronary stent deployment may be needed. 28 On the other hand, the delay of the initial deployment has been reported as a drawback. However, with training, this time can be reduced to a median of seven seconds. 9 Data so far have contemplated the use of an ACCD during PCI, in most cases with the Lucas device, and suggested improved ROSC rates along with better survival rate and neurological outcomes at hospital dis-charge compared to manual CCs. ...
Research regarding the use of mechanical compressions in the setting of a cardiac arrest, either outside of or inside the hospital environment has produced mixed results. The debate whether they can replace manual compressions still remains. The aim of this review is to present current literature contemplating the application of mechanical compressions in both settings, data comparing them to manual compressions as well as current guidelines regarding their implementation in everyday clinical use. Currently, their implementation in the resuscitation protocol seems to benefit the victims of an in-hospital cardiac arrest rather than the victims that sustain a cardiac arrest outside of the hospital.
