Coronary Intervention on a Moving Target: A Case Report and Procedural Considerations

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ABSTRACT: Cardiac arrest carries a considerable mortality. Among survivors, the incidence of neurological dysfunction is considerable. Coronary disease is a major cause of cardiac arrest and early and effective resuscitation is related to outcome. We report for the first time a case of successful coronary angiography and primary percutaneous coronary intervention (PCI) during ongoing ventricular fibrillation (VF) supported by mechanical chest compressions following out-of-hospital ST-elevation myocardial infarction (STEMI) and VF cardiac arrest. It illustrates four novel findings permitted by the use of mechanical chest compressions: (1) that it provided a perfusion pressure that facilitated the act of coronary angiography during ongoing VF following out-of-hospital STEMI and VF arrest, which (2) in turn permitted successful primary PCI, with (3) maintained neurological function and survival despite 79 minutes between arrest and PCI, and (4) illustrates the practical considerations that one must consider for PCI during mechanical chest compressions.

J INVASIVE CARDIOL 2013;25(8):E178-E179

Key words: cardiac arrest, mechanical chest compressions

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Cardiac arrest carries a considerable mortality, with survival in the range of 3%-16%.¹ Among survivors, the incidence of neurological sequalae is considerable. Coronary disease is a major cause of cardiac arrest and early and effective resuscitation is related to outcome.² We report a case of out-of-hospital ventricular fibrillation (VF) cardiac arrest with early manual chest compressions followed by mechanical compressions that generated a perfusion pressure enabling successful percutaneous coronary intervention (PCI). The patient was discharged without neurological deficit. We report, for the first time to our knowledge of the published literature, that mechanical chest compressions can provide a circulation sufficient for successful angiography during ongoing VF secondary to out-of-hospital VF arrest and in turn permit successful primary PCI. Second, we demonstrate that this methodology and management maintained neurological function. Third, these outcomes were in spite of over 79 minutes between arrest and return of spontaneous circulation. Fourth, we discuss practical issues surrounding PCI during mechanical compressions.

Case Report. A 60-year-old male suffered a paramedic-witnessed VF arrest following acute anterior ST-elevation myocardial infarction at 08:41 hours. He received prompt resuscitation at home, involving three 150 J biphasic shocks, adrenaline (2 x 1 mg) and 300 mg amiodarone. VF became intractable and he received continuous cardiopulmonary resuscitation (CPR) and further shocks en route to the hospital. The patient arrived in the Emergency Department at 09:01 hours. Mechanical chest compressions were instituted with a Lund University Cardiac Arrest System device (LUCAS; Jolife).1 The mechanical compressions were so effective that despite intractable VF, the patient could open his eyes and squeeze hands on command. He was therefore sedated, intubated, and taken to the cardiac catheterization laboratory at 09:30 hours. Femoral arterial access was challenging but obtained at 09:34 hours. Still in VF and with mechanical compressions in place, the arterial pressure was 64/26 mm Hg (Figure 1). Coronary angiography demonstrated an occluded left anterior descending (LAD) artery. PCI was challenging due to considerable motion artifact (Video 1). An angioplasty wire restored TIMI 2 flow at 09:58 (Figure 2). At this stage, the patient was successfully shocked out of VF and regained output. LAD patency was restored with two drug-eluting stents. After intraaortic balloon pump insertion, the patient was therapeutically cooled in the Intensive Care Unit (ICU) for 24 hours and remained for 14 days to receive veno-venous hemofiltration for acidosis and hyperkalemia, plus antibiotics for pneumonia. He was discharged home 18 days post admission with an ejection fraction of 45% and without neurological deficit. 

Discussion. This case highlights several factors needing consideration for PCI during mechanical CPR. Arterial access is difficult due to significant device-induced motion, weak arterial pulses, and difficulty differentiating arterial and venous vessels. A medial to lateral approach with fluoroscopic or ultrasound guidance may help. Image acquisition is hindered by motion artifact, creating a moving target, and anteroposterior views are obstructed by the LUCAS device. Mechanical chest compressions are more effective than manual compressions because they minimize interruptions and maintain optimum organ perfusion as demonstrated in animal models,² but they are associated with more chest wall and thoracic injuries that may lead to chest infection and delayed recovery. Restoration of normal rhythm and return of spontaneous circulation remain the primary aims. Thus, PCI and simultaneous resuscitation must proceed simultaneously, and a distinct team should perform each task. Therapeutic cooling in the Intensive Care Unit plays an important part in recovery. 

Conclusion. To our knowledge, this is the first report of the use of mechanical chest compressions to permit a hemodynamic status sufficient to improve cerebral function and provide a systemic circulation that could enable angiography during ongoing VF following out-of-hospital VF arrest, in turn followed by successful primary PCI. This report builds upon the use of the LUCAS device prehospital, in-hospital, and in the cardiac laboratory.^1,3,4 However, unlike those cases, we report successful use of the LUCAS device for ongoing VF following out-of-hospital arrest rather than, for instance, the very different scenario of cardiac arrest occurring within the cardiac laboratory.⁵ While only 5% of patients are discharged without neurological sequelae following out-of-hospital cardiac arrest,⁶ our case had no neurological deficit despite 79 minutes from arrest to return of spontaneous circulation. As emergency physicians and cardiologists strive to improve survival following out-of-hospital cardiac arrest, we point out practical issues that arise during PCI with concomitant mechanical chest compressions and emphasize its ability to provide perfusion that can maintain neurological function and permit coronary revascularization, which may have implications for cases where currently PCI is not performed in fear of universally poor outcomes.

References

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