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Khaled M. Ziada, MD

Director, Cardiovascular Catheterization LaboratoriesGill Heart Institute, University of Kentucky

Utilizing the Cath Lab for Cardiac Arrest

UK/AHA Strive to Revive SymposiumMay 2013

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Presenter Disclosure Information

KHALED M. ZIADA, MD

Gill Foundation Professor of Interventional Cardiology

FINANCIAL DISCLOSURE

No relevant financial relationships to disclose.

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Cardiac Arrest - Definition

� Ineffective cardiac contractions resulting in hemodynamic collapse

� Essentially a catastrophic arrhythmic event

� Pulseless ventricular tachycardia

� Ventricular fibrillation

� Pulseless electrical activity (PEA)

� Asystole

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Cardiac Arrest – Rhythm Sequence

Akhtar M et al. Ann Intern Med 1991; 114: 499

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Cardiac Arrest- Underlying Substrate

67%

13%

10%

3%7%

CAD

CM

Valv/ HTN

LQTS

Others

Deshpande S et al. SCD in Brown DL: Cardiac Intensive Care; 1998, p391

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How Can the Cath Lab Help?

CADSTEMI

Cardiogenic shock

NSTEMI & chronic CAD

Anomalies

Therapeutic Hypothermia

Pulmonary Embolism

ThrombolysisReferral to

surgery

IVC filter

Monitoring and

Resuscitation

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Cardiac Arrest- Relationship to MI

1. Mylotte D et al. JACC 2013; 6:115-25.2. Myerburg RJ et al. SCD. In Zipes D: Cardiac Electrophysiology 2004; p 720

� STEMI presenting with resuscitated arrest 4-5% 1

� Resuscitated arrest showing new ST elevation 20% 2

� Resuscitated arrest with evidence of healed MI 40-75% 2

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Arrest and Shock in STEMI

29.6%

Mylotte D et al. JACC 2013; 6:115-25.

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Arrest, Shock and Mortality in STEMI

� 30-day mortality with cardiogenic shock 40-50%

� 30-day mortality with resuscitated arrest 40-50%

� 30 day mortality with arrest and shock 60-70%

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Acute STEMI Care is A Team Sport

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In STEMI Patients, Time is Muscle

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Why FMC-to-Device ≤90 Minutes ?

McNamara, JACC 2006;47:2180-86

Per

cen

t

0

2

4

8

≤90 >90 - 120 >120 - 150

Door-to-Balloon Time (Minutes)

6

>150

In-Hospital Mortality (%)

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Timely Reperfusion is the Goal

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Improvement of Early Mortality in STEMI

Ear

ly

Mor

talit

y (

%)

Pre-CCUEra

30%

CCU Era

DefibrillationMonitoringBeta-blockers

15%

Lytic Era

FibrinolyticsAspirinHeparin

CurrentEra

Primary PCIStentsAnti-platelet Rx

3-4%

7-8%

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Cardiac Arrest in Context of STEMI

Therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by VF or pulseless VT, including patients who undergo primary PCI.

Immediate angiography and PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI.

I IIa IIb III

I IIa IIb III

ACC/AHA STEMI Guidelines, 2013

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Evidence for Early Transfer to Cath Lab

Strote J et al. Am J Cardiol 2012; 109: 451.

� Retrospective propensity matched analysis

� 240 patients with resuscitated out of hospital arrest in the Seattle area

� Prior to routine application of hypothermia

� Improved hospital survival, but no significant difference in neurologic status

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Acute Management and Long Term Outcome

Dumas F et al. JACC 2012; 60:21-27.

Five Year Survival

� 1001 patients who were discharged from hospital with resuscitated out of hospital arrest

� 38% underwent PCI

� 25% underwent hypothermia

� Adjusted RRR of death was reduced with PCI (by 54%) and hypothermia (by 30%)

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Co-Existence of Arrest and Shock in STEMI

Mylotte D et al. JACC 2013; 6:115-25.

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MV PCI for STEMI, Arrest and Shock

Mylotte D et al. JACC 2013; 6:115-25.

Six Months Survival

Single vs. Multi-vessel Disease Culprit only vs. Multi-vessel PCI

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Advanced Support for Cardiogenic Shock

Is There Evidence to Support Mechanical Support?

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Intra-Aortic Balloon Counter-pulsation

o Mainstay of hemodynamic support for cardiogenic shock pts

o Main mechanisms of action:

● Improve cardiac index

● Reduce afterload

● Reduce LVEDP & PCWP

● Improve coronary perfusion

o Indicated for CS (class IB ACC/AHA and IC ESC guidelines)

o Most commonly used support system

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IABP – Cardiogenic Shock

The SHOCK Trial

Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock?*

Hochman, J.S. et al. N Engl J Med 1999;341:625-34

* IABP was used in 86% of patients in each group

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IABP – Acute MI without Shock

Shock II Trial

Randomized Comparison of IABP vs. OMT in Addition to Revascularization in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock

Thiele H et al. N Engl J Med 2012, 367: 1287-96

o 600 pts with AMI + CS

o >95% revascularization

o 1:1 randomization to IABP+OMT vs. OMT alone

o Primary Endpoint: All-cause mortality at 30 days

Mor

talit

y (%

)

Time After Randomization (Days)

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� A miniaturized pump motor that is delivered to the LV, with inlet and outlet holes straddling the aortic valve

� Femoral access (13F)� Arterial access only — faster and easier to deliver� Axial flow of 2.5L/min, Impella CP can provide 4.0L/min� Impella 5.0 usually requires an arterial cut-down

Percutaneous LVADs – Impella®

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Percutaneous LVADs – Impella®

The PROTECT II Trial: Post-hoc Analysis 1

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Log rank test, p=0.04

Death, Stroke, large MI, TVR

IABP

IMPELLA

All Patients,

Counting

Only

Large MIs

(N=426)

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Percutaneous LVADs – Impella®

Caudal –High OM

Cranial -Mid LAD

Baseline Angiograms

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Percutaneous LVADs – Impella®

Final Angiograms

Caudal –High OM

Cranial -Mid LAD

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� A miniaturized percutaneous centrifugal pump

� Femoral access

� Requires arterial and venous access

� Requires trans-septal puncture, venous catheter placed in LA

� More technically challenging

Percutaneous LVADs – Tandem Heart ®

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� A percutaneous cardiopulmonary bypass system

� Complete support of cardiac output and respiratory function

� Femoral and/or neck access

� Requires arterial and venous access

� Not time consuming to insert, but requires a perfusionist

Percutaneous LVADs – ECMO

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Non-Coronary Arrest in the Cath Lab

� Massive and submassive PE

� Hypertrophic cardiomoypathy

� Anomalous coronary arteries

� anomalous LM arising from R cusp

� Functional conditions

� Long QT syndromes

� Electrolyte disturbances

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Pulmonary Embolism

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Pulmonary Thrombolysis

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Cardiac Arrest in the Young

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Cardiac Arrest in the Young

Lim M J et al. Circulation 2005;111:e108-e109

RVOT

Aorta

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Impact of Therapeutic Hypothermia

77 VT-VF patients, with No Cardiogenic Shock

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Impact of Therapeutic Hypothermia

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Hypothermia – Making the Guidelines

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Cardiac Arrest in Context of STEMI

Therapeutic hypothermia should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest caused by VF or pulseless VT, including patients who undergo primary PCI.

Immediate angiography and PCI when indicated should be performed in resuscitated out-of-hospital cardiac arrest patients whose initial ECG shows STEMI.

I IIa IIb III

I IIa IIb III

ACC/AHA STEMI Guidelines, 2013

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Endovascular Induction of Hypothermia

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Endovascular Induction of Hypothermia

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Induction of Hypothermia with ECMO

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