Short-term mechanical circulatory supports (MCS) are used to stabilize patients with severe cardiogenic shock (CS). Catheter ablation may be an option to suppress recurrent arrhythmias preventing MCS weaning. We retrospectively analysed a dedicated registry to identify CS patients who underwent a catheter ablation between January 2020 and August 2024 for treatment resistant and hemodynamically significant arrhythmias while being on the MCS. Patients with supraventricular and ventricular tachycardias (SVT/VT) were analysed separately. Nine patients (8 males, 69 [IQR 60;74] years) were ablated for a refractory VT. Impella CP was used in 6 patients, VA ECMO in 2 patients, and 1 patient was on ECPELLA. Seven patients (78%) were successfully weaned off the MCS after the catheter ablation. 3 patients (33%) died within 30 days. The arrhythmia recurred in 5 patients (56%). Significant complications of MCS were reported in 6 patients (66%). The catheter ablation was complicated in one patient. SVT ablation was performed in 4 patients (3 males, 73 [IQR 67; 78] years, 1x VA ECMO, 2x Impella CP, 1x Impella 5.5). Three patients with atrial fibrillation were treated by a non-selective AV node ablation (pace and ablate strategy). One patient underwent an ablation of focal atrial tachycardia. The MCS was successfully explanted in all patients and no patient died in 30 days. The MCS use was complicated in one patient. Catheter ablation of refractory arrhythmias in CS patients treated by MCS is a safe and feasible approach to facilitate the MCS weaning process.
- MeSH
- kardiogenní šok * terapie chirurgie patofyziologie mortalita MeSH
- katetrizační ablace * metody MeSH
- komorová tachykardie chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace MeSH
- podpůrné srdeční systémy * MeSH
- retrospektivní studie MeSH
- senioři MeSH
- supraventrikulární tachykardie chirurgie MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
BACKGROUND: Although bilirubin is a proven antioxidant substance and a protective factor against the development of various diseases, in emergency medicine, its increased concentration is considered solely a marker of organ damage and negative prognosis. However, clinical data on the role of bilirubin in cardiac arrest (CA) and reperfusion injury, are sparse. The presented study investigates the protective effects of increased serum bilirubin concentrations and genetic determinants (UGT1A1 promoter variations) on the outcomes of patients with refractory out-of-hospital CA (r-OHCA) in a randomized population. METHODS: Between March 1, 2013, and October 25, 2020, 256 randomized Prague OHCA patients with r-OHCA were evaluated for inclusion and categorized as having increased (>10 µmol/l) or low/normal serum bilirubin concentrations on hospital arrival and present or absent genetic variations for mild hyperbilirubinemia. The primary outcome was survival with a good neurological outcome (defined as cerebral performance category 1-2) 180 days after randomization. RESULTS: Finally, 164 patients were included in the bilirubin concentration analysis. Favorable neurological survival after 180 days occurred in 50 of 99 patients (50.5 %) in the group with higher initial serum bilirubin concentrations and 18 of 65 patients (27.7 %) in the low-bilirubin group (absolute difference 22.8 [8.1-37.5]; P = 0.006). The effect persisted also in multivariable analysis (OR for favorable outcome = 3.02 [95 % CI = 1.16-7.84]; P = 0.023). Genetic predisposition for mild hyperbilirubinemia was not associated with any patient outcomes. CONCLUSIONS: A higher initial serum bilirubin concentration predicts better outcomes in patients with refractory OHCA regardless of the treatment used. UGT1A1 gene promotor variations are not associated with refractory OHCA patient outcomes.
- Klíčová slova
- Antioxidants, Bilirubin, Cardiac arrest, Genetic variations, Mechanical circulatory support, Oxidative stress,
- Publikační typ
- časopisecké články MeSH
BACKGROUND: There are limited data on the causes of death in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to analyse the causes of death among patients who received ECPR following out-of-hospital cardiac arrest (OHCA). METHODS: In this post-hoc analysis of a prospective registry, the causes of death were categorized using a predefined method specifically developed for cardiac arrest patients. Two investigators independently assigned each patient to one of five predefined categories of death, with interrater reliability measured using Fleiss' kappa. RESULTS: From January 2012 to December 2023, a total of 1,219 OHCA patients were admitted to the hospital, of whom 210 underwent ECPR. Among these, 152 (72.3%) patients died during their index hospitalization. The median age of deceased patients was 57 years, with 80.9% being male, and the median time to ECPR initiation was 62 min (IQR: 53-72). Interrater agreement was 0.81. The most common primary cause of death was refractory shock (75/152 patients, 49.3%), followed by neurological injury (69/152 patients, 45.3%), rearrest (7/152 patients, 4.6%), and comorbidities (1/152 patients, 0.6%). CONCLUSIONS: Refractory shock was the leading cause of death among our cohort of ECPR patients, followed closely by neurological complications, while other causes were rare.
- Klíčová slova
- Cardiac arrest, Cardiopulmonary resuscitation, Causes of death, Extracorporeal cardiopulmonary resuscitation, Extracorporeal membrane oxygenation,
- MeSH
- kardiopulmonální resuscitace * metody mortalita MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace * mortalita metody MeSH
- příčina smrti MeSH
- prospektivní studie MeSH
- registrace MeSH
- senioři MeSH
- zástava srdce mimo nemocnici * terapie mortalita MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
OBJECTIVES: A Prague out-of-hospital cardiac arrest (OHCA) study has demonstrated that an invasive approach (early transport to the hospital, extracorporeal cardiopulmonary resuscitation [ECPR]) is a feasible and effective treatment strategy in refractory OHCA. This post hoc analysis of the Prague OHCA study aimed to stratify the prognosis of patients according to the detailed course of heart rhythm during prehospital and early hospital periods. DESIGN, SETTING, AND PATIENTS: This analysis included all 256 patients (median age 58, 17% females) randomized to the Prague OHCA study. The sequence of heart rhythms during the prehospital period was analyzed in terms of neurologic outcomes after 180 days. The primary outcome was a composite of survival with Cerebral Performance Category 1 or 2 at 180 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Within the study cohort, 156 (61%) manifested ventricular fibrillation (VF), 45 pulseless electrical activity, and 55 asystole as the initial rhythm. Patients with an initial VF who reached a sustained recovery of spontaneous circulation (ROSC) had the highest proportion of reaching a primary outcome (32/44 [73%]). Patients who had one or more episodes of asystole during cardiopulmonary resuscitation had the lowest rate of primary endpoint (5/39 [13%]). Patients who experienced intermittent ROSC showed a higher success rate in achieving the primary outcome when treated with an invasive-based approach (including ECPR) compared with the conventional strategy (26/34 [76%] vs. 24/50 [48%]; p < 0.05). CONCLUSIONS: Achieving ROSC is the best prognostic marker in OHCA patients with an initially refractory VF. Patients with intermittent ROSC after the initial VF and ongoing VF seem to be optimal candidates for an invasive approach. Asystole detection at any time during resuscitation is a strong negative prognostic marker, irrespective of the initial rhythm.
- Klíčová slova
- Cardiogenic shock, ECMO, Fulminant myocarditis, Impella, Mechanical circulatory support devices,
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
BACKGROUND: Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support. METHODS: These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels. RESULTS: We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts. CONCLUSIONS: The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.
- MeSH
- dospělí MeSH
- konsensus MeSH
- lidé MeSH
- mimotělní membránová oxygenace * metody normy MeSH
- monitorování fyziologických funkcí metody MeSH
- péče o pacienty v kritickém stavu normy metody MeSH
- poranění mozku terapie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- směrnice pro lékařskou praxi MeSH
BACKGROUND: The initial rhythm is a known predictor of survival in extracorporeal cardiopulmonary resuscitation (ECPR) patients. However, the effect of the rhythm at hospital admission on outcomes in these patients is less clear. METHODS: This observational, single-center study assessed the influence of the rhythm at hospital admission on 30-day survival and neurological outcomes at discharge in patients who underwent ECPR for out-of-hospital cardiac arrest (OHCA). RESULTS: Between January 2012 and December 2023, 1,219 OHCA patients were admitted, and 210 received ECPR. Of these, 196 patients were analyzed. The average age was 52.9 years (±13), with 80.6 % male. The median time to ECPR initiation was 61 min (IQR 54-72). Patients with ventricular fibrillation as both the initial and admission rhythm had the highest 30-day survival rate (52 %: 35/67), while those with asystole in both instances had the lowest (6 %: 1/17, log-rank p < 0.00001). After adjusting for age, sex, initial rhythm, resuscitation time, location, bystander, and witnessed status, asystole at admission was linked to higher 30-day mortality (OR 4.03, 95 % CI 1.49-12.38, p = 0.009) and worse neurological outcomes (Cerebral Performance Category 3-5) at discharge (OR 4.61, 95 % CI 1.49-17.62, p = 0.013). CONCLUSIONS: The rhythm at hospital admission affects ECPR outcomes. Patients presenting with and maintaining ventricular fibrillation have a higher chance of favorable neurological survival, whereas those presenting with or converting to asystole have poor outcomes. The rhythm at hospital admission appears to be a valuable criterion for deciding on ECPR initiation.
- Klíčová slova
- Cardiac arrest, Cardiac rhythm, Cardiopulmonary resuscitation, Extracorporeal cardiopulmonary resuscitation, Extracorporeal membrane oxygenation, Heart arrest, Heart rhythm, Rhythm conversion,
- MeSH
- dospělí MeSH
- fibrilace komor terapie mortalita komplikace MeSH
- hospitalizace * statistika a číselné údaje MeSH
- kardiopulmonální resuscitace metody statistika a číselné údaje MeSH
- lidé středního věku MeSH
- lidé MeSH
- mimotělní membránová oxygenace * metody statistika a číselné údaje MeSH
- míra přežití trendy MeSH
- mozek * patofyziologie MeSH
- příjem pacientů * statistika a číselné údaje MeSH
- retrospektivní studie MeSH
- senioři MeSH
- srdeční frekvence * fyziologie MeSH
- zástava srdce mimo nemocnici terapie mortalita MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- pozorovací studie MeSH
BACKGROUND: It is unclear how invasive resuscitative protocols may impact the time-dependent prognosis of out-of-hospital cardiac arrest (OHCA) resuscitations, or the relationship between intra-arrest transport and outcomes. METHODS: We performed a secondary analysis of the Prague OHCA Study, which randomized refractory OHCAs to "invasive" (intra-arrest transport for possible ECPR initiation) vs. "standard" resuscitation strategies (predominantly performed on-scene). Between groups, we compared outcomes of the initial resuscitation and 180- and 30-day favourable neurological outcomes (CPC 1-2), and within categories based on resuscitation duration (collapse-to-ROSC/ECPR interval). We plotted the dynamic probability of favourable outcomes with increasing durations of unsuccessful resuscitation. RESULTS: Among invasive and standard groups, respectively: 34/124 (27%) vs. 58/132 (44%) had sustained ROSC (difference -17%, 95%CI -5.0, -28); 38/124 (31%) vs. 24/132 (18%) had 30-day favourable neurological outcomes (difference 12%; 95%CI 2.0, 23); and 39/124 (31%) vs. 29/132 (22%) had 180-day favourable neurological outcomes (difference 9.5%; 95%CI -1.3, 20). For favourable outcome cases: standard group resuscitation durations were right-skewed within the first 60 min; for the invasive group the distribution was bimodal, extending to 77 min. For invasive- and standard-treated cases, the probability of favourable outcomes among those in refractory arrest at 30 min was 28% and 7.6%, respectively; declining to 0% at 77 and 60 min. CONCLUSION: In comparison to standard resuscitation, invasive strategy cases had fewer achieve sustained ROSC, however improved overall 30-day favourable neurological outcomes. While standard resuscitation yield was limited to < 60 min, invasive protocols offer a second extended window of potential successful resuscitation.
- Klíčová slova
- Cardiopulmonary resuscitation, Extracorporeal membrane oxygenation, Heart arrest, Out-of-Hospital Cardiac Arrest,
- MeSH
- časové faktory MeSH
- kardiopulmonální resuscitace * metody MeSH
- lidé středního věku MeSH
- lidé MeSH
- senioři MeSH
- urgentní zdravotnické služby metody MeSH
- zástava srdce mimo nemocnici * terapie mortalita MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- randomizované kontrolované studie MeSH
BACKGROUND: Critical care of patients on extracorporeal membrane oxygenation (ECMO) with acute brain injury (ABI) is notable for a lack of high-quality clinical evidence. Here, we offer guidelines for neurological care (neurological monitoring and management) of adults during and after ECMO support. METHODS: These guidelines are based on clinical practice consensus recommendations and scientific statements. We convened an international multidisciplinary consensus panel including 30 clinician-scientists with expertise in ECMO from all chapters of the Extracorporeal Life Support Organization (ELSO). We used a modified Delphi process with three rounds of voting and asked panelists to assess the recommendation levels. RESULTS: We identified five key clinical areas needing guidance: (1) neurological monitoring, (2) post-cannulation early physiological targets and ABI, (3) neurological therapy including medical and surgical intervention, (4) neurological prognostication, and (5) neurological follow-up and outcomes. The consensus produced 30 statements and recommendations regarding key clinical areas. We identified several knowledge gaps to shape future research efforts. CONCLUSIONS: The impact of ABI on morbidity and mortality in ECMO patients is significant. Particularly, early detection and timely intervention are crucial for improving outcomes. These consensus recommendations and scientific statements serve to guide the neurological monitoring and prevention of ABI, and management strategy of ECMO-associated ABI.
- Klíčová slova
- Acute brain injury, ECMO, Guidelines, ICU care, Neurological care, Neurological outcomes, Neuromonitoring, Stroke,
- MeSH
- delfská metoda MeSH
- dospělí MeSH
- konsensus * MeSH
- lidé MeSH
- mimotělní membránová oxygenace * metody normy MeSH
- monitorování fyziologických funkcí metody normy MeSH
- poranění mozku terapie patofyziologie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
- Research Support, N.I.H., Extramural MeSH
