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Home , Cardiac catheterization

Emergent Percutaneous in Patients Having Cardiovascular Collapse in the Cardiac Catheterization Laboratory

DavidW. Grambow, MD, G. MichaelDeeb, MD, Gregory S. Pavlides,MD, Ann Margulis, RN, WilliamW. O’Neill,MD, and Eric R. Bates, MD

ercutaneous cardiopulmonary bypass (PCB) has Percutaneous cardiopulmonary bypass (PCB) was been used in the cardiac catheterization laboratory hmtttuted in 30 initially stable patients who de- Pto provide prophylactic support during percuta- veloped either ctadiac arrest refractory to resus- neous transluminal coronary (PTCA) in pa- citatton (n = 7) or (mean arts tients with severe left ventricular dysfunction (left ven- rial biood pressure cB0 mm Hg unresponsive to tricular ~25%) or during PTCA of a fluid resuscttation or vv) (n = 23) target vessel supplying >50% of the remaining viable after a cat- ion laboratory complication. myocardium.‘,* PCB has also been used as a temporary Events leadhrg to collapse included abrupt clo- emergency support measure in patients sustaining car- sure during pe muaneous transkrminal coronary diovascular collapse from acute , an~opiasty (P7CA) (n = 22), complications from pulmonaty embolism, trauma, drug overdose, unsuc- dh#nostic cardiac catheterization (n = 6), left cessful PTCA, postoperative deterioration and aortic ventftcular perfo&ion duttng mitral valvule stenosis, and after rupture of .34 Two plasty (n q 1), and right ventricular perforation previous small studies suggested that the use of PCB in during pericardiocente& (n = 1). PCB was initi- patients with improved resuscitative ef- ated within 20 minutes of cardiovascuiar col- forts.4,6 However, the mechanism for this improvement lapse in 33% of patii (atvesk 21+ 13 minutes is not clear, because direct myocardial perfusion does not [range 10 to 501; and sho& 17 + 6 minutes occur while patients are on PCB, and regional myocar- [range 10 to 301). Mean arterial dial ischemia has been shown when PCB is used in those i~onPCBfromOtoB6mmHginps with .7 Therefore, we reviewed tients with cardiac arrest and from 37 to 63 mm our experience with emergent PCB in patients develop- Hg in those with cardiogenic shock at mean PCB ing refractory cardiac arrest or cardiogenic shock in the flow rates of 2.5 to 5.0 iiirs/min. Subsequent cardiac catheterization laboratory from a procedural re- therapy on PCB included emergent cardiac lated complication to further examine the use of this surgery (n q 19, P7CA (II = 13) and medial ther- technology. spy (n q 3). Six patients (20%) survived to hospi- tal dischar@ (3 with cardiac sur@ry, 2 with METHODS PTCA, and 1 with medical therapy). All 7 patients Study patients: A retrospective review was per- with refractory cardiac arrest died despite fur- formed of the use of emergent PCB for cardiovascular ther interventions on PCB, whereas 6 of 23 collapse occurring in the cardiac catheterization labora- (26%) with cardiogenic shock survived to hospi- tories of the University of Michigan and William Beau- tal discharge. Thus, in response to cardiovascu- mont Hospitals. Between January 1988 and January lar collapse in the catheterization laboratory, 1992, 30 patients were identified who presented to the PCB does not salvage patients who do not r-e= cardiac catheterization laboratory with stable hemody- gain a stabte cardiac rhythm. PCB can stabilize namics and had PCB initiated emergently for either re- patients who develop cardiogenic shock for fur- fractory cardiac arrest or cardiogenic shock occurring as ther interventions whi& are Bfesaving in only a a result of a catheterization laboratory complication. Pa- minoftty of patients. tients were considered to have refractory cardiac arrest (Am J Cardiol1994;73:872-375) only if aggressive attempts at resuscitation were unsuc- cessful in establishing a stable cardiac rhythm. Patients were placed on PCB for cardiogenic shock if hypoten- sion and peripheral hypoperfusion persisted despite ag- gressive fluid replacement and inotropic support. Technique of percutaneous cardiopulmonary by From the Cardiology Division, Department of Internal Medicine, and pass: A portable PCB system (C.R. Bard, Inc., Biller- Department of Thoracic Surgery, University of Michigan, Ann Arbor, ica, Massachusetts) was used, and included a centrifu- Michigan; and the Department of Cardiology, William Beaumont Hos- gal nonocclusive pump with a hollow-fiber membrane pital, Royal Oak, Michigan. Manuscript received July 7, 1993; revised oxygenator and water-based heat exchanger. Femoral ar- manuscript received and accepted October 7, 1993. Address for reprints: Eric R. Bates, MD, Division of Cardiology, terial and venous access were obtained contralateral to B 1-F245, University Hospital, University of Michigan, 1500 East Med- the site of cardiac catheterization. Over a 0.035inch ical Center Drive, AM Arbor, Michigan 48 109-0022. guidewire, progressive dilatation of the femoral artery

872 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 73 MAY 1, 1994 1 rTABLE I Clinical Characteristics TABLE II Details of Emergent Percutaneous Cardiopulmonary Bypass Refractory Cardiogenic Cardiac Arrest Shock Refractory Cardiogenic Cardiac Shock P Patients 7 23 Arrest (n = 7) (n = 23) Value Age (years) 572 11 63 + 6 Men 3 (43%) 14 (61%) Time to initiation of bypass (min) 21 + 13 17?6 NS Risk factors Duration of bypass (min) 40 + 22 165 + 213 0.2 6 (86%) 16 (70%) Mean arterial blood pressure on 56 e 7 63 + 9 NS 2 (29%) 3 (13%) bypass (mm Hg) Smoking 1(15%) 6 (26%) Hypercholesterolemia 1 (15%) 7 (34%) Previous events Myocardial infarction 4 (57%) 10 (44%) cardiovascular collapse needing PCB support (n = 22). Coronary angroplasty 1(15%) 3 (13%) Severe left main coronary artery disease was present in Coronary bypass surgery 1(15%) 5 (22%) 5 patients needing PCB because of complications from Angina class 3-4 5 (72%) 20 (87%) diagnostic cardiac catheterization, whereas an additional Congestive failure class 3-4 2 (29%) 3 (13%) one with 3-vessel coronary artery disease developed re- Left ventricular ejection fraction (%) 46 + 20 43 + 14 Number of arteries narrowed > 50% fractory cardiac arrest after contrast injection of the right in diameter coronary artery and was placed on PCB. Left ventricular 0 1(15%) 1(5%) perforation during mitral valvuloplasty, and right ven- 1 2 (29%) 5 (22%) tricular laceration with cardiac tamponade at pericar- 2 1(15%) 7 (30%) 3 3 (42%) 10 (43%) diocentesis were other catheterization laboratory com- Left main 0 6 (23%) plications for which emergent PCB was instituted. Percutaneous cardiopulmonary support: PCB was initiated within 20 minutes of cardiovascular collapse in was performed before insertion of an 18Fr cannula. An 25 of 30 patients (83%) (Table II). The mean arterial 18Fr multihole femoral venous cannula was inserted by blood pressure for patients in refractory cardiac arrest a similar technique, and was positioned with on PCB increased from 0 to 56 mm Hg at flow rates of at the junction of the inferior vena cava and right . 3 to 5 liters/min. No patient in the refractory cardiac ar- Intravenous heparin was administered to maintain an ac- rest group regained consciousness while on PCB. Mean tivated clotting time of >400 seconds throughout the pro- arterial blood pressure in patients in cardiogenic shock cedure. The cannula system was connected to the on PCB increased from 37 to 63 mm Hg at flow rates portable PCB in a manner to ensure an air-free system. of 2.5 to 5.0 liters/min. PCB was initiated at 2 liters of flow/min and was in- Treatment after initiation of percuteneous cardict creased until the mean arterial blood pressure was >60 pulmonary bypass: After PCB was established, 14 pa- mm Hg or further increases in flow were limited by in- tients were sent for emergent , 13 had re- adequate venous return. The pulmonary capillary wedge peat PTCA, and 3 were not considered candidates for pressure was maintained at >lO mm Hg to ensure unim- revascularization and were managed medically. Six pa- peded venous return at higher flow rates. Periodic mon- tients (20%) survived to hospital discharge. All 7 pa- itoring of arterial blood gases, pulmonary capillary tients with refractory cardiac arrest died despite further wedge pressures, electrocardiograms, coagulation vari- interventions on PCB. Emergent cardiac surgery was ables, electrolytes and mixed venous oxygen saturations performed in 3 patients (2 coronary artery bypass graft was performed. procedures and 1 repair of right ventricular laceration); Termination of percutaneous cardiopulmonary however, none were able to be weaned from PCB after bypass: Patients achieving hemodynamic stability in the surgery. Repeat PTCA was performed on PCB in 4 pa- catheterization laboratory had PCB gradually weaned tients, but none regained a stable cardiac rhythm after over 10 to 15 minutes, with an intraaortic balloon pump PICA and all died in the cardiac catheterization labo- and inotropic agent support used as necessary. These pa- ratory. tients were then sent for surgical removal of the cannula Of patients having PCB for cardiogenic shock, 13 of system. Patients having cardiac surgery were transported 23 (57%) survived 24 hours after the initial intervention to the operating room on PCB and had PCB terminated on PCB and were successfully weaned from PCB, but after standard cardiopulmonary bypass was established. only 6 (26%) were discharged eventually from the hos- pital. Subsequent deaths in early surviving patients were RESULTS due to refractory congestive (n = 4), sepsis Patient charecteristks: Clinical and angiographic (n = 2) and multisystem failure (n = 1). The surgical in- characteristics of patients are listed in Table I. Seven pa- terventions in patients with cardiogenic shock included tients were placed on PCB because of refractory cardiac coronary artery bypass grafting (n = 9), repair of left arrest and 23 because of cardiogenic shock. Of patients ventricular perforation (n = l), and orthotopic cardiac in cardiogenic shock, 16 (70%) initially had cardiac ar- transplantation (n = 1) after 2 days on an extracorporeal rest (mean duration 13 minutes [range 3 to 451) and were membrane oxygenation system. Surgical patients sur- successfully resuscitated before the initiation of PCB. viving to hospital discharge included 2 who underwent Events leading to cardiovascular collapse: Abrupt coronary artery bypass grafting, and 1 who had cardiac closure during PTCA was the most frequent cause of transplantation. Repeat PTCA on PCB was performed

EMERGENT PERCUTANEOUS CARDIOPULMONARY BYPASS 873 have shown that regional and global left ventricular dys- TABLE III Percutaneous Cardiopulmonary Bypass for function occur with PTCA balloon inflation during PCB “Refractory” Cardiac Arrest despite reductions in measured afterload and maximal Number Early Surviving oxygen consumption requirements. Myocardial regions Study of Patients Patients Discharged supplied by stenotic vessels had deterioration of wall Baird et all2 19 3 3 (16%) motion when patients were placed on PCB before bal- Mattox and Beall 43 17 (40%) loon inflation and had further deterioration with balloon Phillips et all3 5 3 (60%) Reichman et al3 36 18 6 (17%) inflation. Thus, whereas cerebral, renal and hepatic blood Shawl et al4 7 6 4 (57%) flow are maintained on PCB during cardiovascular col- Mooney et al6 11 7 (64%) lapse, coronary blood flow is not equally preserved, and Present study 7 0 0 progressive myocardial ischemia occurs in patients with Total 128 40 (31%) coronary artery disease. Resuscitation from refractory cardiac arrest on PCB would be more difficult owing to this progressive ischemia. in 9 patients. PTCA was successful in 7 patients; 6 were We found PCB to be useful in stabilizing patients in weaned from PCB before leaving the catheterization lab- cardiogenic shock as a result of a catheterization labo- oratory, with 2 eventually surviving to hospital discharge. ratory complication, including patients initially present- Three patients with cardiogenic shock were not consid- ing with cardiac arrest who were successfully resusci- ered candidates for surgery or PTCA; intraaortic balloon tated to a stable rhythm before PCB initiation. However, counterpulsation with inotropic agent support enabled 2 we did not find use for this technique in patients with of these to be weaned from PCB, and 1 survived to hos- refractory cardiac arrest. No patient with refractory car- pital discharge. diac arrest in this study was salvaged with the use of Compkatiis: Most PCB-related complications PCB, although 6 of 7 were placed on PCB within 20 were related to cannula insertion sites. Bleeding need- minutes of arrest. ing transfusion occurred in 8 patients. A femoral artery Early studies of animals suggested that cardiopul- thrombosis developed in 1 patient after sheath removal, monary bypass could successfully facilitate defibrillation and 2 needed surgical repair of femoral artery fistulae. in dogs with intractable ventricular fibrillationloJi; how- Follow-up: The mean hospital stay in the 6 patients ever, its usefulness in refractory cardiac arrest in humans surviving to discharge was 22 days (range 6 to 62). Fol- is controversial.3*4Jj,12,13Table III reviews the results of low-up was available in 5 patients at a mean of 18 weeks. studies that evaluated the use of emergent PCB in car- Four patients were free of cardiac symptoms, and 1 was diac arrest. Survival rates ranged from 16 to 64%. Events being managed medically for recurrent stable angina. preceding cardiac arrest and location within the hospital when PCB was initiated widely varied between studies. DISCUSSION In the study by Baird et al,12 PCB was begun for cardiac Percutaneous cardiopulmonary bypass was advo- arrest in patients presenting to the hospital with acute my- cated recently for prophylactic use in high-risk PTCA’ ocardial infarction. In other studies, PCB was initiated and for emergency use in sudden cardiovascular col- for cardiac arrest occurring as a complication of several lapse.2-6 In contrast to the intraaortic balloon pump, PCB medical conditions including trauma, sepsis, drug over- can maintain hemodynamic stability in the absence of dose, pulmonary embolism, myocardial infarction, car- an intrinsic cardiac rhythm or effective diomyopathy and postoperative collapse.3J3J4 PCB was and can improve tissue perfusion in cases of severe left initiated in many different hospital locations ranging from ventricular failure; it cannot be used in patients with ile- the emergency room to the . Many of ofemoral disease nor for >24 hours, because of disrup- the aforementioned studies did not specify the specific tion of blood elements. etiology of the cardiac arrest, the duration of the arrest The rationale for use of PCB in patients with car- nor the extent of the resuscitative efforts performed be- diovascular collapse is to provide temporary hemody- fore initiation of PCB. namic support for subsequent percutaneous or surgical Shawl et al4 and Mooney et al6 were the Iirst to ex- intervention. Rapid initiation of PCB within 20 minutes amine PCB for cardiac arrest occurring in, or in prox- of cardiovascular collapse appears necessary if subse- imity to, the catheterization laboratory and reported the quent interventions are to prove successful in achieving highest late survival rates for this technique. However, hemodynamic stability.’ The ability to rapidly place a the extent of resuscitative efforts before initiating PCB patient on PCB in the catheterization laboratory suggests was not discussed. Previous studies reporting a high suc- that PCB could help salvage a large number of patients cess of PCB in reversing refractory cardiac arrest may with cardiovascular collapse from catheterization labo- have included patients who would have regained stable ratory complications. However, several studies suggest cardiac rhythm with more persistent resuscitation alone. that whereas PCB supports the peripheral circulation, In the present study, 23 of 30 patients placed on PCB coronary blood flow is not maintained and actually de- had cardiac arrest, but 16 of these regained a stable car- creases when PCB is initiated.7 This decrease in coro- diac rhythm during resuscitation before initiation of nary blood flow has been hypothesized to be a result of PCB. Thirty percent of the resuscitated patients survived coronary steal8 or impaired autoregulation of the cardiac to hospital discharge, while none of the 7 with refrac- microcirculation from nonpulsatile flo~.~ Pavlides et al7 tory cardiac arrest survived despite PCB.

874 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 73 MAY 1, 1994 Study limitations: The retrospective nature of this 6. Mooney MR, Arom KV, Joyce LD, Mooney JF, Goldenberg IF, Von Rueden investigation, together with the small study size, limits TJ, Emery RW. Emergency cardiopulmonary bypass support in patients with car- diac arrest. J Thorac Cardiovasc Surg 1991;101:45@454. generalization of the findings. All patients developed car- 7. Pavlides GS, Hauser AM, Stack RK, Dudlets PI, Grines C, Timmis GC, O’Neill diovascular collapse after a cardiac catheterization lab- WW. Effect of peripheral cardiopulmonary bypass on left ventricular size, after- oratory complication, and thus the use of PCB in car- load and myccardial function during elective supported coronary angioplasty. JAm Cdl Cardiol 1991; 18:499-505. diovascular collapse from other etiologies cannot be 8. Ciardullo RC, Schatt HV, Flaherty JT. Comparison of regional myocardial blood extrapolated. flow and metabolism distal to a critical coronary stenosis in the fibrillating heart during alternate periods of pulsatile and non-pulsatile perfusion. J Thorac Cardio- YUSCSurg 1978;75:193-204, 9. Mooney MR, Fishman-Mooney J, Mathias D. Clinical applications of percuta- 1. Vogel RA, Shawl F, Tommaso C, O’Neill W, Overlie P, O’Toole J, Vandor- neous cardiopulmonary bypass for high risk coronary angioplasty. J /nvest Cardiol mael M, Top01 E, Tabari KK, Vogel J, Smith S, Freedmann R, White C, George 1990;2:161-169. B, T&stein P. Initial report of the National Registry of Elective Cardiopulmonary 10. Proctor E, Kowalik TA. Circulatory suppon by pump-oxygenator in expai- Bypass Supported Coronary Angioplasty. J Am Coil Cardiol 1990;15:23-29. mental ventricular fibrillation and acute left heart failure induced by coronary artery 2. Shawl F, Domanski M, Punja S, Hemandez TJ. Percutaneous cardiopulmonary ligation. Cardiovasc Res 1967;1:189-193. bypass support in high-risk patients undergoing percutaneous transluminal cow 11. Evans D, Miyagishima RT, Tutassaura H, Ameli M, Baird RJ. The effects of nary angioplasty. Am J Cardiol 1989;64:1258-1263, closed chest venoarterial bypass with oxygenation on cardiopulmonary hemody- 3. Reichman RT, Joyo CI, Dembitsky WP, Griffith LD, Admonson RM, Daily PO, namics. J Thorac Cardiovasc Surg 1971;1:7&83. Overlie PA, Smith SC, Jaski BE. Improved patient survival after cardiac arrest us- 12. Baird RJ, de la Rocha AG, Miyagishima RT, Tutassaura H, Wilson DR, Evans ing a cardiopulmonary support system. Ann Thorac Surg 1990;49:101-105, D. Beanlands DS. Assisted circulation following myocardial infarction: a review 4. Shawl FA, Domanski Ml, Wish MH, Davis M, Punja S, Herandez TJ. Emer- of 25 patients treated before 1971. Can Med Assoc J 1972;107:287-291. gency cardiopulmonary bypass support in patients with cardiac arrest in the - 13. Phillips SJ, Ballentine B, Slonine D, Hall J, Vandehaar I, Kongtahwom C, ization laboratory. Cathet Cardiovasc Diag 1990; 198-12. Reckmo K, Gray D. Percutaneous initiation of cardiopulmonary bypass. Ann Tho- 6. Shawl FA, Domanski MJ, Hemandez TJ, Punja S. Emergency percutaneous car- rat Surg 1983;36:223-225. diopulmonq bypass support in cardiogenic shock from acute myocardial infarc- 14. Mattox KL, Beall AC. Application of portable cardiopulmonary bypass. J Am tion. Am J Cardiol 1989;641967-970. Cd Emerg Physicians 1975;4:528-531.

EMERGENT PERCUTANEOUS CARDIOPULMONARYBYPASS 875