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Three Part Question

In [patients with cardiac arrest refactory to ACLS intervention] is [institution of cardiopulmonary bypass ] of any benefit in [improving survival]?

Clinical Scenario

You are the arrest team leader for a 56 year old patient that has just been brought in by emergency ambulance. He collapsed suddenly in the town centre, but had early effective bystander CPR. Fourteen minutes have elapsed since and he remains in VF despite 3 pre-hospital DC shocks. A single additional DC shock at 360 J restores sinus rhythm with an output.
Your ICU collegues informs you 4 days later that this patient has had severe anoxic brain damage and is unlikely to be discharged from hospital. You feel that failure has been snatched from the jaws of success and wonder whether some other intervention such as cardiopulmonary bypass support might have improved his chances of a functional survival.

Search Strategy

Medline 1966-03/04 using the OVID interface.
[exp Heart Arrest/ OR exp life support care/ OR cardiac arrest.mp OR cardiac massage.mp OR CPR.mp] AND [exp Cardiopulmonary Bypass/ OR Cardiopulmonary Bypass.mp OR cardiopulmonary support.mp] LIMIT to Human AND English

Search Outcome

Altogether 387 papers were found of which a review was found summarising 35 papers. Eight papers not included in this review were also found. Thus 9 relevant papers are summarised in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kurusz et al, 2002, USA	Review of clinical reports of CPB in cardiac arrest or cardiogenic shock 13 papers found reporing CPB after cardiac arrest and 17 papers reporting CPB after cardiogenic shock	Review (4)	Survival after cardiac arrest	88 of 407 reported in the literature (21%)	Not systematic, search strategies not reported Some papers missed
			Survival after cardiogenic shock	137/335 (41%)
			Poor survival	Patients with unwitnessed cardiac arrest or CPR over 30mins
Nagao et al, 2000, Japan	36 patients arriving in the ER after out of hospital arrest, if return of spontaneous circulation could not be achieved in patients with VF after unsynchronized electric shocks, with the second administration of epinephrine, or in patients without VF after the second administration of epinephrine, emergency CPB and intra-aortic balloon pumping (IABP) were immediately performed in the emergency room.	Prospective cohort study (4)	Return of spontanous circulation	32 or 36 patients had return of spontaneous circulation	Poorly presented data on CPS patients
			Survival to discharge	9 of 36 patients 25% Survival
Tisherman et al, 1990, USA	28 year old woman brought to the Emergency Department with recurrent VF CPS instituted after 46 mins of CPR	Case report (4)	CPB duration	15 hours
			Outcome	Survival to discharge, normal neurologically
Jaski et al, 1999, USA	10 patients who had an out of hospital Acute Myocardial Infarction and cardiac arrest were placed on percutaneous CPB All patients had revascularisation after initiation of Extracorporeal Cardiopulmonary bypass	Case series (4)	Long term survival	4 or 10 patients are long term survivors 40% survivors	One surviving patient required an above knee amputation for leg ischaemia
			Cause of death	Neurologic insufficiency in 2, ineffective CPB in 2, recurrent collapse after weaning in 2
			Mean CPR time prior to CPB	17 mins in survivors and 54 mins for non survivors
Martin et al, 1998, USA	10 patients attending the ED with out of hospital cardiac arrest unresponsive to conventional methods, placed on Fem fem CPB CPB weaned after 2 hours	Case series (4)	Long term survivors	No long term survivors, mean survival 48 hours	No definitive interventions attempted while on CPB
			Weaning from CPB	7 successfully weaned from CPB with spontaneous circulation
			Cardiac arrest to CPB	Mean time 32 mins
Rees et al, 1992, UK	Percutaneous Cardiopulmonary Support (CPS) initiated in 4 patients in cardiogenic shock, 4 patients in asystole and 1 patients in resistant VF 4 asystolic patients arrested in catheter labpt in VF arrested on the ward 24hrs after angioplasty CPS established 25-40 mins post arrest	Case-series (4)	Survival in arrest group	All 5 patients reverted to sinus rhythm after angioplasty on CPS, and 3 survived to discharge 1 death due to aortic root rupture and 1 due to bronchopneumonia after 2 months 60% survival	Small study No patients with out of hospital arrest
			Survival in cardiogenic shock group	All 4 patients died. All had evidence of MI 5-24hrs prior to CPS. 3 had angioplasty on CPS, one had AVR, and one had a large irreparable VSD
			Duration of CPS	40mins to 29 hours of successful support
Schwarz et al, 2003, USA	46 patients supported with venoarterial cardiopulmonary bypass, 25 because of cardiogenic shock unresponsiveto pharmacologic therapy and 21 because of cardiopulmonaryarrest unresponsive to ACLS	Case-series (4)	Successful weaning from CPS	28 of 46 patients weaned	Not out of hospital pts
			Survival to discharge	19 of 25 patients with cardiogenic shock, 3 of 21patients with cardiopulmonary arrest 14% survival after cardiac arrest
Karmy-Jones R et al, 1999,	29-year-old woman whom, while undergoing an elective gynecological procedure, acutely arrested. ACLS ineffective. CPB was instituted	Case report (4)	Outcome	Restoration of Sinus rhythm after 40 mins of CPB and discharge home after 2 months
Fujimoto et al, 2001,	9 patients suffering circulatory collapse after AMI refractory to ACLS resuscitation put on CPS All in–hospital patients	Case series (4)	Long term survival	4 survivors although one had a poor neurological outcome
			Procedures under CPB	All patients required a surgical procedure, including VSD repair in 4 and free wall rupture in 2

Comment(s)

There is a large variability in the reported papers. The prior clinical status of the patient is one very important factor in determining survival, as a patient with known coronary arterial disease arresting in the catheter lab will clearly have a superior survival to an our of hospital arrest with unknown pathology. However some studies relied only on CPB and gradually weaned the patient after a number of hours, whereas other investigators immediately took the patient to the catheter lab to establish a diagnosis or to theatre for a definitive procedure. In addition there were differences in technique in the method of cardiopulmonary bypass. One important difference is whether the venous return adequately drains the right atrium, as failure to do this will cause the heart to distend and cause pulmonary oedema.

Clinical Bottom Line

Around 15-25% of selected patients who suffer witnessed cardiac arrest and who are not responsive to ACLS resuscitation may be successfully resuscitated with the assistance of cardiopulmonary bypass.

References

1. Kurusz M, Zwischenberger JB. Percutaneous cardiopulmonary bypass for cardiac emergencies. Perfusion 2002;17:269-277.
2. Nagao K, Hayashi N, Kanmatsuse K, et al. Cardiopulmonary Cerebral Resuscitation Using Emergency Cardiopulmonary Bypass, Coronary Reperfusion Therapy and Mild Hypothermia in Patients With Cardiac Arrest Outside the Hospital. Journal of the American College of Cardiology 2000;36:776-783.
3. Tisherman SA, Grenvik A, Safar P. Cardiopulmonary-cerebral resuscitation: advanced and prolonged life support with emergency cardiopulmonary bypass. Acta Anaesthesiologica Scandinavica. Supplementum 1990;94:63-72.
4. Jaski BE, Lingle RJ, Overlie P, et al. WP Long-term survival with use of percutaneous extracorporeal life support in patients presenting with acute myocardial infarction and cardiovascular collapse. ASAIO Journal 1999;45:615-618.
5. Martin GB, Rivers EP, Paradis NA, et al. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest. Chest 1998;113:743-751.
6. Rees MR, Browne T, Sivananthan UM, et al. Cardiac resuscitation with percutaneous cardiopulmonary support. Lancet 1992;340:513-514.
7. Schwarz B, Mair P, Margreiter J, et al. Experience with percutaneous venoarterial cardiopulmonary bypass for emergency circulatory support. Critical Care Medicine 2003;31:758-764.
8. Karmy-Jones R, Hamilton A, Koshal A. The management of non-traumatic cardiac arrest in the operating room with cardiopulmonary bypass. Resuscitation 1999;40:107-110.
9. Fujimoto K, Kawahito K, Yamaguchi A, et al. Percutaneous extracorporeal life support for treatment of fatal mechanical complications associated with acute myocardial infarction. Artificial Organs 2001;25:1000-1003.