Beneficial outcome after prostaglandin-induced post-partum cardiac arrest using levosimendan and extracorporeal membrane oxygenation

BACKGROUND: Administration of high doses of prostaglandins is a frequently performed and effective method for the treatment of atonic uterine haemorrhage in order to increase uterine muscle tone. Rarely, however, these drugs may cause life-threatening complications including bronchospasm, acute pulmonary oedema and myocardial infarction caused by coronary spasms. METHODS: We discuss the management of a patient suffering post-partum atonic uterine bleeding, catecholamine-resistant cardiac arrest and fulminant pulmonary failure due to deleterious side-effects of treatment with prostaglandins. RESULTS: During therapy resistant cardiopulmonary resuscitation, the addition of levosimendan to standard medications resulted in a prompt stabilization of haemodynamics. Subsequent treatment of pulmonary failure was successfully managed with ECMO. CONCLUSION: Although levosimendan is not approved for pharmacological treatment of cardiopulmonary arrest, the beneficial effects in this patient suggest an important role of calcium sensitization and vasodilation during prostaglandin-induced cardiac arrest.     

Papillary fibroelastoma of the aortic valve with atypical chest pain: late presentation with acute myocardial infarction and cardiac arrest

We report a case of a 54-year-old female with papillary fibroelastoma of the aortic valve who presented with ST-elevation myocardial infarction and cardiac arrest. Though her initial symptom was only atypical chest pain, life-threatening complications such as acute myocardial infarction and cardiac arrest developed. After cardiopulmonary resuscitation, we promptly resected the fibroelastoma on cardiopulmonary bypass, and the patient was discharged without any other complications.     

Clinical experience with portable cardiopulmonary bypass in cardiac arrest patients

To evaluate the use of portable cardiopulmonary bypass as a resuscitative tool and its impact on long-term survival of patients in cardiac arrest, we reviewed the results of 32 consecutive patients resuscitated by cardiopulmonary bypass for cardiac arrest or severe hemodynamic compromise at Northwestern Memorial Hospital over a 2-year period. Overall survival was 12.5%. Only 1 (3.4%) of the 29 patients who had cardiac arrest survived and left the hospital. All 3 patients who had severe hemodynamic compromise but not cardiac arrest were long-term survivors. Our study suggests that portable cardiopulmonary support systems used as a resuscitative tool do not prolong the survival of most cardiac arrest patients but may be useful for patients with shock due to mechanical causes and for those with profound hemodynamic compromise due to ischemia or myocardial infarction. Portable heart-lung machines can provide patients with excellent hemodynamic support; however, neurological or cardiac recovery is unlikely once cardiac arrest occurs.     

Successful excision of a saphenous vein graft aneurysm with different methods

Aneurysm of an aortocoronary saphenous vein graft (SVG) is a rare but potentially fatal complication after coronary artery bypass grafting (CABG). Prevention of cerebral infarction or myocardial infarction due to the intraluminal debris from the SVG aneurysm is an important issue during surgical procedures. We report two patients with SVG aneurysms located in the proximal and distal portions of the SVG body, respectively. The surgical strategy for each case was determined according to the location of the aneurysm. We used low-flow cardiopulmonary bypass without aortic clamping in one patient and cardiac arrest with aortic clamping in the other. Both patients were discharged without sequelae.     

Pilot multi‐centre randomised trial of the impact of pre‐operative focused cardiac ultrasound on mortality and morbidity in patients having surgery for femoral neck fractures (ECHONOF‐2 pilot)

Hip fracture surgery is common, usually occurs in elderly patients who have multiple comorbidities, and is associated with high morbidity and mortality. Pre‐operative focused cardiac ultrasound can alter diagnosis and management, but its impact on outcome remains uncertain. This pilot study assessed feasibility and group separation for a proposed large randomised clinical trial of the impact of pre‐operative focused cardiac ultrasound on patient outcome after hip fracture surgery. Adult patients requiring hip fracture surgery in four teaching hospitals in Australia were randomly allocated to receive focused cardiac ultrasound before surgery or not. The primary composite outcome was any death, acute kidney injury, non‐fatal myocardial infarction, cerebrovascular accident, pulmonary embolism or cardiopulmonary arrest within 30 days of surgery. Of the 175 patients screened, 100 were included as trial participants (screening:recruitment ratio 1.7:1), 49 in the ultrasound group and 51 as controls. There was one protocol failure among those recruited. The primary composite outcome occurred in seven of the ultrasound group patients and 12 of the control group patients (relative group separation 39%). Death, acute kidney injury and cerebrovascular accident were recorded, but no cases of myocardial infarction, pulmonary embolism or cardiopulmonary arrest ocurred. Focused cardiac ultrasound altered the management of 17 participants, suggesting an effect mechanism. This pilot study demonstrated that enrolment and the protocol are feasible, that the primary composite outcome is appropriate, and that there is a treatment effect favouring focused cardiac ultrasound – and therefore supports a large randomised clinical trial.     

Thrombolysis during cardiopulmonary resuscitation

Between 40 and 90 cardiopulmonary resuscitations are performed per 100,000 inhabitants each year in western industrialised nations. In 50-70% of these patients, either fulminant pulmonary embolism or acute myocardial infarction is the underlying cause of cardiac arrest. Based on this fact, thrombolysis may represent a new and effective causal therapeutic strategy in patients suffering from cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. In the past, thrombolysis was contraindicated during cardiopulmonary resuscitation due to great fears of severe bleeding complications (resuscitation-mediated or lysis-induced intracerebral bleeding). For a long time, only clinical case reports or small clinical case series were reported in the literature, however, recently, the first clinical studies focusing on the safety and efficacy of thrombolytic therapy during out-of-hospital cardiopulmonary resuscitation have been published. Besides a specific therapeutic causal effect on pulmonary artery emboli and coronary artery thrombosis, experimental data strongly indicate that thrombolysis might also have an impact on cerebral microcirculatory reperfusion during and after cardiopulmonary resuscitation. This effect might be responsible for the exceptionally good neurological outcome observed in patients treated with thrombolytic agents during cardiopulmonary resuscitation and might be a result of the proven imbalance of the endogenous coagulation system in patients suffering from cardiac arrest. This coagulation imbalance is thought to be responsible for postresuscitation cerebral microcirculatory reperfusion disorders in patients after cardiac arrest and cardiopulmonary resuscitation. In summary, recent clinical and experimental data focusing on thrombolysis during cardiopulmonary resuscitation strongly indicate, that thrombolysis may represent a new and relatively safe therapeutic option during resuscitation after cardiac arrest due to acute myocardial infarction or fulminant pulmonary embolism. If the results of an international randomised, controlled clinical multicentre trial presently underway confirm the previous clinical findings, thrombolysis during cardiopulmonary resuscitation could become an important part of future cardiopulmonary resuscitation algorithms.     

Automated external defibrillator use during cardiopulmonary resuscitation during flight

Automated External Defibrillator (AED) during cardiopulmonary resuscitation should reduce mortality rate after out-of-hospital cardiac arrest. We report a case of defibrillation with AED during flight in a patient suffering cardiac arrest complicating an acute myocardial infarction. Two hours before landing, a 56-years-old man presented sudden cardiac arrest. Flight attendants performed basic cardiac life support, including AED. Five shocks were delivered. After landing, acute myocardial infarction was diagnosed and treated by prehospital thrombolysis and angioplasty with favorable outcome. AED is a crucial link of the chain of survival, especially where advance cardiac live support cannot be performed, like during flight. Despite an increasing AED availability, survival after cardiac arrest during flight remains exceptional.     

The antioxidant N-acetylcysteine preserves myocardial function and diminishes oxidative stress after cardioplegic arrest

OBJECTIVE: Oxidative stress contributes to myocardial ischemia-reperfusion injury. We hypothesized that administration of the antioxidant N-acetylcysteine would have beneficial effects on myocardial function after cardiopulmonary bypass and cardioplegic arrest. METHODS: Anesthetized dogs (n = 18) were instrumented with myocardial ultrasonic crystals and a left ventricular micromanometer. Systolic function was measured by preload recruitable stroke work. Myocardial tissue water was determined by microgravimetry. Treated animals received 100 mg.kg(-1) N-acetylcysteine 10 minutes before initiation of cardiopulmonary bypass followed by 20 mg.kg(-1).h(-1) continuous infusion until 1 hour after cardiopulmonary bypass. After baseline, cardiopulmonary bypass and 2-hour crystalloid cardioplegic arrest was initiated, then reperfusion/rewarming for 40 minutes and separation from cardiopulmonary bypass. Myocardial function parameters and myocardial tissue water were measured at 30, 60, and 120 minutes after cardiopulmonary bypass. Oxidative stress was measured by 8-isoprostane concentrations in the coronary sinus plasma. RESULTS: Preload recruitable stroke work did not decrease from baseline in the N-acetylcysteine group and was significantly greater in N-acetylcysteine group compared with controls at 30 (104% +/- 9% vs 80% +/- 4%; P <.05) and 120 minutes (98% +/- 7% vs 79% +/- 4%; P <.05) after cardiopulmonary bypass. Concentrations of 8-isoprostane in the coronary sinus plasma of the control dogs were significantly higher 30 minutes after cardiopulmonary bypass compared with baseline but were unchanged in the N-acetylcysteine group. Myocardial edema resolution was significantly greater in the N-acetylcysteine group at 30 minutes after cardiopulmonary bypass compared with control (-2.5% +/- 0.7% vs -0.3% +/- 0.5% myocardial tissue water; P <.05). CONCLUSIONS: Administration of the antioxidant N-acetylcysteine preserves systolic function and enhances myocardial edema resolution after cardiopulmonary bypass/cardioplegic arrest. Furthermore, oxidative stress was significantly reduced in the treated animals. Therefore, our findings support the hypothesis that oxidative stress is the main cause for myocardial dysfunction after ischemia-reperfusion.     

Thrombolytic therapy during or after cardiopulmonary resuscitation. Efficacy and safety of a new therapeutic approach

Acute myocardial infarction (MI) and massive pulmonary embolism (PE) are the underlying causes of cardiac arrest in more than 70% of patients. Thrombolysis is an effective therapy for patients presenting with acute MI or massive PE and has experimentally shown to have beneficial effects on the microcirculatory reperfusion after cardiac arrest, but this treatment has been widely withheld up to now mainly because of the fear of severe bleeding complications. To assess the efficacy and safety of thrombolysis after and during cardiopulmonary resuscitation (CPR), we reviewed the currently available clinical studies on thrombolysis after and during CPR. From these data, there is increasing evidence that thrombolytic therapy during or shortly after CPR can contribute significantly to a restoration of spontaneous circulation in patients suffering from cardiac arrest. Although the use of thrombolytic agents is associated with a higher incidence of bleeding complications, currently available data do not suggest an increase of complications if thrombolysis is combined with CPR. Considering the poor outcome of patients suffering from cardiac arrest and the lack of effective and causal treatment options, the potential risks of thrombolysis after or during CPR probably do not outweigh the benefits of this treatment option.     

Minimally invasive coronary artery bypass grafting for myocardial muscle bridging

Myocardial bridging is a congenital anomaly of the left anterior descending coronary artery (LAD), which is associated with myocardial ischemia and infarction, cardiac arrhythmias, and sudden cardiac death. Two cases are reported of symptomatic myocardial bridging refractory to medical management treated by minimally invasive coronary artery bypass grafting without cardiopulmonary bypass. We conclude that minimally invasive coronary artery bypass techniques are appropriate alternatives to endovascular stent placement, muscle bridge division, or aortocoronary grafting with cardiopulmonary bypass for the management of symptomatic myocardial bridging.     

Successful surgical management of papillary muscle rupture following acute myocardial infarction in an elderly patient

Papillary muscle rupture is rare but catastrophic complication of acute myocardial infarction. We report a 91-year-old woman who underwent successful management of papillary muscle rupture following acute myocardial infarction. She was transferred to our hospital because of severe pulmonary edema and cardiogenic shock. Echocardiography revealed severe mitral valve regurgitation due to total rupture of anterolateral papillary muscle. After intubation, intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) insertion, mitral valve replacement was successfully performed. She was discharged 134 days after operation. In papillary muscle rupture deteriorating hemodynamics, early diagnosis and immediate cardiopulmonary support are required before surgical treatment. She was, to the best of our knowledge, the oldest among the reported cases of successful surgical treatment of papillary muscle rupture in Japan.     

Metabolic changes and myocardial injury during cardioplegia: a pilot study.

BACKGROUND: The timing, nature, and severity of both increased cardiac troponin I (cTn-I) levels and myocardial injury during ischemic arrest with cardioplegia are unknown. To define them more accurately, we studied myocardial metabolic activity and the release of markers of myocardial cell injury into the coronary sinus before, during, and after cardioplegia. METHODS: We simultaneously measured creatine kinase, creatine kinase-MB, cTn-I, lactate, phosphate, and blood gases in coronary sinus and systemic arterial blood from 12 patients before cardiopulmonary bypass, after removal of the aortic cross-clamp, and after discontinuation of cardiopulmonary bypass. We also measured coronary sinus flow and transmyocardial fluxes of all analytes and calculated myocardial oxygen consumption, myocardial carbon dioxide production, and myocardial energy expenditure. RESULTS: Myocardial lactate release increased 10-fold after removal of the aortic cross-clamp (p = 0.012) and was accompanied by a surge in myocardial phosphate uptake (p = 0.056). These events were associated with only partial cardioplegia-induced suppression of myocardial oxygen consumption (p = 0.0047), myocardial carbon dioxide production (p = 0.0022), and myocardial energy expenditure (p = 0.0029). Simultaneously, coronary sinus cTn-I levels increased from a mean of 0.76 to 2.43 ng/mL after removal of the aortic cross-clamp, and 2.51 ng/mL after cardiopulmonary bypass (p = 0.014), leading to an increase in arterial cTn-I concentration from 0.18 to 0.98 and 3.01 ng/mL (p = 0.0002). Thus, cTn-I release across the myocardium was absent at baseline, became detectable (p = 0.012) after removal of the aortic cross-clamp, and correlated with cross-clamp and pump times. Similar changes occurred with creatine kinase-MB. CONCLUSIONS: Metabolic myocardial stress occurs during ischemic arrest with cardioplegia and is associated with inadequate suppression of metabolism and with a surge in cTn-I and creatine kinase-MB release, which is maximal after removal of the aortic cross-clamp. These changes are likely to represent structural myocardial cell injury.     

Side Effects of Cardiopulmonary Bypass:

Despite many years of clinical and experimental research, the contribution of cardiopulmonary bypass (CPB) and cardioplegic arrest to morbidity and mortality following cardiac surgery remains unclear. This is due, in part, to lack of suitable control group against which bypass and cardioplegic arrest can be compared. The recent success of beating heart coronary artery bypass grafting has, however, for the first time, provided an opportunity to compare the same operation, in similar patient groups, with, or without CPB and cardioplegic arrest. CPB is associated with an acute phase reaction of protease cascades, leucocyte, and platelet activation that result in tissue injury. This is largely manifest as subclinical organ dysfunction that produces a clinical effect in those patients that generate an excessive inflammatory response or in those with limited functional reserve. The contribution of myocardial ischemia/reperfusion, secondary to aortic cross-clamping, and cardioplegic arrest, to the systemic inflammatory response and wider organ dysfunction is unknown, and requires further evaluation in clinical trials.     

Myocardial ischemia revisited

Does perioperative myocardial ischemia lead to postoperative myocardial infarction? By Stephen Slogoff and Arthur S. Keats. Anesthesiology 1985; 62:107-14. Reprinted with permission. To determine if a relationship exists between perioperative myocardial ischemia (ST segment depression greater than or equal to 0.1 mV) and postoperative myocardial infarction (PMI), nonparticipating observers recorded all electrocardiographic, hemodynamic, and other events between arrival of patients in the operating room and onset of cardiopulmonary bypass during 1,023 elective coronary artery bypass operations (CABG). The roles of preoperative patient characteristics, quality of the operation limited by disease as rated by the surgeon and duration of ischemic cardiac arrest as risk factors for PMI also were quantified. Electrocardiographic ischemia occurred in 36.9% of all patients, with almost half the episodes occurring before induction of anesthesia. PMI was almost three times as frequent in patients with ischemia (6.9% vs. 2.5%) and was independent of when ischemia occurred. Ischemia was related significantly to tachycardia but not hypertension nor hypotension and was frequent in the absence of any hemodynamic abnormalities. The anesthesiologist whose patients had the highest rate of tachycardia and ischemia had the highest rate of PMI. Although neither single nor multiple preoperative patient characteristics related to PMI, suboptimal quality of operation and prolonged ischemic cardiac arrest increased the likelihood of PMI independent of the occurrence of myocardial ischemia. The authors conclude that perioperative myocardial ischemia is common in patients undergoing CABG, occurs randomly as well as in response to hemodynamic abnormalities, and is one of three independent risk factors the authors identified as related to PMI. PMI is unrelated to preoperative patient characteristics such as ejection fraction and left main coronary artery disease, and its frequency will relate primarily to perioperative management rather than patient selection.     

Aortocoronary artery graft during early and late phases of acute myocardial infarction

From April, 1968, to August, 1972, 30 patients received one to three emergency saphenous vein grafts during acute myocardial infarction. In all but 1 patient, acute myocardial infarction occurred while the patients were in the hospital awaiting coronary angiography or myocardial revascularization.The patients were divided into two groups: those in the early and those in the late phases of acute myocardial infarction, depending on the time interval between the onset of chest pain and operation. Twenty-four patients (early phase) received grafts within 10 hours after the onset of infarction, and 18 of these 24 patients underwent operation within 4 hours after infarction. Two patients included in this group sustained myocardial infarctions in the operating room during elective myocardial revascularization procedures; another patient was brought to the operating room following cardiac arrest and was supported by internal cardiac massage throughout the opening of the chest and cardiac cannulation. Six patients (late phase) received grafts from three to fourteen days after acute infarction because of postinfarction angina. Only 1 patient was in cardiogenic shock prior to operation.Two patients, both from the early phase group, died in the postoperative period; and 1 patient died seven months postoperatively from a noncardiac cause. Twenty-five of 27 surviving patients became asymptomatic, and 2 patients continue to have mild angina (Functional Class II). Sixteen patients with 24 grafts were restudied in the postoperative period, and 22 of the grafts were found to be patent.This experience suggests that early operative intervention in acute myocardial infarction by the saphenous vein graft technique is beneficial to the patient. The rationale of revascularization in the early phase of acute myocardial infarction is to minimize the area of muscle necrosis by increasing perfusion to the ischemic myocardium around the infarct.     

Post-resuscitation haemodynamics in a novel acute myocardial infarction cardiac arrest model in the pig

BACKGROUND AND OBJECTIVES: Although a considerable amount of promising experimental research has been performed on cardiopulmonary resuscitation, clinical data indicate an ongoing limited outcome in human beings. One reason for this discrepancy could be that experimental studies use healthy animals whereas most human beings undergoing cardiopulmonary resuscitation suffer from acute or chronic myocardial dysfunction. To overcome this problem, we sought to develop a new model of myocardial infarction, that is easy to perform in all kind of laboratories and compromises on the myocardial function significantly. METHODS: Following approval by the local authorities, 14 domestic pigs were instrumented for measurement of arterial, central venous, left atrial and left ventricular pressures. Myocardial infarction was induced in eight pigs by clipping the circumflex artery close to its origin from the left coronary artery (infarction group; n = 8). Six animals (no infarction group, n = 6) served as no-infarct controls. Following a 4-min period of cardiac arrest, internal cardiac massage was performed in these two groups, and haemodynamics were recorded during the first 30 min of reperfusion. RESULTS: All animals were resuscitated successfully. Compared to the no-infarction group, the infarction group showed significantly decreased myocardial contractility, coronary perfusion pressure and cardiac index (30 min after restoration of spontaneous circulation: infarction group: 57 +/- 7 and 89 +/- 19 mL min-1 kg-1 in the no-infarction group; mean +/- SD; P < 0.05) during reperfusion. Two animals from the infarction group (25%), but none of the animals in the no-infarction group, died during the reperfusion period.CONCLUSION: These data demonstrate that clipping of the circumflex artery leads to a reduced myocardial performance after successful resuscitation, whereas the rate of restoration of spontaneous circulation is not reduced. Therefore, this set-up provides a reproducible model for future studies of post-resuscitation haemodynamics and treatment.     

Hypoxic-ischaemic brain injury (HIBI) after cardiopulmonary arrest

Hypoxic-ischaemic brain injury (HIBI) is unfortunately a common complication after cardiopulmonary arrest (CPA) with devastating neurologic complications. Intensive care unit (ICU) management is initially aimed at cardiovascular stabilization and correction of the underlying cause of arrest such as ventricular fibrillation (VF), myocardial infarction from symptomatic coronary artery disease (CAD), or respiratory arrest. Once the patient is stabilized from a cardiac standpoint, growing evidence suggests that therapeutic hypothermia may provide cerebral neuroprotective benefit for VF-related CPA. Practical ICU evaluation and implementation of therapeutic hypothermia is discussed. Evaluation and management of HIBI-related autonomic disturbances or paroxysmal autonomic instability with dystonia (PAID) is discussed. Finally, we review the literature regarding neurological prognostication after cardiac arrest and the tests with highest specificity that can aid in the decision-making process.     

Changing predictors of postoperative mortality in acute type A aortic dissection

OBJECTIVES: Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies. METHODS: We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999. RESULTS: Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p < 0.01) and malperfusion of more than 1 vital organ (adjusted odds ratio 4.97, p < 0.01), especially myocardial ischemia due to coronary artery dissection (adjusted odds ratio 3.21, p < 0.05), significantly increased the likelihood of operative death. Multivariate logistic regression analysis showed only cardiopulmonary arrest (p < 0.01) and concomitant coronary artery bypass grafting necessitated in cases complicated by evolving myocardial infarction (p < 0.05) to be independent predictors of postoperative mortality. CONCLUSION: Preoperative complication from coronary dissection was the most important predictor of early postoperative mortality in this series. In such cases, rapid surgical intervention before myocardial infarction develops is vital to saving lives.     

Multi-recurrent cardiac arrest: when to discontinue cardiopulmonary resuscitation?

A 52-year-old man developed an out-of-hospital cardiac arrest complicating a myocardial infarction. After prolonged cardiopulmonary resuscitation, he was admitted to an intensive care unit, where 25 episodes of cardiac arrests occurred within a few hours. Finally the outcome was favourable. This case raises the question of the duration a cardiopulmonary resuscitation in case of out-of-hospital and in-hospital cardiac arrest. The question is to determine how long resuscitation efforts must be prolonged after recurrent cardiac arrests.     

Traumatic pseudoaneurysm of the heart

Missile injuries to heart are one of the most severe penetrating chest injuries, and mostly fatal. The presentation in those who survive may be unusual and insidious. Pseudoaneurysms of the heart, usually sequel to myocardial infarction, may rarely present after penetrating cardiac wounds. Their management is a challenging one, and requires the provision of cardiopulmonary bypass. We report a case of ventricular pseudoaneurysm as a consequence of bullet injury, successfully managed in our center.