Myocardial Infarction and Cardiac Death
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A fortiori, further clinical parameters become considerably important, which in turn may limit the use of an early PCI in the individual Table 2. Important clinical parameters limiting prognosis and the additional benefit of an early aggressive invasive treatment strategy by PCI. These parameters include the following: [ 6 ] unwitnessed cardiac arrest;. Other factors to consider include comorbidities such as advanced dementia, persistent mechanical ventilation, respiratory failure, frailty, physical or neurological disability and multisystemic disorders.
All these factors should be taken into account independently of the documented primary arrhythmia on ECG because they postpone the indication for early invasive diagnostics and therapies. Emergency coronary angiography of a year-old female patient surviving out-of-hospital cardiac arrest with immediate nonprofessional resuscitation. Ventricular fibrillation was documented as primary arrhythmia, with consecutive min of CPR, multiple external electrical defibrillations and final ROSC. Severe coronary 3-vessel disease was found, with a chronic total occlusion of the right coronary artery CTO with ipsilateral and contralateral retrograde collateral connections A.
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By implantation of a venous-arterial extra-corporal membrane oxygenation VA-ECMO via the left femoral artery and vein hemodynamic collapse was rapidly stabilized and complex multivessel PCI could have been initiated D. First, rotablation 1. Severe coronary artery disease of a year-old male patient with ST segment elevation myocardial infarction STEMI of the anterior wall, consecutive cardiogenic shock and prolonged cardiac arrest. Right coronary artery was normal not shown.
Thirdly, rotablation 1. Impell device was removed after PCI due to recovery of circulation. European guidelines recommend immediate coronary revascularization in patients with recurrent ventricular tachycardia or fibrillation, in order to prevent suspected myocardial ischemia. However, graduation of recommendation is based on expert consensus only grade of recommendation I, level of evidence C; [ 1 , 22 ].
In cardiogenic shock, early coronary revascularization was associated with improved long-term survival compared to drug therapy [ 29 , 30 ]. This prognostic benefit was attributed to fewer amount of contrast use and consecutive fewer rates of renal failure, when the culprit lesion was treated at first presentation and all other critical coronary artery stenoses underwent PCI some days later after hemodynamic recovery [ 34 , 35 ].
However, the advantages for immediate PCI consist of a better accessibility of cardiac catheterization laboratories compared to cardiac surgery units, including rapid feasibility of PCI with minimally invasive access. Beside revascularization therapy of all critical coronary artery stenoses or occlusion, further interventional and surgical therapeutic option have become available for patients after cardiac arrest.
These advanced therapies reveal two main therapeutic goals: cerebral neuroprotection and myocyte protection after episodes of ongoing hypoxemia during cardiac arrest; and. Cerebral and myocardial protection can be achieved by myocardial reperfusion and targeted temperature management TTM. The TTM may attenuate various signaling pathways leading to cell death by revealing anti-apoptotic and anti-inflammatory effects [ 37 ].
MI-RISK: Risk factors for sudden cardiac death during acute myocardial infarction
Smaller cohort studies demonstrated that invasive treatment after cardiac arrest including TTM and coronary angiography with reperfusion therapy by PCI can reduce myocardial infarction size [ 38 ]. In addition, it could have been shown that TTM alone without reperfusion reveals adverse effects because the extent of myocardial infarction was comparable independently of treatment with TTM.
TTM plus reperfusion resulted in the best recovery of cardiac function with the lowest myocardial infarction size [ 39 ].
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This experimental evidence confirms the disadvantage of delayed coronary revascularization and limits the benefit of sole TTM after cardiac arrest. It is well documented from several cohort studies that a combined PCI plus TTM improves survival and neurological outcome in patients with cardiac arrest and persistent coma [ 6 ].
TTM consists of controlled intravenous infusion systems e. TTM may not be initiated out-of-hospital only in order to achieve potentially best possible prognostic and neurological outcome [ 41 , 42 ]. In this situation, cardiac ventricular assist devices VAD may achieve stabilization or normalization of circulation. Cardiac index may be normalized, myocardial oxygen consumption and perfusion of secondary organs including brain and kidneys will be improved [ 25 ].
The presence of the acute emergency, in which post-cardiac arrest patients with prolonged cardiogenic shock are situated, favors minimally invasive or percutaneous VAD. Depending on the device type, each individual VAD increases cardiac output either with left LV or right ventricular RV mechanical support. Recommendation for mechanical circulatory support in cardiogenic shock caused by myocardial infarction is based purely on expert opinion grade of evidence IIb, level of evidence C; [ 22 ]. VAD were shown to stabilize patients suffering from hemodynamically unstable ventricular tachycardia.
In contrast, VAD may also complicate the therapeutic management in emergency situations because clinical application of VAD demands more members of stuff. Additionally, mechanical assist devices were also shown to alleviate the incidence of ventricular tachycardia by the VAD itself [ 1 ]. In particular, IABP was not associated with a reduction of day or 1-year mortality in patients surviving cardiogenic shock due to myocardial infarction [ 47 , 48 ].
Therefore, the use of IABP is recommended only in case of mechanical complications in order to bridge the patient for cardiac surgery [ 22 , 49 ].
More and more meta-analyses have recently been published, which conclusively analyzed smaller studies evaluating the benefit of VAD in patients after cardiac arrest or with cardiogenic shock. Therefore, no evidence-based recommendation can be given. However, transseptal puncture is rarely performed on a regular basis and only by a smaller number of interventional cardiologists. In addition, dislocation of the LA cannula into pulmonary veins or left atrial appendage during relocation maneuvers or during intensive care transports are potential complications.
In , Takayama et al. Half of these patients needed a permanent surgical VAD at follow-up. Modern medical technologies have been developed in recent years, which make VAD applicable for percutaneous access in critical and unstable situations. It should be emphasized that mechanical support after cardiac arrest and consecutive cardiogenic shock is not limited to the left heart only. In principle, and always depending on the underlying individual clinical condition, RV support can also be performed by another RVAD at the same time.
The femoral access route is usually preferred for implantation of the LVAD. For RVAD, both the femoral and the transjugular access routes are possible. Direct and central unload of the congested heart is always recommended, but depends on technical applicability in each individual clinical situation. In contrast, insertion of cannulas at peripheral femoral vessels will always provide indirect unload for the congested heart because extracorporeal blood re-circulated to peripheral vessels.
As a result, contrary effects were recently demonstrated for peripheral assist devices Figure 3d , e , left ; [ 45 ]. The increasing amount of peripherally recirculated blood volume automatically raises wall tension in the peripheral arterial system. In turn, this leads to considerable increase of afterload, which may be harmful for the congested, severely impaired LV after cardiac arrest.
In contrast, unloading at the right atrium was associated with a significant increase of LV wall tension and LV unloading becomes even less effective [ 60 ]. Direct unloading within LA or LV e. Additional unloading is usually achieved by an additionally inserted cannula, which is positioned in the LA after transseptal puncture, while it can be integrated into the peripheral VA-ECMO circuit via Y-connectors Figure 3e , right. Unfavorable effects on the cardiovascular system due to peripherally placed assist devices can be reduced.
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The grade of recommendation for early invasive coronary angiography with immediate PCI in post cardiac arrest patients is still based only on non-randomized cohort studies or expert opinions, depending on the pretest probability and on the type of myocardial infarction i. Decision-making for either an interventional-invasive or surgical approach should always include important prognostic cofactors.
Advanced interventional and operative therapies include targeted temperature management in combination with coronary revascularization and extracorporeal mechanical cardiac support systems, which include intra-aortic counter pulsation IABP , central LVAD and RVAD, as well as peripheral ECMO systems. Randomized prospective studies comparing the use of VAD in post cardiac arrest patients is lacking.
Sudden death isn't always so sudden - Harvard Health
Use of VAD is still limited to specialized centers and a widespread routine application is still a long way off. Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3. Help us write another book on this subject and reach those readers. Login to your personal dashboard for more detailed statistics on your publications.
We are IntechOpen, the world's leading publisher of Open Access books. Built by scientists, for scientists. Enter your email address and we'll send you a link to reset your password. Use within 30 days of surgery pre- or postoperatively. May be used in cardiac or noncardiac procedures. Use in patients undergoing surgery, within 30 days of surgery pre- or postoperatively. Improves on prior perioperative major cardiac event risk calculators for surgical patients by using datasets built on modern standards of care in cardiac event assessment e.
CK -based markers , in addition to stratifying risk based on type of planned procedure. Pulmonary edema and complete heart block, outcomes for previous perioperative cardiac risk calculators, were not part of the NSQIP database from which this calculator was derived. Identifying higher risk patients who will benefit from pre-operative medical cardiac optimization is important. Please fill out required fields. May help determine which patients require additional post-surgical cardiac monitoring. Patients with known or suspected heart disease cardiovascular disease, significant valvular disease, symptomatic arrhythmias should undergo routine preoperative cardiac evaluation if indicated for the proposed surgery.
Calc Function Calcs that help predict probability of a disease Diagnosis. Subcategory of 'Diagnosis' designed to be very sensitive Rule Out. Disease is diagnosed: prognosticate to guide treatment Prognosis.