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Revascularization During Cardiac Arrest While Receiving Extracorporeal Life Support in Patients With Acute Myocardial
Takahiro Nakashima1,2, Marina Arai3, Akihiko Inoue4
1Department of Emergency Medicine and The Harry Max Weil Institute for Critical Care Research and InnovationUniversity of Michigan, Ann Arbor, Michigan, USA.
Insights
Extracorporeal cardiopulmonary resuscitation (ECPR) enables primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) patients with refractory out-of-hospital cardiac arrest (OHCA). Survival to discharge was achieved by 21.1% of these patients, with key predictors identified.
Area of Science:
- Cardiology
- Emergency Medicine
- Intensive Care Medicine
Background:
- Extracorporeal cardiopulmonary resuscitation (ECPR) has expanded treatment options for refractory out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI).
- ECPR now allows primary percutaneous coronary intervention (PCI) in patients previously ineligible due to refractory cardiac arrest.
Purpose of the Study:
- To characterize patients with OHCA secondary to AMI undergoing primary PCI during refractory cardiac arrest despite ECPR.
- To clarify the outcomes and identify predictors of survival in this patient cohort.
Main Methods:
- A multicenter registry in Japan identified patients (≥18 years) with AMI and OHCA who underwent PCI with ECPR between 2013-2018.
- In-hospital mortality was the primary outcome; predictors of survival to discharge were assessed using mixed-effects logistic regression.
Main Results:
- Of 671 patients, 251 (37%) had refractory cardiac arrest despite ECPR and underwent primary PCI.
- Following reperfusion, 64.9% achieved sustained return of spontaneous circulation (ROSC), 21.1% survived to discharge, and 10.4% had favorable neurological status.
- Predictors of survival included intermittent prehospital ROSC, shorter time to ECPR initiation, and postprocedural TIMI flow grade 3.
Conclusions:
- One-third of AMI patients with refractory OHCA treated with ECPR did not achieve sustained ROSC before PCI.
- Two-thirds achieved sustained ROSC post-reperfusion, with one-fifth surviving to hospital discharge.
Background:
Extracorporeal cardiopulmonary resuscitation (ECPR) has allowed patients with refractory out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI) to receive primary percutaneous coronary intervention (PCI); they were previously ineligible.
Objectives:
The purpose of this study was to clarify the characteristics and outcomes of patients with OHCA secondary to AMI who underwent primary PCI during refractory cardiac arrest despite ECPR.
Methods:
Patients with AMI and OHCA aged ≥18 years who underwent PCI with ECPR in 2013 to 2018 were identified from a multicenter ECPR registry in Japan. The primary outcome was in-hospital mortality. We also assessed possible predictors of survival to discharge using mixed effects logistic regression to account for group differences among facilities.
Results:
Among 671 patients with AMI and OHCA who underwent PCI with ECPR from 30 institutions, 251 (37%) patients had refractory cardiac arrest despite ECPR initiation and subsequently underwent primary PCI. Following coronary reperfusion, 64.9% (163/251) of patients achieved the sustained return of spontaneous circulation (ROSC), 21.1% (53/251) survived, and 10.4% (26/251) had favorable neurological status at hospital discharge. Multivariable analysis revealed that intermittent prehospital ROSC (OR: 5.22; 95% CI: 1.54-17.79), shorter time to ECPR initiation (OR: 0.89; 95% CI: 0.82-0.98), and postprocedural TIMI flow grade 3 (OR: 5.08; 95% CI: 1.50-17.22) are significantly associated with survival to hospital discharge.
Conclusions:
Among patients with AMI and refractory OHCA treated with ECPR, one-third did not have sustained ROSC prior to PCI. Of those, two-thirds achieved sustained ROSC following reperfusion and one-fifth survived to discharge.
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