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Ann Thorac Surg 2006;82:651-656
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Improved Survival After Cardiac Arrest Using Emergent Autopriming Percutaneous Cardiopulmonary Support

Kiick Sung, MD, Young Tak Lee, MD*, Pyo Won Park, MD, Kay-Hyun Park, MD, Tae-Gook Jun, MD, Ji-Hyuk Yang, MD, Yi-Kyung Ha, RN

Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Accepted for publication March 7, 2006.

* Address correspondence to Dr Lee, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul, 135-710, Korea. (Email: ytlee55{at}yahoo.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Emergent percutaneous cardiopulmonary support (PCPS) has the potential to rescue patients in cardiac arrest who might otherwise die. We retrospectively reviewed the results of PCPS using preassembled, heparin-coated, and autopriming devices in patients in cardiac arrest.

METHODS: From November 2003 to July 2005, 22 patients in cardiac arrest underwent PCPS using the Capiox emergent bypass system (Terumo, Tokyo, Japan). The mean ± SD age was 63 ± 14 (range, 31 to 85) years. In six patients, the underlying disease causing cardiac arrest was not diagnosed before PCPS. The procedure involved 14 to 21 Fr percutaneous femoral arterial cannulae and 17 to 28 Fr percutaneous femoral long venous cannulae. The mean duration of cardiopulmonary resuscitation before PCPS was 48.5 ± 29.0 (range, 15 to 143) minutes. An intraaortic balloon pump was used concomitantly in six patients.

RESULTS: Fourteen patients received additional surgical or interventional procedures during PCPS. Thirteen (59%) patients could be weaned off PCPS after 52.3 ± 47.8 (range, 4 to 141) hours of support. Twelve complications occurred in 11 patients, including eight related to PCPS: low perfusion flow (two), gastrointestinal bleeding (two), surgical wound bleeding (one), femoral arterial catheter dislodgement (one), hemolysis with acute renal failure (one), and mitral valve thrombus (one). Nine patients (41%) were discharged from hospital without neurologic complications. The incidence of complications differed in comparisons between patients who survived and did not survive.

CONCLUSIONS: The use of preassembled, heparin-coated and autoprimed devices enabled us to rescue in-hospital cardiac arrest patients who might have died without this procedure.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Emergent cardiopulmonary support has been used to treat cardiac arrest for some time. As early as 1937, Dr John Gibbon proposed the concept of a clinical heart-lung machine to treat severe pulmonary embolism [1]. Since the introduction of cardiopulmonary bypass in 1953 [2], cardiopulmonary bypass has been used in a variety of emergency cases, such as acute myocardial infarction and pulmonary embolism [3–6], and has saved many patients who would have otherwise died. However, because of the complexity of the system and crude nature of the materials, the system has not been widely implemented. In 1983, a report by Phillips and colleagues [7] describing percutaneous cannulation led to the commercial development of preassembled percutaneous cardiopulmonary support systems using long, thin-walled, kink-resistant cannulae [8]. Since then, the indications for percutaneous cardiopulmonary support (PCPS) have expanded to include medically emergent cases.

Since a multi-institutional study performed by Hill and colleagues in 1992 [9], several reports on emergent PCPS use have been published with relatively good results, using a variety of PCPS equipment on a variety of patients and circumstances in cardiac arrest [10–19]. The overall survival rate has been reported to be between 15% and 60% [14]. Most centers have PCPS teams with well-trained perfusionists and (or) nurses. Our center did not have a specialized team or equipment. Since November 2003, we have used the preassembled, heparin-coated, and autopriming PCPS system to rescue our in-hospital patients in cardiac arrest who might have otherwise not survived. We have reviewed these patients to assess the effects of our new system in the care of emergent cases.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
This study received Institutional Review Board approval and informed consent was waived due to the life threatening emergencies. From November 2003 to July 2005, 22 patients underwent PCPS during CPR. The mean age ± SD of the patients was 63 ± 14 (range, 31 to 85) years. The underlying diseases related to the cardiac arrest are summarized in Table 1. In six patients, there was no evident disease diagnosed before PCPS.


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  		Table 1. Patient Characteristics
 
During CPR, both femoral areas were draped under sterile conditions if PCPS was indicated. After intravenous injection of 10 mg/kg of heparin, both the femoral artery and femoral vein were cannulated percutaneously using the Seldinger technique. In four patients, femoral cannulation was completed after an inguinal incision because of difficulties with the percutaneous cannulation. The PCPS could be inserted into all patients for whom it was intended. According to the patient's size, 14 to 21 Fr percutaneous femoral arterial cannulae (DLP; Medtronic Inc, Minneapolis, MN or RMI; Edwards Lifesciences, Irvine, CA) and 17 to 28 Fr percutaneous femoral long venous cannulae (DLP; Medtronic Inc, or RMI; Edwards Lifesciences) were used. In 14 patients, distal femoral arterial perfusion was performed using a central line catheter (Arrow International, Reading, PA) after distal femoral artery puncture to avoid ischemia of the distal lower leg [20]. The PCPS was then started using the Capiox emergency bypass system (EBS; Terumo Inc, Tokyo, Japan), which comprises a centrifugal pump, a polypropylene hollow fiber membrane oxygenator, and a heparin-coated circuit (Fig 1). As mentioned, the most important benefit of this system is its autopriming, which requires less than five minutes to prime the circuit before use [21] and does not require specially trained personnel. Once the femoral cannulation was established, the PCPS system could be run to stabilize the patient; then CPR was discontinued. The mean duration of CPR before PCPS was 48.5 ± 29.0 (range, 15 to 143) minutes. The locations where CPR was performed are summarized in Table 1.


Figure 1
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  		Fig 1. The percutaneous cardiopulmonary support system used at our institution. It consists of a pump console, flowmeter, back-up console, and a holder for the centrifugal pump and oxygenator module with a drive motor. This system can be transported using a cart or clamped onto the bed. The emergency bypass system circuit, which consists of the centrifugal pump, oxygenator, and tubing, is sterilely packed.

 
In six patients, an intraaortic balloon pump (IABP) was applied simultaneously during PCPS. If possible, we tried to maintain the hematocrit above 35%, the platelet count above 100,000 per µL, and the activated clotting time (ACT) at 150 to 200 seconds to minimize complications of bleeding and thromboembolic complications [22]. After weaning the patients from the PCPS, we surgically removed the femoral artery and venous cannulae and repaired the cannulation sites to avoid ischemic limb complications.

Statistics
All measurements are expressed as mean ± SD. The {chi}2 test or Mann-Whitney test were used to compare variables in patients who survived and were discharged with those who did not survive. A p value less than 0.05 was accepted as significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
During PCPS, cardiac catheterization, echocardiography, exploratory laparotomy, or cardiac muscle biopsy, or some combination, was performed to diagnose the underlying disease in six patients whose disease was not evident before cardiac arrest. In 14 patients, additional procedures were performed during the PCPS (Table 2). Additional procedures to fix the underlying disease causing cardiac arrest were performed in 12 patients and to fix the complications of PCPS or CPR in two patients. Thirteen patients (59%) could be weaned from the PCPS; the mean duration for PCPS in these patients was 52.3 ± 47.8 (range, 4 to 141) hours. One patient who had giant cell myocarditis could not be weaned and underwent cardiac transplantation after 208 hours of support. In 12 patients who had undergone additional procedures to fix the primary disease, nine (75%) patients could be weaned from PCPS. In one patient, exploratory laparotomy was performed due to suspicion of intraabdominal bleeding; however, although we found no abnormality, we could not wean the patient from PCPS. Twelve complications occurred in 11 patients (Table 3). Gastrointestinal bleeding was managed medically in two patients. In one patient who had undergone aortobifemoral bypass surgery, the femoral arterial catheter was dislodged a few hours after PCPS. In one patient who arrested during percutaneous intervention (PCI), the family of the patient did not want further aggressive treatment after the failed PCI because of the age of the patient age (85 years). Other reasons for the inability to wean from PCPS are summarized in Table 3.


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  		Table 2. Additional Procedures During PCPS
 

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  		Table 3. Complications or Inability to Wean
 
Nine patients (41%) were discharged from the hospital, and none displayed any neurologic or other complications. The last patient to be weaned from PCPS remains in the hospital because of hypoxic brain damage. Excluding this one patient, we compared patient characteristics, underlying disease, and variables associated with CPR and PCPS and compared these factors in patients who survived and were discharged with those who did not survive (Table 4). The presence of complications during CPR or PCPS differed between the two groups. Except for one patient, with recurrent angina at 13 months follow-up, none of the patients discharged from hospital exhibited any remarkable events in recent follow-up.


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  		Table 4. Comparisons Between the Patients Who Survived and Were Discharged From the Hospital and Patients Who Died in the Hospital
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Unlike some hospitals where specially trained personnel are present at all times, in most settings, PCPS relies on clinical perfusionists who generally leave the hospital after completing their daily clinical duties in the operating room. In our hospital, before the introduction of the EBS system, implementation of emergent PCPS using conventional cardiopulmonary bypass required more than 30 minutes if a perfusionist was available during the day, and sometimes more than one hour if a perfusionist was not available. Many patients did not survive before introduction of the EBS system because of the long duration of CPR. The most important aspect of the EBS system is the autopriming function; this takes less than five minutes to remove air, and offers a very simple process for implementation. Intensive care unit nurses, residents, and fellows can operate the EBS system after a brief training. We no longer depend on perfusionists after completing their duties. The cost of the whole PCPS set and cannulas is less than $2,000 US dollars. Most of the cost in Korea is covered by the national insurance system, so the patient is responsible for only about 10% of the cost. Therefore, we do not hesitate to provide PCPS support where indicated.

In individual circumstances, it can be difficult to determine whether PCPS should be inserted during CPR. We considered an unwitnessed arrest [9] and severe comorbid disease such as the terminal stage of malignancy or cerebral hemorrhage as contraindications for PCPS. Tentatively we do not consider CPR time and advanced age alone as contraindications. Duration of CPR for more than 30 minutes may produce adverse results [9, 10], although some investigators have reported good results after a long CPR duration [11–14, 23, 24]. However, another important consideration is the effectiveness of the CPR provided. In our patients, the duration of CPR before PCPS was less than 30 minutes in only six patients. Despite the long CPR duration, the rate of weaning (59%) and discharge (41%) were relatively high. Even more important, the patients who were discharged from hospital had no neurologic complications despite the long CPR duration. The longest CPR time noted in discharged patients was 75 minutes. This patient arrested because of a massive pulmonary embolism just before arriving at the intensive care unit after hip surgery. She was already intubated and monitored; CPR was started immediately after arrest and was performed effectively before PCPS. Most of our patients in this study arrested in the intensive care unit or catheterization room; the location of the arrest was not significantly related to survival. A CPR duration of more than 30 minutes alone should not be considered as a contraindication to PCPS. The circumstances of the arrest should be considered together with the time element.

Old age might be considered as a contraindication for emergent PCPS [23] because of comorbid diseases, although this is controversial [10]. In our patients, the mean age of the nine patients who were discharged from hospital was 59.8 ± 11.4 years, and two patients were over 70 years. There was no significant difference in age in survivors compared with those who did not survive. For our protocol any patient that did not have evident severe comorbid disease was a candidate for PCPS.

In patients presenting in cardiac arrest it can be difficult to determine the cause of cardiac arrest. In the six patients, whose underlying disease was not diagnosed prior to PCPS, three (one acute myocardial infarction, one massive pulmonary embolism, and one intraabdominal bleeding) could be weaned from PCPS after correction of the underlying problem. One patient who had giant cell myocarditis underwent cardiac transplantation. The other two (one cardiac amyloidosis and one unknown cause) could not be weaned from PCPS. Furthermore, surgical or interventional procedures were performed in 12 patients to correct the underlying pathology causing cardiac arrest. All patients except two could be weaned from PCPS after these procedures. Of the two patients who could not be weaned, one underwent incomplete PCI and the other patient, mentioned above, who arrested because of an unknown cause, underwent exploratory laparotomy that did not detect any abdominal bleeding. Sometimes patients had to be transported from the intensive care unit, ward, or catheterization room to the catheterization or surgical room in the hospital. As mentioned earlier, once established, PCPS can provide hemodynamic stability to allow interventional or surgical procedures. Our system enables us to do so safely because of its compact size and an hour-long battery life.

Some recommend that PCPS should be changed to a more durable long-term extracorporeal membrane oxygenator (ECMO) or ventricular assist device (VAD) when more than six hours of support is needed [15, 16]. However, the recently developed centrifugal pump, heparin-coated circuit, microporous oxygenator, and large-bore catheters might provide an option for increased duration of PCPS without causing severe hemolysis or plasma leakage [17, 21]. However, most agree that PCPS should be discontinued after a few days of support, especially in patients with end-stage cardiac disease. Unfortunately, we do not have a more durable ECMO or VAD, except for the centrifugal pump. In some of our patients, the long-term ECMO or VAD might be necessary and produce better results. Regardless, our PCPS system is durable enough to be used for several days without inducing severe complications. The maximum support time was 208 hours in one patient who had to wait for transplantation because of giant cell myocarditis. The oxygenator of the EBS system can last for three days for most patients, given sufficient anticoagulation. During PCPS, we try to maintain the ACT level at about 180 to 200 seconds. However, in patients with bleeding complications, we adjust the ACT level to about 150 seconds. In such circumstances, the PCPS system could be maintained over one to two days without causing plasma leakage, oxygenator failure, or other thromboembolic complications. One patient, who had giant cell myocarditis, had mitral valve thrombus during PCPS. Because the patient was bleeding from the trachea and lung, we could not maintain a sufficient level of anticoagulation; even more transfusion or injection of cryoprecipitate, fresh frozen precipitate, and aprotinin were used for hemostasis. Excluding this one patient, there were no other thromboembolic complications. Despite the existing controversy, we think that heparin coating might reduce the risk of bleeding or thromboembolic complications [10, 25].

We used cannulae that were relatively large for small Asian people (up to 28 Fr venous cannulae and 21 Fr arterial cannulae) when long-term support was expected. Large bore cannulae (28 Fr) produce less hemolysis (plasma hemoglobin, 26.3 ± 4.1 µmol/L) compared with small cannulae (17 Fr arterial, 21 Fr venous) (plasma hemoglobin, 63.3 ± 0.3 µmol/L) [17]. After two to three days, we frequently had to change the circuit, due to hemolysis rather than plasma leakage or failure of the oxygenator. To reduce the complications related to large cannulae, we placed an additional distal arterial cannula [20] and repaired the arterial cannulation site when weaning from PCPS. Occasionally, patients required an endarterectomy during cannulation site repair. After this procedure we found no distal limb ischemic complications.

During PCPS, five patients were supported with an IABP in addition to PCPS. We use IABP liberally through the other femoral artery; IABP can generate pulsatile flow, increase coronary blood flow, and might decrease left ventricular afterload [16, 18]. We do not routinely use IABP; however, concomitant use of IABP might have a positive effect on left ventricular recovery with minimal additional risk, especially in patients with coronary disease with severe left ventricular dysfunction. More importantly, we think that IABP might facilitate weaning from PCPS.

Limitations of this study included the absence of a control group for comparisons. A selection bias may have resulted from treating patients who came to our attention as a result of a referral. But, all patients referred were treated with PCPS if indicated. They were rescued with PCPS refractory to conventional cardiopulmonary resuscitation. Another limitation is that we only used one PCPS system. Several reports have been published with other PCPS systems. It is difficult to compare the other results with ours because of patient characteristics, duration of CPR time, circumstances of CPR and (or) hospital conditions. Our results were achieved regardless of undiagnosed underlying causes of arrest in 27.2% of the patients, relatively advanced age, relatively long duration of CPR time, absence of an established PCPS team, and no reliable VAD or other long-term support system. The simple, safe and effective PCPS allowed for good outcomes in our patients.

In conclusion, use of this autopriming preassembled PCPS system allowed for rescue of patients who might otherwise have died. We performed diagnostic and therapeutic interventions safely during the PCPS. We think that our system might be reliable and useful, especially emergent PCPS, and should be considered in patients with no definite contraindications.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

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