Presentation TCT Washington 2

8/7/2019 Presentation TCT Washington 2

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PCI and hypothermia for PCI and hypothermia for STEMI in a patient foundSTEMI in a patient found

and resuscitated in aand resuscitated in ahospital elevator hospital elevator

Kristina Maric Besic, MDKristina Maric Besic, MD

Department of Cardiovascular Department of Cardiovascular MedicineMedicine

School of Medicine & University Hospital CentreSchool of Medicine & University Hospital Centre

ZagrebZagreb

Zagreb, CroatiaZagreb, Croatia


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Disclosure Statement of Financial InterestDisclosure Statement of Financial Interest

I,I, Kristina Maric BesicKristina Maric Besic DO NOT have aDO NOT have a

financial interest/arrangement or affiliationfinancial interest/arrangement or affiliationwith one or more organizations that couldwith one or more organizations that couldbe perceived as a real or apparent conflictbe perceived as a real or apparent conflictof interest in the context of the subject of of interest in the context of the subject of

this presentation.this presentation.


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CASE REPORT:CASE REPORT:

March 2010March 2010 - - male, 45 years, no history or male, 45 years, no history or known risk factors for CVDknown risk factors for CVD

UUnwitnessed cardiac arrest in a hospitalnwitnessed cardiac arrest in a hospitalelevator (found at aprox.elevator (found at aprox. 7 7:20 p.m):20 p.m)CPR in ER: adrenalin 3 mg, DCx4 for VFCPR in ER: adrenalin 3 mg, DCx4 for VFECG:sinus rhythm, anterolateral STEMIECG:sinus rhythm, anterolateral STEMI

AAdmitted to CCU (arounddmitted to CCU (around 8 8:00 p.m) RR:00 p.m) RR90/60 mmHG, without spontaneus90/60 mmHG, without spontaneusbreathing, comabreathing, coma GCS 3GCS 3


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UUrgent coronary angiography and PPCIrgent coronary angiography and PPCIwithout prior neurological examinationwithout prior neurological examinationHHypothermia after PCIypothermia after PCI

NG tubeNG tube retention 500 mlretention 500 ml- - did not recievedid not recieveaspirin or clopidogrel befor PCIaspirin or clopidogrel befor PCIUUnfractioned heparin during PCInfractioned heparin during PCICoronary angiography findingCoronary angiography finding- - occlusionocclusionof prox. LAD, significant stenosis of LCXof prox. LAD, significant stenosis of LCXand RCAand RCA


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PPerforation of coronary arteryerforation of coronary artery - -call the surgeon?call the surgeon?


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PCI PROCEDUREPCI PROCEDURE

StartedStarted 8 8:55 p.m, ended 10:52 p.m.:55 p.m, ended 10:52 p.m.

RResuscitatedesuscitated adrenalin, atropinadrenalin, atropinLADLAD 5 stents5 stents - - TIMI 3TIMI 3

RCARCA 2 stents2 stents TIMI 3TIMI 3


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ANTITHROMBOTIC THERAPYANTITHROMBOTIC THERAPY

15 000 IU unfractioned heparin during PCI15 000 IU unfractioned heparin during PCI

Continuous iv unfractioned heparin after Continuous iv unfractioned heparin after PCIPCI-- was not given because of was not given because of prolongedprolongedAPTTAPTT


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ECHOECHO-- no pericardial effusionno pericardial effusion

NNeurological examinationeurological examination pupils no lightpupils no lightresponse, corneal reflex and MTR absentresponse, corneal reflex and MTR absent

HHypothermia (induced at 1:15 a.m)ypothermia (induced at 1:15 a.m)

MMidazolam, rocuronium (sedation andidazolam, rocuronium (sedation andneuromuscular blockade)neuromuscular blockade)

CCooling induction with cold saline 4ooling induction with cold saline 4 CC(30ml/kg during 30(30ml/kg during 30- -60 min) and ice60 min) and icepackages (neck, armpits, groins)packages (neck, armpits, groins) targettargetbody temperature 32body temperature 32- -3434C during 2C during 2- -6 h6 h


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AAt 5:30 a.m RRt 5:30 a.m RR 90/60 mmHg 90/60 mmHg - - dopaminedopamine

AAt 7:30 a.m RR 70/50 mmHgt 7:30 a.m RR 70/50 mmHg - - dobutaminedobutamineand noradrenalineand noradrenaline

Hgb (132 Hgb (132- -126126--120120--97g/L), normal platlet97g/L), normal platlet

count, APTT >120, >150 s (24.0count, APTT >120, >150 s (24.0- -33.0)33.0)X rayX ray-- left pleural effusionleft pleural effusion

AAtt 22:20 p.m VT, VF,:20 p.m VT, VF, - - CPR, urgentCPR, urgent

evacuation of pleural effusionevacuation of pleural effusion 1500 ml of 1500 ml of bloodblood- - autotransfusionautotransfusion

DDeath at 3:45 p.meath at 3:45 p.m hemorrhagic shockhemorrhagic shock


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2005 AHA Guidelines for Cardiopulmonary2005 AHA Guidelines for Cardiopulmonary

Resuscitation and EmergencyResuscitation and EmergencyCardiovascular Care:Cardiovascular Care:

UUnconscious patients with ROSC after outnconscious patients with ROSC after out- -of of--hospital cardiac arrest should be cooledhospital cardiac arrest should be cooledto 32to 32C to 34C to 34 C for 12C for 12- -24 hours when the24 hours when theinital rhytm was VF (Class IIa)inital rhytm was VF (Class IIa)

MMay be beneficial for patients with nonay be beneficial for patients with non- -VFVFarrest out of hospital or for inarrest out of hospital or for in- -hospitalhospitalarrest (Class IIb)arrest (Class IIb)


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HYPOTHERMIA INDICATIONSHYPOTHERMIA INDICATIONS

CCardiorespiratory arrest (VT,VF, PEA,ardiorespiratory arrest (VT,VF, PEA,asystolia)asystolia)

DDuration of cardiorespiratory arrest 5 uration of cardiorespiratory arrest 5- -15 15

min (from the beginning until CPR)min (from the beginning until CPR)DDuration to spontaneous circulationuration to spontaneous circulation 60 60 minmin

CComa, GCS


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HYPOTERMIA CONTRAINDICATIONSHYPOTERMIA CONTRAINDICATIONS

HHaemodinamic instabilityaemodinamic instability

RRecurrent or refractory VF or VTecurrent or refractory VF or VT

HHaemorrhageaemorrhage

RRefractory hypoxiaefractory hypoxia

OOther:ther: unwitnessed arrest,unwitnessed arrest, coma of other coma of other etiology, head trauma, operation before 14etiology, head trauma, operation before 14days, terminal illnes, pregnancy, sepsis,days, terminal illnes, pregnancy, sepsis,burns, sickle cell anemiaburns, sickle cell anemia


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HYPOTERMIA RELATIVEHYPOTERMIA RELATIVE

CONTRAINDICATIONSCONTRAINDICATIONS

CCoagulopathy: INR > 2, trc < 50 000, APTToagulopathy: INR > 2, trc < 50 000, APTT

> 65, cryoglobulinaemia, Raynaud sy> 65, cryoglobulinaemia, Raynaud sy

H ypothermia is not contraindicated in PCI H ypothermia is not contraindicated in PCI and thrombolysis for AMI and thrombolysis for AMI


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DILEMMASDILEMMAS

ShouldShould all or selected cardiac arrestall or selected cardiac arrestpatients undergo PPCIpatients undergo PPCI ? ? -- unwitnessedunwitnessedcardiac arrest (poor predictor of survival)cardiac arrest (poor predictor of survival)

PCI before or after neurologicalPCI before or after neurologicalexamination?examination? - - waist of time?waist of time?Hypothermia before or after PCI?Hypothermia before or after PCI?

AAntiplatlet and antithrombotic therapy, GPntiplatlet and antithrombotic therapy, GP

IIb/IIIa in prolonged CPR and hypothermia?IIb/IIIa in prolonged CPR and hypothermia?


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THINK ABOUTTHINK ABOUT

CComplications after prolonged CPR are notomplications after prolonged CPR are notrare (sternal or rib fractures,rare (sternal or rib fractures,hematothorax, pneumothorax.....)hematothorax, pneumothorax.....)

HHypothermia and bleeding complicationsypothermia and bleeding complications(coagulopathy(coagulopathy- - platlet count, platletplatlet count, platletfunction, kinetics of clotting enzymes andfunction, kinetics of clotting enzymes andplasminogen activator inhibitors...)plasminogen activator inhibitors...)

Other hypothermia complicationsOther hypothermia complications- -arrhythmias, sepsis, hyperglycemia...arrhythmias, sepsis, hyperglycemia...


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TREATMENT OPTIONSTREATMENT OPTIONS

ECMO (ExtraCorporeal MembraneECMO (ExtraCorporeal MembraneOxygenation) in cardiac arrestOxygenation) in cardiac arrest

PProtocolrotocol CPR, ECMO, IABP, PPCI,CPR, ECMO, IABP, PPCI,hypothermiahypothermiaNew studiesNew studies- -CHEER (refractory out of CHEER (refractory out of hospital cardiac arrest treated withhospital cardiac arrest treated withmehanical CPR, Hypothermia, ECMO andmehanical CPR, Hypothermia, ECMO andEarlyEarly RReperfusion)eperfusion)

New guidelines 2010New guidelines 2010


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Thank you for your attention

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Presentation TCT Washington 2