Figure 4 - available via license: Creative Commons Attribution 4.0 International
Content may be subject to copyright.
Standard cardiopulmonary resuscitation vs. intravascular cardiopulmonary resuscitation. Comparison of standard cardiopulmonary resuscitation (sCPR) (n =10) or intravascular cardiopulmonary resuscitation (iCPR) (n =10). Data are presented as the mean ± standard error of the mean. *P ≤0.05, comparing sCPR vs. iCPR. BL, Baseline (that is, 5 minutes prior to cardiac arrest). (A) Calculated coronary perfusion pressure (CPP). (B) Mean pulmonary artery pressure (MPAP). (C) Survival data. Animals with severe neurocognitive outcomes were killed 48 hours post-CPR (n =5) or when they were not able to stand or walk (n =1). ROSC, Return of spontaneous circulation. (D) Overall Performance Categories (OPC). OPC 1, Normal; no obvious neurologic damage; OPC 2, Moderate disability; animals being conscious and aware, standing but unable to walk; OPC 3, Severe disability; animals being neither fully aware nor unconscious, but with reaction to pain and auditory stimuli, not able to stand or walk; OPC 4, Coma; OPC 5, Death or brain death.
Source publication
Despite improvements in pre-hospital and post-arrest critical care, sudden cardiac arrest (CA) remains one of the leading causes of death. Improving circulation during cardiopulmonary resuscitation (CPR) may improve survival rates and long-term clinical outcomes after CA.
In a porcine model, we compared standard CPR (sCPR, n = 10) with CPR using an...
Similar publications
Objective:
To assess interruptions in chest compressions associated with advanced airway placement during cardiopulmonary resuscitation (CPR) of out-of-hospital cardiac arrest (OHCA) victims.
Methods:
The method used was observational analysis of prospectively collected clinical and defibrillator data from 339 adult OHCA victims, excluding victi...
Background
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support under extracorporeal cardiopulmonary resuscitation (eCPR) is the last option and may be offered to selected patients. Several factors predict outcome in these patients, including initial heart rhythm, comorbidities, and bystander cardiopulmonary resuscitation (CPR). We ev...
Aims:
Mechanical chest compression (CC) during cardiopulmonary resuscitation (CPR) with AutoPulse or LUCAS devices has not improved survival from cardiac arrest. Cohort studies suggest risk of excess damage. We studied safety of mechanical CC and determined possible excess damage compared with manual CC.
Methods and results:
This is a randomized...
Successful resuscitation from cardiac arrest depends on provision of adequate blood flow to vital organs generated by cardiopulmonary resuscitation (CPR). Measurement of end-tidal expiratory pressure of carbon dioxide (ETCO2) using capnography provides a noninvasive estimate of cardiac output and organ perfusion during cardiac arrest and can theref...
Objectives
Cardiopulmonary resuscitation (CPR) is lifesaving. Yet, cardiac arrest survival remains low despite CPR intervention. Education has been highlighted as a strategy to overcome this issue. Virtual Reality technology has been gaining momentum in the field of clinical education. Published studies report benefits of virtual reality for CPR ed...
Citations
... High-quality chest compressions with minimal interruptions are critical to improve both survival and good outcomes of CA [4][5][6]. In line with this, previous research in a large animal model of CA has demonstrated that using a minimally invasive percutaneous left ventricular assist device (pLVAD) (Impella 2.5) instead of manual chest compressions can double survival rates and improve clinical outcomes compared to manual chest compressions [7]. A combination of chest compressions with a pLVAD for resuscitation has also shown promising results, with a good neurologic outcome in a preclinical animal model [8]. ...
... Preclinical [7,8] and clinical [9,13,14] data suggest that the implantation of a transvalvular pLVAD during CA is feasible and can lead to good neurologic outcomes. Particularly in the catheter laboratory setting, pLVADs can provide rapid and uninterrupted circulatory support while the underlying cause of CA can be solved [8,19]. ...
... For the insertion during CA, thoracic compressions are typically used to open the aortic valve [13] and direct the tip of the wire across the valve. In our previous trials, the guidewire was placed in the LV before induction of CA for this reason [7,20]. Successful deployment of the Impella ECP via a previously established introducer sheath could be achieved in less than a minute on average during this trial. ...
The survival rate of cardiac arrest (CA) can be improved by utilizing percutaneous left ventricular assist devices (pLVADs) instead of conventional chest compressions. However, existing pLVADs require complex fluoroscopy-guided placement along a guidewire and suffer from limited blood flow due to their cross-sectional area. The recently developed self-expandable Impella CP (ECP) pLVAD addresses these limitations by enabling guidewire-free placement and increasing the pump cross-sectional area. This study evaluates the feasibility of resuscitation using the Impella ECP in a swine CA model. Eleven anesthetized pigs (73.8 ± 1.7 kg) underwent electrically induced CA, were left untreated for 5 min and then received pLVAD insertion and activation. Vasopressors were administered and defibrillations were attempted. Five hours after the return of spontaneous circulation (ROSC), the pLVAD was removed, and animals were monitored for an additional hour. Hemodynamics were assessed and myocardial function was evaluated using echocardiography. Successful guidewire-free pLVAD placement was achieved in all animals. Resuscitation was successful in 75% of cases, with 3.5 ± 2.0 defibrillations and 1.8 ± 0.4 mg norepinephrine used per ROSC. Hemodynamics remained stable post-device removal, with no adverse effects or aortic valve damage observed. The Impella ECP facilitated rapid guidewire-free pLVAD placement in fibrillating hearts, enabling successful resuscitation. These findings support a broader clinical adoption of pLVADs, particularly the Impella ECP, for CA.
... 4 Similarly, Derwall et al. demonstrated an improved coronary perfusion pressure and increased rates of ROSHB in a swine model. 8 Lotun et al. also demonstrated improved survival with both a pL-VAD and pL-VAD + mCPR in an in-hospital cardiac arrest (IHCA) swine model. 9 However, the optimal resuscitation strategy for patients in cardiac arrest following the initiation of pL-VAD therapy remains unclear. ...
Background
Recent studies describe an emerging role for percutaneous left ventricular assist devices such as Impella CP® as rescue therapy for refractory cardiac arrest. We hypothesized that the addition of mechanical chest compressions to percutaneous left ventricular assist device assisted CPR would improve hemodynamics by compressing the right ventricle and augmenting pulmonary blood flow and left ventricular filling. We performed a pilot study to test this hypothesis using a swine model of prolonged cardiac arrest.
Methods
Eight Yorkshire swine were anesthetized, intubated, and instrumented for hemodynamic monitoring. They were subjected to untreated ventricular fibrillation for 5.75 (SD 2.90) minutes followed by mechanical chest compressions for a mean of 20.0 (SD 5.0) minutes before initiation of percutaneous left ventricular assist device. After percutaneous left ventricular assist device initiation, mechanical chest compressions was stopped (n = 4) or continued (n = 4). Defibrillation was attempted 4, 8 and 12 minutes after initiating percutaneous left ventricular assist device circulatory support.
Results
The percutaneous left ventricular assist device + mechanical chest compressions group had significantly higher percutaneous left ventricular assist device flow prior to return of spontaneous heartbeat at four- and twelve-minutes after percutaneous left ventricular assist device initiation, and significantly higher end tidal CO2 at 4-minutes after percutaneous left ventricular assist device initiation, when compared with the percutaneous left ventricular assist device alone group. Carotid artery flow was not significantly different between the two groups.
Conclusion
The addition of mechanical chest compressions to percutaneous left ventricular assist device support during cardiac arrest may generate higher percutaneous left ventricular assist device and carotid artery flow prior to return of spontaneous heartbeat compared to percutaneous left ventricular assist device alone. Further studies are needed to determine if this approach improves other hemodynamic parameters or outcomes after prolonged cardiac arrest.
... They concluded that using modified Impella 2.5 Ò led to improved CoPP and doubled the rate of ROSC. 14 Similarly, Panagides et al. evaluated a retrospective multicenter international registry which indicated that patients undergoing Impella CP Ò insertion during ongoing CPR achieved a 37.1% rate of 30-day survival without neurological impairment, a survival rate similar to that achieved by ECMO. 15,16 Additionally, current studies using endovascular balloon occlusion of the aorta (AO) as a resuscitative strategy during CPR have been reported to lead to higher CoPP and improved ROSC rate in a swine model of prolonged cardiac arrest. ...
Aim:
To investigate the effect of tandem use of transient balloon occlusion of the descending aorta (AO) and percutaneous left ventricular assist device (pl-VAD) during cardiopulmonary resuscitation in a large animal model of prolonged cardiac arrest.
Methods:
Ventricular fibrillation was induced and left untreated for 8 minutes followed by 16 minutes of mechanical CPR (mCPR) in 24 swine, under general anesthesia. Animals were randomized to 3 treatment groups (n = 8 per group): A) pL-VAD (Impella CP®) B) pL-VAD+ AO, and C) AO. Impella CP® and the aortic balloon catheter were inserted via the femoral arteries. mCPR was continued during treatment. Defibrillation was attempted 3 times starting at minute 28 and then every 4 minutes. Haemodynamic, cardiac function and blood gas measurements were recorded for up to 4 hours.
Results:
Coronary perfusion pressure (CoPP) in the pL-VAD+AO Group increased by a mean (SD) of 29.2(13.94) mmHg compared to an increase of 7.1(12.08) and 7.1(5.95) mmHg for groups pL-VAD and AO respectively (p=0.02). Similarly, cerebral perfusion pressure (CePP) in pL-VAD+AO increased by a mean (SD) of 23.6 (6.11), mmHg compared with 0.97 (9.07) and 6.9 (7.98) mmHg for the other two groups (p<0.001). The rate of return of spontaneous heartbeat (ROSHB) was 87.5%, 75%, and 100% for pL-VAD+AO, pL-VAD, and AO.
Conclusion:
Combined AO and pL-VAD improved CPR hemodynamics compared to either intervention alone in this swine model of prolonged cardiac arrest.
... As ECMO has already been investigated as a rescue-device in refractory cardiac arrest with early implantation of the device in the field [13,22,23], the objective of this study was to compare the two percutaneous mechanical circulatory support devices that can be deployed early: The Impella CP versus ECMO. We compared ROSC obtention, hemodynamic parameters, myocardial recovery, and peripheral organ damage in a porcine model of ventricular fibrillation (VF) cardiac arrest, as the best model in cardiac arrest study [12,24,25]. ...
... In a similar animal experimental setup, Derwall et al. showed increased survival and improved outcome by CPR using Impella instead of chest compression [24]. Standard CPR with chest compression alone, even of high quality by a mechanical thumper demonstrated disappointing results [40]. ...
... The expected reduction of LVEDP following LV unloading was not confirmed in our experiment. In fact, the pulmonary pressures did not decrease with unloading as shown previously in other experiments [24]. ...
Introduction:
Despite the improvements in standardized cardiopulmonary resuscitation, survival remains low, mainly due to initial myocardial dysfunction and hemodynamic instability. Our goal was to compare the efficacy of two left ventricular assist devices on resuscitation and hemodynamic supply in a porcine model of ventricular fibrillation (VF) cardiac arrest.
Methods:
Seventeen anaesthetized pigs had 12 min of untreated VF followed by 6 min of chest compression and boluses of epinephrine. Next, a first defibrillation was attempted and pigs were randomized to any of the three groups: control (n = 5), implantation of an percutaneous left ventricular assist device (Impella, n = 5) or extracorporeal membrane oxygenation (ECMO, n = 7). Hemodynamic and myocardial functions were evaluated invasively at baseline, at return of spontaneous circulation (ROSC), after 10-30-60-120-240 min post-resuscitation. The primary endpoint was the rate of ROSC.
Results:
Only one of 5 pigs in the control group, 5 of 5 pigs in the Impella group, and 5 of 7 pigs in the ECMO group had ROSC (p < 0.05). Left ventricular ejection fraction at 240 min post-resuscitation was 37.5 ± 6.2% in the ECMO group vs. 23 ± 3% in the Impella group (p = 0.06). No significant difference in hemodynamic parameters was observed between the two ventricular assist devices.
Conclusion:
Early mechanical circulatory support appeared to improve resuscitation rates in a shockable rhythm model of cardiac arrest. This approach appears promising and should be further evaluated.
... Despite the growing clinical use of mechanical circulatory support (MCS) for cardio-pulmonary resuscitation (CPR) after CA, the contribution towards a higher survival rate and the better functional outcome is yet to be demonstrated. An animal study showed a beneficial effect of the early use of a percutaneous mechanical circulatory support device, termed intravascular CPR (iCPR), on post-CPR survival [1]. An additional inhaled nitric oxide (iNO) application in an animal model resulted in improved trans-pulmonary blood flow and was associated with improved neurological outcomes [2]. ...
... Thus, in the present study, we aimed to better understand the effect of iNO during iCPR on the myocardial performance and mechanics in a well-established large animal model of CA [1,2]. The left (LV) and right ventricular (RV) function before, during, and after iCPR were analyzed using 2-D transesophageal echocardiography (TEE), deformation imaging, tissue Doppler (TDI) and non-invasive myocardial work measurement. ...
... The experimental protocol was approved by the appropriate governmental institution (Landesamt für Natur, Umwelt und Verbraucherschutz NRW (LANUV), Recklinghausen, Germany) and has been previously described [1,2]. All animals received adequate care according to the precepts of the Helsinki declaration. ...
Background
Resuscitation using a percutaneous mechanical circulatory support device (iCPR) improves survival after cardiac arrest (CA). We hypothesized that the addition of inhaled nitric oxide (iNO) during iCPR might prove synergistic, leading to improved myocardial performance due to lowering of right ventricular (RV) afterload, left ventricular (LV) preload, and myocardial energetics. This study aimed to characterize the changes in LV and RV function and global myocardial work indices (GWI) following iCPR, both with and without iNO, using 2-D transesophageal echocardiography (TEE) and GWI evaluation as a novel non-invasive measurement.
Methods
In 10 pigs, iCPR was initiated following electrically-induced CA and 10 min of untreated ventricular fibrillation (VF). Pigs were randomized to either 20 ppm (20 ppm, n = 5) or 0 ppm (0 ppm, n = 5) of iNO in addition to therapeutic hypothermia for 5 h following ROSC. All animals received TEE at five pre-specified time-points and invasive hemodynamic monitoring.
Results
LV end-diastolic volume (LVEDV) increased significantly in both groups following CA. iCPR alone led to significant LV unloading at 5 h post-ROSC with LVEDV values reaching baseline values in both groups (20 ppm: 68.2 ± 2.7 vs. 70.8 ± 6.1 mL, p = 0.486; 0 ppm: 70.8 ± 1.3 vs. 72.3 ± 4.2 mL, p = 0.813, respectively). LV global longitudinal strain (GLS) increased in both groups following CA. LV-GLS recovered significantly better in the 20 ppm group at 5 h post-ROSC (20 ppm: − 18 ± 3% vs. 0 ppm: − 13 ± 2%, p = 0.025). LV-GWI decreased in both groups after CA with no difference between the groups. Within 0 ppm group, LV-GWI decreased significantly at 5 h post-ROSC compared to baseline (1,125 ± 214 vs. 1,835 ± 305 mmHg%, p = 0.011). RV-GWI was higher in the 20 ppm group at 3 h and 5 h post-ROSC (20 ppm: 189 ± 43 vs. 0 ppm: 108 ± 22 mmHg%, p = 0.049 and 20 ppm: 261 ± 54 vs. 0 ppm: 152 ± 42 mmHg%, p = 0.041). The blood flow calculated by the Impella controller following iCPR initiation correlated well with the pulsed-wave Doppler (PWD) derived pulmonary flow (PWD vs. controller: 1.8 ± 0.2 vs. 1.9 ± 0.2L/min, r = 0.85, p = 0.012).
Conclusions
iCPR after CA provided sufficient unloading and preservation of the LV systolic function by improving LV-GWI recovery. The addition of iNO to iCPR enabled better preservation of the RV-function as determined by better RV-GWI. Additionally, Impella-derived flow provided an accurate measure of total flow during iCPR.
... Despite the growing clinical use of mechanical circulatory support (MCS) for cardio-pulmonary resuscitation (CPR) after CA, the contribution towards a higher survival rate and the better functional outcome is yet to be demonstrated. An animal study showed a bene cial effect of the early use of a percutaneous mechanical circulatory support device, termed intravascular CPR (iCPR), on post-CPR survival [1]. An additional inhaled nitric oxide (iNO) application in an animal model resulted in improved trans-pulmonary blood ow and was associated with improved neurological outcomes [2]. ...
... Thus, in the present study, we aimed to better understand the effect of iNO during iCPR on the myocardial performance and mechanics in a well-established large animal model of CA [1,2]. The left (LV) and right ventricular (RV) function before, during, and after iCPR were analyzed using 2-D transesophageal echocardiography (TEE), deformation imaging, tissue Doppler (TDI) and non-invasive myocardial work measurement. ...
... The experimental protocol was approved by the appropriate governmental institution (Landesamt für Natur, Umwelt und Verbraucherschutz NRW (LANUV), Recklinghausen, Germany) and has been previously described [1,2]. All animals received adequate care according to the precepts of the Helsinki declaration. ...
Background
Resuscitation using a percutaneous mechanical circulatory support device (iCPR) improves survival after cardiac arrest (CA). We hypothesized that the addition of inhaled nitric oxide (iNO) during iCPR might prove synergistic, leading to improved myocardial performance due to lowering of right ventricular (RV) afterload, left ventricular (LV) preload, and myocardial energetics. This study aimed to characterize the changes in LV and RV function and global myocardial work indices (GWI) following iCPR, both with and without iNO, using 2-D transesophageal echocardiography (TEE) and GWI evaluation as a novel non-invasive measurement. Methods
In 10 pigs, iCPR was initiated following electrically-induced CA and 10min of untreated ventricular fibrillation (VF). Pigs were randomized to either 20ppm ( 20ppm , n=5) or 0ppm ( 0ppm , n=5) of iNO in addition to therapeutic hypothermia for 5h following ROSC. All animals received TEE at five pre-specified time-points and invasive hemodynamic monitoring. ResultsLV end-diastolic volume (LVEDV) increased significantly in both groups following CA. iCPR alone led to significant LV unloading at 5h post-ROSC with LVEDV values reaching baseline values in both groups ( 20ppm: 68.2±2.7 vs. 70.8±6.1 mL, p=0.486; 0ppm : 70.8±1.3 vs. 72.3±4.2 mL, p=0.813, respectively). LV global longitudinal strain (GLS) increased in both groups following CA. LV-GLS recovered significantly better in the 20ppm group at 5h post-ROSC ( 20ppm : -18±3% vs. 0ppm : -13±2%, p=0.025). LV-GWI decreased in both groups after CA with no difference between the groups. Within 0ppm group, LV-GWI decreased significantly at 5h post-ROSC compared to baseline (1,125±214 vs. 1,835±305 mmHg%, p=0.011). RV-GWI was higher in the 20ppm group at 3h and 5h post-ROSC ( 20ppm : 189±43 vs. 0ppm : 108±22 mmHg%, p=0.049 and 20ppm : 261±54 vs. 0ppm : 152±42 mmHg%, p=0.041). The blood flow calculated by the Impella controller following iCPR initiation correlated well with the pulsed-wave Doppler (PWD) derived pulmonary flow (PWD vs. controller: 1.8±0.2 vs. 1.9±0.2L/min, r =0.85, p=0.012). ConclusionsiCPR after CA provided sufficient unloading and preservation of the LV systolic function by improving LV-GWI recovery. The addition of iNO to iCPR enabled better preservation of the RV-function as determined by better RV-GWI. Additionally, Impella-derived flow provided an accurate measure of total flow during iCPR.
... This clinical report verified the ability of the Impella device to maintain CO and perfusion pressure despite a non-pulsatile LV. Furthermore, several reports demonstrate Impella support safely bridging patients through ventricular tachycardia ablation procedures, acute right ventricular failure, and even cardiac arrest [89][90][91][92]. In a canine model of acute decompensated HF, Kawashima et al. [44] demonstrate that Impella support led to superior ventricular unloading compared with ECMO, and hearts supported by Impella had a higher rate of successful defibrillation and recovery of sinus rhythm. ...
Heart failure is a major cause of morbidity and mortality around the world, and myocardial infarction is its leading cause. Myocardial infarction destroys viable myocardium, and this dead tissue is replaced by a non-contractile scar that results in impaired cardiac function and a significantly increased likelihood of the patient developing heart failure. Limiting infarct scar size has been the target of pre-clinical and clinical investigations for decades. However, beyond reperfusion, few therapies have translated into the clinic that limit its formation. New approaches are needed. This review will focus on new clinical and pre-clinical data demonstrating that acute ventricular unloading prior to reperfusion by means of percutaneous left ventricular support devices reduces ischemia-reperfusion injury and limits infarct scar size. Emphasis will be given to summarizing our current mechanistic understanding of this new therapeutic approach to treating myocardial infarction.
... Large animal preclinical studies have shown that Impella can support systemic circulation without chest compressions during ischemic VF cardiac arrest but that intravascular volume loading is required. 88 Derwall et al, 89 using a porcine model of VF, found that this device can generate coronary perfusion pressures of 20 mm Hg, twice that of manual chest compressions. Compared with chest compressions alone, this increased hemodynamic support translated into a significant survival advantage at 24 hours (2 of 10 versus 9 of /10; P=0.003) in animals. ...
Coronary artery disease is prevalent in different causes of out-of-hospital cardiac arrest (OHCA), especially in individuals presenting with shockable rhythms of ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). The purpose of this report is to review the known prevalence and potential importance of coronary artery disease in patients with OHCA and to describe the emerging paradigm of treatment with advanced perfusion/reperfusion techniques and their potential benefits on the basis of available evidence. Although randomized clinical trials are planned or ongoing, current scientific evidence rests principally on observational case series with their potential confounding selection bias. Among patients resuscitated from VF/pVT OHCA with ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 70% to 85%. More than 90% of these patients have had successful percutaneous coronary intervention. Conversely, among patients resuscitated from VF/pVT OHCA without ST-segment elevation on their postresuscitation ECG, the prevalence of coronary artery disease has been shown to be 25% to 50%. For these patients, early access to the cardiac catheterization laboratory is associated with a 10% to 15% absolute higher functionally favorable survival rate compared with more conservative approaches of late or no access to the cardiac catheterization laboratory. In patients with VF/pVT OHCA refractory to standard treatment, a new treatment paradigm is also emerging that uses venoarterial extracorporeal membrane oxygenation to facilitate return of normal perfusion and to support further resuscitation efforts, including coronary angiography and percutaneous coronary intervention. The burden of coronary artery disease is high in this patient population, presumably causative in most patients. The strategy of venoarterial extracorporeal membrane oxygenation, coronary angiography, and percutaneous coronary intervention has resulted in functionally favorable survival rates ranging from 9% to 45% in observational studies in this patient population. Patients with VF/pVT should be considered at the highest severity in the continuum of acute coronary syndromes. These patients have a significant burden of coronary artery disease and acute coronary thrombotic events. Evidence from randomized trials will further define optimal clinical practice.
... However, it has the advantages of using smaller vascular access, and unloads the left ventricle. Several experimental reports suggest that in a porcine model of cardiac arrest, the Impella 2.5 device can support the systemic circulation without concurrent chest compressions and improved the rate of return of spontaneous circulation [24,25]. An early clinical experience of 8 refractory cardiac arrest patients showed that using the Impella plus conventional treatment was associated with 50% survival to discharge [26]. ...
Background:
Cardiac arrest in the Catheterization Lab is a rare and unique scenario that is often logistically challenging. It often has dire prognosis especially in patients suffering from severe pre-existing illnesses (high risk patient) such as acute myocardial infarction with cardiogenic shock, or patients undergoing high risk procedures. As the number of complex interventional procedures increases, cardiac arrest in the cath lab will become more common and optimal management of this scenario is critical for both the patient and operator.
Conclusion:
In this review, we will discuss the special challenges during the resuscitation efforts in cath lab, especially with tradition chest compression. We will discuss the alternative options including mechanical compression devices and Invasive Percutaneous Mechanical Circulatory Support Devices. Finally, we will offer management suggestions on selecting the appropriate circulatory support device based on clinical and anatomic risks.
... 12 Derwall et al. used a porcine model of ventricular fibrillation and found that this device can generate coronary perfusion pressures of 20 mmHg, twice that of manual chest compressions. 13 Compared to chest compressions alone, this increased hemodynamic support translated into a significant survival advantage at 24 hours (2/10 vs 9/10; p¼0.003). Percutaneous venousearterial (VA) extracorporeal membrane oxygenation (ECMO) has been initiated for refractory cardiac arrest in the CCL. ...
