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Aims Because re-establishment of spontaneous circulation (ROSC) in patients with cardiac arrest is frequently not achieved by conventional cardiopulmonary resuscitation (C-CPR), selected patients may undergo resuscitation with extracorporeal membrane oxygenation (E-CPR). We compared angiographic features and percutaneous coronary intervention (PCI) between patients undergoing E-CPR and those with ROSC after C-CPR. Methods and results Forty-nine consecutive E-CPR patients undergoing immediate coronary angiography admitted between August 2013 and August 2022 were matched to 49 patients with ROSC after C-CPR. Multivessel disease (69.4% vs. 34.7%; P = 0.001), ≥ 50% unprotected left main (ULM) stenosis (18.4% vs. 4.1%; P = 0.025), and ≥1 chronic total occlusion (CTO) (28.6% vs. 10.2%; P = 0.021) were more often documented in E-CPR group. There was no significant differences in the incidence, features, and distribution of acute culprit lesion which was present in >90%. Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) (27.6 vs. 13.4; P = 0.002) and GENSINI (86.2 vs. 46.0; P = 0.001) scores were increased in E-CPR group. Optimal cut-off predicting E-CPR was 19.75 for SYNTAX (sensitivity 74%, specificity 87%) and 60.50 (sensitivity 69%, specificity 75%) for GENSINI score. More lesions were treated (1.3 vs. 1.1 lesions/patient; P = 0.002) and stents implanted (2.0 vs. 1.3/patient; P < 0.001) in E-CPR group. Final TIMI three flow was comparable (88.6% vs. 95.7%; P = 0.196) but residual SYNTAX (13.6 vs. 3.1; P < 0.001) and GENSINI (36.7 vs. 10.9; P < 0.001) scores remained increased in E-CPR group. Conclusion Extracorporeal membrane oxygenation patients have more multivessel disease, ULM stenosis, and CTO but similar incidence, features, and distribution of acute culprit lesion. Despite more complex PCI, revascularization is less complete.

Kontext: Alternujici blokada leveho a praveho ramenka Tawarova (ramenkova blokada) casto "rozostřuje" ischemicke změny na elektrokardiogramu. I když se toho o alternujici blokadě leveho a praveho ramenka Tawarova přilis nevi, může být pro klinickou praxi významna. Kasuistika: Popisujeme připad muže s potvrzenou blokadou leveho Tawarova ramenka (left bundle-branch block, LBBB), u něhož při akutnim koronarnim syndromu doslo k rozvoji blokady praveho Tawarova ramenka (right bundle-branch block, RBBB). Koronarogram prokazal subtotalni proximalni stenozu ramus interventricularis anterior (RIA), ktera byla řesena implantaci stentu. Po perkutanni koronarni intervenci doslo k vymizeni RBBB a znovuobjeveni LBBB. Možným důvodem pro alternujici ramenkovou blokadu v popisovanem připadu je nový zdroj komorových impulsů po pocatecni farmakoterapii. Nově vznikla RBBB je zahadnou klinickou entitou, casto spojenou s akutnim infarktem myokardu. Blokadu praveho Tawarova ramenka lze přidat k infarktu myokardu s elevacemi useku ST jako rovnocennou indikaci k urgentni reperfuzni lecbě. Proc by si měl být lekař na odděleni urgentniho přijmu vědom popsane možnosti? Alternujici ramenkova blokada může ukazovat na reperfuzi, ktere vyžaduje změnu lecebneho postupu u pacienta s akutnim koronarnim syndromem. © 2019, CKS.

OBJECTIVES To evaluate the use and outcomes of percutaneous mechanical circulatory support (pMCS) utilized during transcatheter aortic valve implantation (TAVI) from high-volume centers. METHODS AND RESULTS Our international multicenter registry including 13 high-volume TAVI centers with 87 patients (76.5�������11.8���years, 63.2% men) who underwent TAVI for severe aortic stenosis and required pMCS (75.9% VA-ECMO, 19.5% Impella CP, 4.6% TandemHeart) during the procedure (prior to TAVI 39.1%, emergent rescue 50.6%, following TAVI 10.3%). The procedures were considered high-risk, with 50.6% having severe left ventricular dysfunction, 24.1% biventricular dysfunction, and 32.2% severe pulmonary hypertension. In-hospital and 1-year mortality were 27.5% and 49.4%, respectively. Patients with prophylactic hemodynamic support had lower periprocedural mortality compared to patients with rescue insertion of pMCS (log rank��=��0.013) and patients who did not undergo cardiopulmonary resuscitation during the TAVI procedure had better short and long term survival (log rank

Background: The benefit of emergency coronary angiography after resuscitation from out-of-hospital cardiac arrest is uncertain for patients without ST-segment elevation. The aim of this randomized trial was to evaluate the efficacy and safety of early coronary angiography and to determine the prevalence of acute coronary occlusion in resuscitated patients with out-of-hospital cardiac arrest without ST-segment elevation. Methods: Adult (>18 years) comatose survivors without ST-segment elevation after resuscitation from out-of-hospital cardiac arrest were prospectively randomized in a 1:1 fashion under exception to informed consent regulations to early coronary angiography versus no early coronary angiography in this multicenter study. Early angiography was defined as ≤120 minutes from arrival at the percutaneous coronary intervention–capable facility. The primary end point was a composite of efficacy and safety measures, including efficacy measures of survival to discharge, favorable neurologic status at discharge (Cerebral Performance Category score ≤2), echocardiographic measures of left ventricular ejection fraction >50%, and a normal regional wall motion score of 16 within 24 hours of admission. Adverse events included rearrest, pulmonary edema on chest x-ray, acute renal dysfunction, bleeding requiring transfusion or intervention, hypotension (systolic arterial pressure ≤90 mm Hg), and pneumonia. Secondary end points included the incidence of culprit vessels with acute occlusion. Results: The study was terminated prematurely before enrolling the target number of patients. A total of 99 patients were enrolled from 2015 to 2018, including 75 with initially shockable rhythms. Forty-nine patients were randomized to early coronary angiography. The primary end point of efficacy and safety was not different between the 2 groups (55.1% versus 46.0%; P =0.64). Early coronary angiography was not associated with any significant increase in survival (55.1% versus 48.0%; P =0.55) or adverse events (26.5% versus 26.0%; P =1.00). Early coronary angiography revealed a culprit vessel in 47%, with a total of 14% of patients undergoing early coronary angiography having an acutely occluded culprit coronary artery. Conclusions: This underpowered study, when considered together with previous clinical trials, does not support early coronary angiography for comatose survivors of cardiac arrest without ST elevation. Whether early detection of occluded potential culprit arteries leads to interventions that improve outcomes requires additional study. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02387398.

Aims We investigated the spectrum of emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported interventions including percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI) and invasive electrophysiology (EP). Methods and results Between June 2010 and February 2020, 52 consecutive patients underwent VA ECMO implantation for refractory cardiac arrest (E-CPR) and 78 for profound cardiogenic shock. Percutaneous interventions on VA ECMO included PCI (n = 29), TAVI (n = 4) and EP (n = 1). Surgical interventions were cardiac (n = 36) or non-cardiac (n = 5). During PCI, ECMO flow was maintained at 2.7 ± 1.0 L/min. Of the 40 treated lesions, 48% were located on left anterior descending and 20% on the left main artery. An average 2.0 ± 1.8 DES/patient with diameter 3.2 ± 0.5 mm and stented length 41 ± 35 mm were implanted. PCI success was 83%. TAVI was performed in 4 patients with left ventricular ejection fraction 21 ± 10% and mean aortic valve gradient 41 ± 5 mmHg. After successful valve implantation supported by 1.4 ± 0.1 L/min ECMO flow, mean gradient decreased to 11 ± 5 mmHg without significant aortic regurgitation. In one patient radiofrequency ablation of His bundle followed by permanent pacemaker implantation was performed under ECMO flow of 2.8 L/min. Overall survival to hospital discharge with good neurological recovery was 29% in E-CPR and 44% in profound cardiogenic shock. Conclusions Our study showed feasibility and effectiveness of VA ECMO-supported percutaneous interventions in patients with profound hemodynamic collapse.

Only up to 20% of patients with out-of-hospital cardiac arrest (OHCA) receive immediate and optimal initial cardiac resuscitation and consequently regain consciousness soon after return of spontaneous circulation (ROSC). In the present study, we compared the outcome of conscious survivors of OHCA presenting with ST-elevation myocardial infarction (STEMI) in post-resuscitation electrocardiogram undergoing immediate invasive coronary strategy with randomly selected STEMI patients without preceding OHCA undergoing primary PCI.We conducted a single-centre registry-based analysis of all conscious OHCA survivors with STEMI over the last 10 year period. We gathered clinical and angiographic data and compared them with a randomly selected cohort of non-OHCA patients with STEMI within the same period. Patients were matched by sex, age and STEMI location.86 conscious survivors of OHCA were admitted between 2006 and 2016. OHCA was witnessed in all patients (85% EMS witnessed), and all patients presented with initial shockable rhythm. Clinical and angiographic features were well matched with randomly selected STEMI patients without OHCA presenting to our department within the same study period. Delay from symptoms to EMS arrival but not delay from EMS to PCI was significantly shorter in conscious OHCA survivors (1.2 ± 1.3 h vs 3.1 ± 3.8 h, p 0.001), yielding decreased total myocardial ischemic time (2.6 ± 1.3 h vs 4.6 ± 4.0 h, p 0.001). Hospital and 1-year survival with normal neurological condition in conscious survivors of OHCA (cerebral performance category 1) was excellent and numerically even better than survival of STEMI patients without OHCA.Conscious survivors of OHCA with STEMI have excellent survival if they undergo immediate invasive coronary strategy. Since there is no obvious post-resuscitation brain injury in this subgroup of OHCA patients, it is probably shorter duration of myocardial ischemia driven by shorter delay from symptoms to EMS arrival that contributes to the good outcome, which is at least similar to STEMI patients without OHCA.

Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

Aims Our aim was to describe our protocol for emergency percutaneous implantation of femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO) in the catheterisation laboratory and to compare its effectiveness and safety with implantation in the intensive care unit and the operating room. Methods and results Our retrospective observational study enrolled 56 consecutive patients undergoing VA ECMO implantation in the catheterisation laboratory (n=23), the intensive care unit (n=8) and the operating room (n=25). Among patients undergoing catheterisation laboratory implantation, 11 patients had profound cardiogenic shock but preserved arterial pulsations, and 12 patients had refractory cardiac arrest undergoing automated mechanical chest compression. Using our fluoroscopy-guided protocol, arterial and venous cannulas were successfully implanted and the desired ECMO flow obtained in each patient. There was no vessel perforation/dissection. Moderate/severe GUSTO or BARC 3 and 5 bleeding occurred in 13%. Ipsilateral limb ischaemia occurred in one of eight patients (13%) with upfront perfusion sheath implantation, and in two of three patients (75%) in whom this strategy was not used (p=0.15). There was no infection at the site of cannula implantation. Complications related to implantation in the catheterisation laboratory were comparable to surgical implantation in the operating room and percutaneous implantation in the intensive care unit using ultrasound guidance. Conclusions Fluoroscopy-guided emergency implantation of femoral VA ECMO by an interventional cardiologist in the catheterisation laboratory is effective and safe for both patients in cardiogenic shock and those in refractory cardiac arrest.

Out-of-hospital cardiac arrest (OHCA) remains the leading cause of death in developed countries, with an annual incidence from 36 to 81 events per 100,000. Prehospital treatment includes immediate recognition, bystander cardiopulmonary resuscitation, defibrillation, and advanced cardiac life support known as a ‘chain of survival’. Owing to improvements in the ‘chain of survival’, the proportion of patients with re-establishment of spontaneous circulation on the field may nowadays exceed 50%. This leads to increased hospital admission observed in communities with mature prehospital emergency services. According to autopsy and immediate coronary angiography (CAG), significant coronary artery disease may be documented in more than 70% of patients. Moreover, in the presence of ST-elevation myocardial infarction (STEMI) in post-resuscitation electrocardiogram, acute thrombotic lesions may be found in up to 90%. However, the absence of STEMI does not exclude obstructive or thrombotic coronary stenosis, which may be present in 25–58% of patients. Because of these findings, interventional cardiologists are increasingly alerted for immediate CAG and percutaneous coronary intervention in OHCA patients.

We describe a patient with severe accidental hypothermia (≤25.4°C) and prolonged refractory ventricular fibrillation, lasting at least 4 hours and 8 minutes, who underwent cardiopulmonary resuscitation with extracorporeal membrane oxygenation and survived without neurologic deficit.

A 29-year-old woman presented with influenza A ARDS at 23+0 weeks of gestation. Mechanical ventilation failed and VV-ECMO was started in a non-ECMO hospital. Transportation was performed on ECMO. Within 5 days ECMO weaning was successful. Fetal condition was stable, and decision to continue pregnancy was taken. However, second VV-ECMO was needed due to ventilator-associated pneumonia. At 25+6 weeks, the patient spontaneously delivered a neonate vaginally. Patient’s condition improved, and ECMO could be removed 10 days postpartum. 2-year follow-up showed no severe consequences in the mother and the child.

Chain of survival in out-of-hospital cardiac arrest is improving and more patients are being admitted. Coronary disease is the leading cause of cardiac arrest. Patients return to consciousness after return of spontaneous circulation follow ESC/AHA guidelines on acute coronary syndrome management, but there is debate on how to approach comatose patients. There is consensus that the STEMI subgroup with shockable rhythm should be brought directly to the catheterization laboratory as they have acute coronary lesion in 90% of cases and expected survival of more than 50%. On the other hand, there is a big debate on whether patients without STEMI benefit from an early invasive approach as acute coronary lesion is found less frequently. Nonshockable first rhythm carries a much worse prognosis, and a less invasive strategy in this subgroup seems reasonable.

Postresuscitation electrocardiogram (ECG) in patients with aborted cardiac death may demonstrate ST-elevation myocardial infarction (STEMI), ST-T changes, intraventricular conduction delay, or other nonspecific findings. In the present study, we compared ECG to urgent coronary angiogram in 158 consecutive patients with STEMI and 54 patients not fulfilling criteria for STEMI admitted to our hospital from January 1, 2003 through December 31, 2008. At least 1 obstructive lesion was present in 97% of patients with STEMI and in 59% of patients without STEMI with ≥1 occlusion in 82% and 39%, respectively (p0.001). Obstructive lesion was considered acute in 89% of patients with STEMI and in 24% of patients without STEMI (p0.001). An acute lesion in STEMI had a higher thrombus score (2.6 vs 1.3, p = 0.05) and more often presented with Thrombolysis In Myocardial Infarction grade 0 to 1 flow (75% vs 36%, p0.01). Percutaneous coronary intervention, which was attempted in 148 lesions in patients with STEMI and in 17 lesions in patients without STEMI, resulted in final Thrombolysis In Myocardial Infarction grade 3 flow in 87% and 71%, respectively (p = 0.34). In conclusion, STEMI on postresuscitation ECG is usually associated with the presence of an acute culprit lesion. However, in the absence of STEMI, an acute culprit lesion is still present in 1/4 of patients. An acute lesion in STEMI is more thrombotic and more often leads to complete occlusion. Urgent percutaneous coronary intervention is feasible and successful regardless of postresuscitation ECG.

Purpose of review To review the evidence on urgent coronary angiography and percutaneous coronary intervention after resuscitated cardiac arrest and during ongoing cardiocerebral resuscitation. Recent findings In almost 450 patients with acute ST-elevation myocardial infarction after reestablishment of spontaneous circulation, success rate of primary percutaneous coronary intervention was 89%. Survival rates in conscious patients after reestablishment of spontaneous circulation were comparable to patients without preceding cardiac arrest while in comatose patients, survival was 57% and survival with acceptable neurological outcome 38%. Nonrandomized trials in 106 comatose survivors of cardiac arrest indicate that urgent invasive coronary strategy can be safely combined with mild induced hypothermia. Percutaneous coronary intervention is also feasible in patients undergoing cardiocerebral resuscitation. In 34 reported patients, the success rate of percutaneous coronary intervention was 88% and survival to hospital discharge 41%. Summary Urgent coronary angiography and percutaneous coronary intervention should be attempted in conscious patients after reestablishment of spontaneous circulation similarly as in patients with acute coronary syndromes without preceding cardiac arrest. In comatose survivors, urgent coronary strategy is reasonable if acute ischemic cause is suspected and if there is realistic hope for neurological recovery that should be facilitated with mild induced hypothermia. Urgent coronary invasive strategy may be successful also during ongoing resuscitation in selected patients without advanced heart diseases and significant comorbidities.

Patients with sudden cardiac arrest who regain consciousness after ROSC should undergo immediate coronary angiography unless obvious non-coronary cause is identified. Revascularization strategy should follow the guidelines for acute coronary syndromes and stable coronary disease for patients without preceding cardiac arrest. In comatose survivors of cardiac arrest, immediate coronary angiography should be performed if there is no obvious non-coronary cause and there is realistic hope for neurological recovery. Due to uncertain neurological outcome, immediate percutaneous revascularization should be focused on obvious acute thrombotic lesions followed by staged intervention if patient wakes from the coma.

After successful cardiopulmonary resuscitation, acute ST-elevation myocardial infarction (STEMI) may be documented. We investigated the incidence and prognosis of patients admitted to our department between 1 January 2000 and 31 December 2004. Among 2393 consecutive patients with STEMI, 135 (5.7%) presented after a return of spontaneous circulation (ROSC). Forty-nine patients (36%) regained consciousness and 86 patients (64%) remained unconscious during initial evaluation. The delay from collapse to advanced cardiac life support (ACLS) was longer in comatose patients (5.8 min versus 0.5 min; p

Coronary artery disease is the most frequent cause of sudden cardiac death. There is general consensus that immediate coronary angiography with percutaneous coronary intervention (PCI) should be performed in all conscious and unconscious patients with ST-elevation myocardial infarction in post-resuscitation electrocardiogram. In these patients acute coronary thrombotic lesion (“ACS” lesion) suitable for PCI is typically present in more than 90%. PCI in these patients is not only feasible and safe but highly effective and there is evidence of improved survival with good neurological outcome. PCI of the culprit lesion is the primary goal while PCI of stable obstructive lesions may be postponed unless post-resuscitation cardiogenic shock is present.