Out-of-hospital extra-corporeal life support implantation during refractory cardiac arrest in a half-marathon runner

Abstract

For patients who present with an out-of-hospital refractory cardiac arrest, in-hospital extracorporeal life-support (ECLS) initiation represents an alternative therapy which allows significant survival. We describe here the first case of out-of-hospital ECLS implantation in a patient presenting with a refractory cardiac arrest during a road race. ECLS was initiated within the MICU ambulance 60 min after cardiac arrest and enabled restoration of cardiac output to 4.5 l min⁻¹. Coronarography revealed a severe isolated stenosis of the right coronary artery, which was treated by angioplasty. The cardiogenic shock resolved progressively, enabling ECLS weaning within 48h, while renal, hepatic, and respiratory functions recovered simultaneously.

Full text

Resuscitation
82 (2011) 1239–
1242
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lists
available
at
ScienceDirect
Resuscitation
jo
u
rn
al
hom
epage
:
www.elsevier.com/locate/resuscitation
Case
report
Out-of-hospital
extra-corporeal
life
support
implantation
during
refractory
cardiac
arrest
in
a
half-marathon
runner夽
Guillaume
Lebretona,
Matteo
Pozzia,
Charles-Edouard
Luytb,
Jean
Chastreb,
Pierre
Carlic,
Alain
Paviea,
Pascal
Leprincea,
Benoît
Vivienc,∗
aService
de
Chirurgie
Cardio-Thoracique,
Hôpital
Pitié-Salpêtrière,
Université
Pierre
et
Marie
Curie
–
Paris
6,
Paris,
France
bService
de
Réanimation
Médicale,
Hôpital
Pitié-Salpêtrière,
Université
Pierre
et
Marie
Curie
–
Paris
6,
Paris,
France
cSAMU
de
Paris,
Département
d’Anesthésie
Réanimation,
Hôpital
Necker
–
Enfants
Malades,
Université
Paris
Descartes
–
Paris
5,
Paris,
France
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Received
9
January
2011
Received
in
revised
form
3
March
2011
Accepted
2
April
2011
Keywords:
Sport
sudden
death
Refractory
cardiac
arrest
Cardiopulmonary
resuscitation
Out-of-hospital
ECLS
a
b
s
t
r
a
c
t
For
patients
who
present
with
an
out-of-hospital
refractory
cardiac
arrest,
in-hospital
extracorporeal
life-
support
(ECLS)
initiation
represents
an
alternative
therapy
which
allows
significant
survival.
We
describe
here
the
first
case
of
out-of-hospital
ECLS
implantation
in
a
patient
presenting
with
a
refractory
cardiac
arrest
during
a
road
race.
ECLS
was
initiated
within
the
MICU
ambulance
60
min
after
cardiac
arrest
and
enabled
restoration
of
cardiac
output
to
4.5
l
min−1.
Coronarography
revealed
a
severe
isolated
stenosis
of
the
right
coronary
artery,
which
was
treated
by
angioplasty.
The
cardiogenic
shock
resolved
pro-
gressively,
enabling
ECLS
weaning
within
48
h,
while
renal,
hepatic,
and
respiratory
functions
recovered
simultaneously.
© 2011 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Risk
of
sudden
cardiac
death
associated
with
road
races
among
athletes
>35
years
of
age
ranges
from
1/15,000
to
1/22,0000.1–3
Whereas
pre-participation
cardiovascular
evaluation
of
competi-
tive
athletes
has
been
shown
to
be
effective
for
the
detection
of
potentially
lethal
cardiomyopathy,
decrease
in
mortality
recently
observed
among
participants
experiencing
cardiac
arrest
during
road
races
is
largely
attributable
to
wider
access
to
defibrillators
now
available
on
many
courses.1,4,5 Elsewhere,
for
cardiac
arrest
patients
who
do
not
respond
to
conventional
cardiopulmonary
resuscitation
(CPR),
extracorporeal
life-support
(ECLS)
may
rep-
resent
an
alternative
therapeutic
approach
allowing
significant
survival
rates.6However,
ECLS
is
not
available
in
every
hospital,
and
time
required
to
transfer
the
patient
from
the
race
to
the
car-
diothoracic
department
may
be
long,
worsening
prognosis.6–7 To
the
best
of
our
knowledge,
we
describe
here
the
first
case
of
out-of-
hospital
ECLS
implantation
in
a
patient
presenting
with
refractory
cardiac
arrest
during
a
road
race.
夽A
Spanish
translated
version
of
the
abstract
of
this
article
appears
as
Appendix
in
the
final
online
version
at
doi:10.1016/j.resuscitation.2011.04.002.
∗Corresponding
author
at:
SAMU
de
Paris,
Département
d’Anesthésie-
Réanimation,
Hôpital
Necker
– Enfants
Malades,
149
Rue
de
Sèvres,
75730
Paris
Cedex
15,
France.
Tel.:
+33
1
44
49
24
72;
fax:
+33
1
44
49
23
25.
E-mail
address:
benoit.vivien@nck.aphp.fr
(B.
Vivien).
2.
Case
A
48
year-old
runner
collapsed
near
the
end
of
the
Paris
half-marathon.
The
patient
was
immediately
taken
care
of
by
pro-
fessional
rescuers
who
performed
BLS
with
no-flow
<1
min.
Five
minutes
later,
the
Mobile
Intensive
Care
Unit
(MICU)
prehospi-
tal
medical
team
found
the
patient
in
asystolic
cardiac
arrest.
After
30
min
ACLS
with
continuous
chest
compressions,
ventila-
tion,
5
times
1
mg
intravenous
epinephrine
administration,
the
patient
was
still
in
refractory
cardiac
arrest
but
presented
signs
of
life,
i.e.
spontaneous
inspiratory
movements,
bilateral
pupil-
lary
light
reflexes,
and
endtidal
CO2about
30
mmHg.
Therapeutic
mild
hypothermia
was
induced
by
infusion
of
1500
ml
of
cold
physiological
saline
(+4 ◦C),
and
moreover
facilitated
by
the
low
outside
temperature
(about
+2 ◦C).
Therefore
the
medical
team
decided
to
set
up
an
ECLS
on
the
out-of-hospital
theater.
While
continuing
CPR
(Fig.
1),
direct
surgical
access
to
right
femoral
ves-
sels
for
veno-arterial
ECLS
implantation
(Revolution
Centrifugal
Blood
Pump,
Sorin
Group
Italia
S.r.l.TM,
Milano,
Italy;
Cannulae
Edwards
FemTrack
18F–28F;
Edwards
LifesciencesTM,
Irvine,
CA)
was
performed
within
the
MICU
ambulance
(Fig.
2).
The
femoral
vein
appeared
collapsed
because
of
severe
hypovolemia,
which
made
cannulation
difficult,
and
therefore
fluid
loading
was
con-
tinued
with
2000
ml
of
physiological
serum.
ECLS
was
initiated
at
the
60th
minute
after
cardiac
arrest
(Fig.
3),
and
enabled
restora-
tion
of
a
cardiac
output
of
4.5
l
min−1.
Subsequently,
return
of
spontaneous
electrical
cardiac
activity
and
circulation
occurred
0300-9572/$
–
see
front
matter ©
2011 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.resuscitation.2011.04.002

1240 G.
Lebreton
et
al.
/
Resuscitation
82 (2011) 1239–
1242
Fig.
1.
Direct
surgical
access
to
right
femoral
vessels
for
veno-arterial
cannulation
performed
by
cardiothoracic
surgeons
within
the
MICU
ambulance.
Cardiopul-
monary
resuscitation
was
continued
by
EMS
providers
during
cannulation.
10
min
later.
Laboratory
tests
performed
on
a
venous
blood
sam-
ple
revealed
lactate
concentration
8.1
mmol
l−1,
pH
7.08,
HCO3−
14.3
mmol
l−1,
PaO271
mmHg,
and
PaCO248
mmHg.
Central
tem-
perature
was
31.9 ◦C
on
hospital
admission.
The
patient
was
transferred
to
the
cardiac
catheterization
laboratory.
Coronarogra-
phy
revealed
a
severe
isolated
stenosis
of
the
right
coronary
artery,
which
was
treated
by
angioplasty
(Fig.
4).
Left
ventricular
ejec-
tion
fraction
was
<20%
with
severe
global
hypokinesia,
requiring
continuation
of
ECLS
during
48
h.
The
patient
was
admitted
into
an
ICU
and
sedated
for
36
h,
and
mild
therapeutic
hypothermia
(32–34 ◦C)
was
continued
for
24
h.
The
cardiogenic
shock
progres-
sively
resolved,
enabling
uneventful
ECLS
weaning,
and
myocardial
function
completely
recovered
within
the
next
5
days.
Contem-
poraneously,
renal,
hepatic
and
respiratory
functions
recovered,
parallely
with
normalization
of
biological
parameters.
However,
the
patient
presented
in
a
persistant
vegetative
state
(Glasgow
Outcome
Scale
=
4).
Neurophysiological
investigations
confirmed
the
severe
post-anoxic
encephalopathy.
According
to
the
patient’s
next-of-kin
wishes,
limitation
of
care
was
decided,
and
the
patient
died
on
day
18.
Fig.
2.
Figure
is
showing
the
centrifugal
pump
system
with
the
oxygenator,
and
the
venous
and
arterial
lines,
respectively
connected
to
venous
and
arterial
femoral
cannulae.
Fig.
3.
Patient
under
extra-corporeal
life
support
(ECLS)
within
the
MICU
ambu-
lance.
Picture
was
taken
a
few
minutes
after
end
of
veno-arterial
femoral
cannulation
and
ECLS
initiation.
3.
Discussion
In
a
recent
meta-analysis
on
ECLS
for
cardiac
arrest,
Cardarelli
et
al.
reported
an
overall
survival
to
hospital
discharge
of
40%,
with
a
negative
trend
in
survival
when
manual
CPR
lasted
>30
min
with-
out
prompt
ECLS
initiation
(OR
1.9;
CI95%
0.9–4.2).6These
authors
also
concluded
in
their
analysis
that
neurological
outcome
was
poorly
described
in
the
reviewed
literature.
Duration
of
low-flow
before
ECLS
initiation
is
classically
considered
as
a
major
endpoint
Fig.
4.
Severe
isolated
distal
stenosis
of
the
right
coronary
artery
(arrow)
revealed
on
the
coronarography
performed
immediately
after
hospital
admission.
Since
this
stenosis
was
the
only
finding
revealed
by
coronarography,
an
ischemia
while
the
patient
was
running
had
been
probably
responsible
for
his
cardiac
arrest.

G.
Lebreton
et
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/
Resuscitation
82 (2011) 1239–
1242 1241
Fig.
5.
MICU
ambulance
pre-equipped
with
a
ready-to-use
ECLS
device
(Sorin
Cen-
trifugal
Pump®,
Sorin
Group
USA,
Inc.).
Since
2009,
the
cardiothoracic
and
medical
team
are
systematically
present
along
the
race
with
this
pre-equipped
ambulance
for
all
half-marathon
and
full
marathon’s
in
Paris.
(1)
Centrifugal
pump
system,
with
oxygenator
and
command
control
panel;
(2)
diathermic
knife;
(3)
pre-filled
venous
line;
(4)
prefilled
arterial
line.
for
both
survival
and
neurologic
outcome.6–8 Conversely,
a
recent
published
study
focused
on
the
major
importance
of
the
no
flow
duration
before
initiation
of
cardiopulmonary
resuscitation:
among
51
out-of-hospital
cardiac
arrest
patients,
the
2
surviving
patients
presented
no
flows
of
1
min
and
0
min,
and
respectively
low
flows
of
132
min
and
170
min.9
As
we
had
previously
observed
several
refractory
cardiac
arrests
during
road
races
in
Paris
with
prolonged
but
unshortenable
times
for
transfer
to
hospital,
we
have
decided
since
2009
to
upgrade
the
medical
team
for
the
Paris’
half-marathon
and
marathon
races:
both
emergency
physicians
and
cardiothoracic
surgeons
are
sys-
tematically
present
along
the
race,
within
a
MICU
ambulance
pre-equipped
with
a
ready-to-use
pre-primed
ECLS
device
(Fig.
5).
Indeed,
recommendations
on
how
to
improve
survival
for
cardiac
arrest
patients
undergoing
ECLS
focus
on
shortening
ECLS
deploy-
ment
time.6,8
ECLS
was
started
60
min
after
the
cardiac
arrest
in
our
patient.
This
time
is
a
little
longer
than
those
reported
by
Cardarelli
et
al.
(40
[1–180]min),
Chen
et
al.
in
2003
(47.6
±
13.4
min)
and
in
2008
(52.8
±
37.2
min),
Sung
et
al.
(48.5
±
29.0
min),
and
Sin
et
al.
(42.1
±
25.7
min),
but
lower
than
those
reported
by
Kurose
et
al.
(73
±
26
min),
Massetti
et
al.
(105
±
44
min),
Mégarbane
et
al.
(120
[60–180]min)
and
Le
Guen
et
al.
(120
[102–149]min),
all
for
in-hospital
ECLS
implantation.6,9–16 Moreover,
all
those
reports
included
only
in-hospital
cardiac
arrests,
excepted
those
of
Mas-
setti,
Mégarbane
and
Le
Guen,
which
represent
the
longest
times.
Therefore,
our
time
of
60
min
CPR
before
out-of-hospital
ECLS
ini-
tiation
should
be
considered
as
reasonable,
and
nevertheless
is
dramatically
faster
than
the
time
that
would
have
been
necessary
for
an
in-hospital
ECLS
implantation.
For
comparison,
since
time
from
cardiac
arrest
to
in-hospital
ECLS
initiation
had
been
110
min
in
a
2009
Paris’
half-marathon
runner,
that
has
been
the
target
for
our
decision
to
upgrade
our
medical
team
for
major
road
races
in
Paris.
In
our
patient,
return
of
spontaneous
circulation
occurred
10
min
after
ECLS
initiation;
organ
functions
and
excepted
neu-
rological
status
recovered
in
48
h,
enabling
ECLS
weaning.
This
was
most
likely
due
to
the
short
no-flow
time.6,11 Although,
our
patient
did
present
with
severe
post-anoxic
encephalopathy.
These
findings
are
consistent
with
experimental
evidence
that
cerebral
neurons
are
more
vulnerable
than
cardiac
myocytes
to
ischemia.17,18 The
major
neurological
deficit
of
our
patient
is
prob-
ably
linked
to
unefficient
chest
compressions
performed
on
an
ischaemic
stone
heart
worsened
by
a
dehydration-related
hypo-
volemia,
as
suggested
by
the
collapsed
femoral
vein
aspect
during
cannulation.
Cerebral
autoregulation
is
lost
during
prolonged
CPR,
and
cerebral
blood
flow
become
directly
dependant
on
cerebral
perfusion
pressure.10 Considering
that
our
patient
presented
a
car-
diac
arrest
near
the
end
of
the
race,
we
should
have
suspected
hypovolemia,
and
consequently
earlier
initiated
fluid
loading.
The
cardiac
arrest
of
our
patient
occurred
near
the
end
of
the
race,
which
is
in
agreement
with
Redelmeier
who
reported
that
the
most
common
course
location
for
cardiac
arrest
is
close
to
the
finish
line.2Consequently,
we
have
decided
going
forward,
for
Paris’
races,
to
locate
the
ECLS-equipped
MICU
ambulance,
obviously
fully
mobile,
preferentially
along
the
end
of
the
race,
which
could
help
to
furthermore
decrease
time
for
ECLS
initiation
in
a
cardiac
arrest
runner.
At
last,
this
case
was
scheduled
for
a
special
sport
event,
i.d.
a
road
race
in
Paris,
during
which
a
sudden
death
is
expected.
Whereas
emergency
in-hospital
ECLS
implantation
is
not
yet
avail-
able
in
most
of
hospitals
(only
in
4
cardiothoracic
departments
and
1
specialized
ICU
in
Paris),
generalization
of
out-of-hospital
ECLS
implantation
may
be
difficult.
On
the
other
hand,
we
have
in
Paris
an
ECLS
team
(“Unité
Mobile
d’Assistance
Circulatoire,
UMAC”)
which
goes
in
other
hospital
in
Paris
and
suburbs
to
implant
ECLS
for
cardiac
failure
and
in-hospital
cardiac
arrest
patients
with
good
prognostic
factors
(limited
no
flow
<5
min).20 Therefore
we
do
think
that
it
would
be
perfectly
possible
to
have
an
ECLS
team
on
duty
for
out-of-hospital
ECLS
implantation.
The
limitation
factors
are
obviously
the
availability
of
the
team,
and
the
requirement
of
a
specified
pre-equipped
MICU.
Nevertheless,
the
patient
should
be
highly
selected
(no
flow
<5
min
and/or
protective
factors
such
as
hypothermia)
and
the
time
required
until
start
of
ECLS
should
be
significantly
shorter
than
the
expected
time
for
transportation
of
the
patient
to
the
cardiothoracic
department.
4.
Conclusion
Finally,
whereas
many
publications
report
successful
trans-
portation
of
patients
under
ECLS
after
out-of-cardiothoracic
department
but
in-hospital
implantation,19 to
the
best
of
our
knowledge,
our
case
is
the
first
one
attesting
to
the
feasibility
of
complete
out-of-hospital
ECLS
implantation
for
refractory
cardiac
arrest.
Despite
the
patient’s
death,
the
positive
results
for
organs
perfusion
and
recovery
encourage
us
to
continue
this
experiment.
Conflict
of
interest
statement
Authors
have
no
conflict
of
interest.
Funding
None.
Consent
for
publication
Consent
for
publication
of
this
case
report
was
obtained
from
the
next
of
kin
(the
wife)
of
the
patient
presented
in
the
manuscript.
References
1.
Roberts
WO,
Maron
BJ.
Evidence
for
decreasing
occurrence
of
sudden
cardiac
death
associated
with
the
marathon.
J
Am
Coll
Cardiol
2005;46:1373–4.
2.
Redelmeier
DA,
Greenwald
JA.
Competing
risks
of
mortality
with
marathons:
retrospective
analysis.
BMJ
2007;335:1275–7.
3. Tunstall
Pedoe
DS.
Marathon
cardiac
deaths:
the
London
experience.
Sports
Med
2007;37:448–50.

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Lebreton
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/
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82 (2011) 1239–
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NB,
Harris
KM,
Smith
SA,
Tankh-Johnson
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Gornick
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BJ.
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in
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young
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D,
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