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

Cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA) are events with profound implications for patient outcomes. We aim to analyze the predictors of CS and OHCA in patients with acute myocardial infarction and their effects on mortality. The analysis is based on data from a national registry between 2016 and 2020. A total of 23,703 patients with ST-elevation myocardial infarction (STEMI) were analyzed: (A) patients without CS and OHCA (19,590), (B) after OHCA (2,262), (C) with CS (713), and (D) after OHCA with CS (1,138). Patients after OHCA without CS had the lowest mean age [62.0 (± 12.6) years], while patients with CS without OHCA were the oldest [68.8 (± 11.8) years] and had the highest proportions of comorbidities. CS was a predictor of 30-day and 1-year mortality, with odds ratios [OR; 95% confidence intervals (CI)] of 5.52 (4.51; 6.75) and 4.66 (3.87; 5.61) for patients after OHCA, and OR (95% CI) 9.28 (7.56; 11.38) and 7.33 (6.04; 8.89) for those without OHCA. For overall survival up to 30 days and in comparison to patients without CS and OHCA, the hazard ratios (95% CI) was 2.77 (2.40; 3.20) for patients with OHCA only, 14.36 (12.57; 16.40) for patients with CS only, and 16.96 (15.19; 18.92) for patients with both CS and OHCA. OHCA altered the 30-day mortality risk after STEMI for both patients with and without CS. CS is a predictor of both 30-day and 1-year mortality in patients with STEMI, irrespective of OHCA status.

• Klíčová slova
• Acute myocardial infarction, Cardiogenic shock, Out-of-hospital cardiac arrest, Outcome, Predictors,
• MeSH
• infarkt myokardu s elevacemi ST úseků komplikace   mortalita   MeSH
• infarkt myokardu * komplikace   mortalita   epidemiologie   MeSH
• kardiogenní šok * mortalita   komplikace   epidemiologie   MeSH
• lidé středního věku MeSH
• lidé MeSH
• registrace statistika a číselné údaje   MeSH
• senioři MeSH
• zástava srdce mimo nemocnici * mortalita   epidemiologie   komplikace   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
• cardiopulmonary resuscitation, extracorporeal cardiopulmonary resuscitation, extracorporeal membrane oxygenation, heart rhythm, refractory cardiac arrest,
• Publikační typ
• časopisecké články MeSH

Higher cholesterol level is a risk factor of coronary artery disease, the major cause of sudden cardiac death (SCD). However, smaller studies observed worse outcomes in SCD patients having lower total and LDL-cholesterol levels. Therefore, the prognostic role of cholesterol itself in patients with SCD remains to be clarified. We aimed to assess the relationship of on-admission cholesterol level to the neurological outcome in a secondary analysis of the randomized Prague OHCA trial population (extracorporeal cardiopulmonary resuscitation (ECPR) vs. standard approach in refractory cardiac arrest). Of 256 included patients with refractory cardiac arrest, 123 were analyzed. The effects of total, HDL and non-HDL cholesterol levels drawn at admission on the best cerebral performance category (CPC) within 180 days were examined. Results are presented as median (interquartile range) and differences compared by the Wilcoxon test. Patients with CPC 1-2 had higher initial levels of total cholesterol [3.70 (3.23-4.27) mmol/L vs. 2.98 (2.35-4.02) mmol/L, p = 0.005], non-HDL cholesterol [2.68 (2.08-3.24) vs. 1.93 (1.62-2.97) mmol/L, p = 0.007 and HDL-cholesterol [0.93 (0.67-1.07) mmol/L vs. 0.74 (0.49-0.96) mmol/L, p = 0.014] compared to patients with CPC 3-5. Chronic use of statins did not influence the outcome. Only the low levels of total and non-HDL cholesterol remained consistent predictors of poor neurological outcomes in all patients and in both separate arms. Lower total and non-HDL cholesterol levels on admission are associated with worse neurological outcomes in patients with refractory cardiac arrest treated by both ECPR and standard approach.

• Klíčová slova
• Cholesterol, Extracorporeal membrane oxygenation, Refractory cardiac arrest, Resuscitation,
• MeSH
• cholesterol * krev   MeSH
• HDL-cholesterol krev   MeSH
• kardiopulmonální resuscitace MeSH
• LDL-cholesterol krev   MeSH
• lidé středního věku MeSH
• lidé MeSH
• příjem pacientů MeSH
• prognóza MeSH
• rizikové faktory MeSH
• senioři MeSH
• srdeční zástava * krev   terapie   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
• randomizované kontrolované studie MeSH
• Názvy látek
• cholesterol * MeSH
• HDL-cholesterol MeSH
• LDL-cholesterol MeSH

The increased accessibility of extracorporeal membrane oxygenation following the COVID-19 pandemic and the publication of the first randomized trial of extracorporeal cardiopulmonary resuscitation (ECPR) prompted the National Heart, Lung, and Blood Institute to sponsor a workshop on ECPR. Two more randomized trials have since been published in 2022 and 2023. Based on the combined findings and review of the evidence, an international panel of authors identified gaps in science, inequities in care and diversity in outcomes, and suggested research opportunities and next steps. The science pertaining to ECPR would benefit from the United States contributing uniform data to existing registries and sharing common data with the ELSO (Extracorporeal Life Support Organization) international registry to increase the sample size for observational research. In addition, well-designed efficacy trials, recruiting across different regions of care evaluating long-term follow-up, including patient reported outcomes, cost effectiveness, and equity measures, would contribute significantly to the body of science. Workshop participants defined the population of patients with out-of-hospital cardiac arrest most likely to benefit from ECPR. ECPR-eligible patients include those aged 18 to 75 years functioning independently without comorbidity; before suffering a witnessed out-of-hospital cardiac arrest and without any obvious cause of the cardiac arrest; presenting in a shockable rhythm and transported with mechanical cardiopulmonary resuscitation to an ECPR-capable institute within 30 minutes, which is recommended after 3 rounds of advanced life support treatment without return of spontaneous circulation. There are significant inequities in out-of-hospital cardiac arrest care that need to be addressed such that outcomes are optimized for each target region before implementing ECPR in a clinical or implementation trial.

• Klíčová slova
• consensus, evidence gaps, extracorporeal membrane oxygenation, out‐of‐hospital cardiac arrest,
• MeSH
• COVID-19 * epidemiologie   MeSH
• kardiopulmonální resuscitace * metody   MeSH
• konsensus MeSH
• lidé MeSH
• mezery v důkazech MeSH
• mimotělní membránová oxygenace * metody   normy   MeSH
• National Heart, Lung, and Blood Institute (U.S.) MeSH
• SARS-CoV-2 MeSH
• zástava srdce mimo nemocnici * terapie   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH
• Geografické názvy
• Spojené státy americké epidemiologie   MeSH

Extracorporeal cardiopulmonary resuscitation (ECPR) is an advanced technique using extracorporeal membrane oxygenation (ECMO) to support patients with refractory cardiac arrest. Age significantly influences ECPR outcomes, with younger patients generally experiencing better survival and neurological outcomes due to many aspects. This review explores the impact of age on ECPR effectiveness, emphasizing the need to consider age alongside other clinical factors in patient selection. Survival rates differ notably between in-hospital (IHCA) and out-of-hospital cardiac arrest (OHCA), highlighting the importance of rapid intervention. The potential of artificial intelligence to develop predictive models for ECPR outcomes is discussed, aiming to improve decision-making. Ethical considerations around age-based treatment decisions are also addressed. This review advocates for a balanced approach to ECPR, integrating clinical and ethical perspectives to optimize patient outcomes across all age groups.

• Klíčová slova
• ECMO, ECPR, age, cardiopulmonary, extracorporeal, outcomes, resuscitation,
• MeSH
• kardiopulmonální resuscitace metody   MeSH
• lidé MeSH
• mimotělní membránová oxygenace * mortalita   MeSH
• srdeční zástava mortalita   terapie   MeSH
• věkové faktory MeSH
• zástava srdce mimo nemocnici mortalita   terapie   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

BACKGROUND: The outcomes of several randomized trials on extracorporeal cardiopulmonary resuscitation (ECPR) in patients with refractory out-of-hospital cardiac arrest were examined using frequentist methods, resulting in a dichotomous interpretation of results based on p-values rather than in the probability of clinically relevant treatment effects. To determine such a probability of a clinically relevant ECPR-based treatment effect on neurological outcomes, the authors of these trials performed a Bayesian meta-analysis of the totality of randomized ECPR evidence. METHODS: A systematic search was applied to three electronic databases. Randomized trials that compared ECPR-based treatment with conventional CPR for refractory out-of-hospital cardiac arrest were included. The study was preregistered in INPLASY (INPLASY2023120060). The primary Bayesian hierarchical meta-analysis estimated the difference in 6-month neurologically favorable survival in patients with all rhythms, and a secondary analysis assessed this difference in patients with shockable rhythms (Bayesian hierarchical random-effects model). Primary Bayesian analyses were performed under vague priors. Outcomes were formulated as estimated median relative risks, mean absolute risk differences, and numbers needed to treat with corresponding 95% credible intervals (CrIs). The posterior probabilities of various clinically relevant absolute risk difference thresholds were estimated. RESULTS: Three randomized trials were included in the analysis (ECPR, n = 209 patients; conventional CPR, n = 211 patients). The estimated median relative risk of ECPR for 6-month neurologically favorable survival was 1.47 (95%CrI 0.73-3.32) with a mean absolute risk difference of 8.7% (- 5.0; 42.7%) in patients with all rhythms, and the median relative risk was 1.54 (95%CrI 0.79-3.71) with a mean absolute risk difference of 10.8% (95%CrI - 4.2; 73.9%) in patients with shockable rhythms. The posterior probabilities of an absolute risk difference > 0% and > 5% were 91.0% and 71.1% in patients with all rhythms and 92.4% and 75.8% in patients with shockable rhythms, respectively. CONCLUSION: The current Bayesian meta-analysis found a 71.1% and 75.8% posterior probability of a clinically relevant ECPR-based treatment effect on 6-month neurologically favorable survival in patients with all rhythms and shockable rhythms. These results must be interpreted within the context of the reported credible intervals and varying designs of the randomized trials. REGISTRATION: INPLASY (INPLASY2023120060, December 14th, 2023, https://doi.org/10.37766/inplasy2023.12.0060 ).

• Klíčová slova
• Bayesian statistical inference, Conventional cardiopulmonary resuscitation, Extracorporeal cardiopulmonary resuscitation, Neurologically favorable survival, Out-of-hospital cardiac arrest, Randomized controlled trials,
• MeSH
• Bayesova věta * MeSH
• kardiopulmonální resuscitace * metody   normy   MeSH
• lidé MeSH
• mimotělní membránová oxygenace metody   MeSH
• randomizované kontrolované studie jako téma metody   MeSH
• výsledek terapie MeSH
• zástava srdce mimo nemocnici * terapie   mortalita   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• metaanalýza MeSH

BACKGROUND: Randomized data evaluating the impact of the extracorporeal cardiopulmonary resuscitation (ECPR) approach on long-term clinical outcomes in patients with refractory out-of-hospital cardiac arrest (OHCA) are lacking. The objective of this follow-up study was to assess the long-term clinical outcomes of the ECPR-based versus CCPR approach. METHODS: The Prague OHCA trial was a single-center, randomized, open-label trial. Patients with witnessed refractory OHCA of presumed cardiac origin, without return of spontaneous circulation, were randomized during ongoing resuscitation on scene to conventional CPR (CCPR) or an ECPR-based approach (intra-arrest transport, ECPR if ROSC is not achieved prehospital and immediate invasive assessment). RESULTS: From March 2013 to October 2020, 264 patients were randomized during ongoing resuscitation on scene, and 256 patients were enrolled. Long-term follow-up was performed 5.3 (interquartile range 3.8-7.2) years after initial randomization and was completed in 255 of 256 patients (99.6%). In total, 34/123 (27.6%) patients in the ECPR-based group and 26/132 (19.7%) in the CCPR group were alive (log-rank P = 0.01). There were no significant differences between the treatment groups in the neurological outcome, survival after hospital discharge, risk of hospitalization, major cardiovascular events and quality of life. Of long-term survivors, 1/34 (2.9%) in the ECPR-based arm and 1/26 (3.8%) in the CCPR arm had poor neurological outcome (both patients had a cerebral performance category score of 3). CONCLUSIONS: Among patients with refractory OHCA, the ECPR-based approach significantly improved long-term survival. There were no differences in the neurological outcome, major cardiovascular events and quality of life between the groups, but the trial was possibly underpowered to detect a clinically relevant difference in these outcomes. Trial registration ClinicalTrials.gov Identifier: NCT01511666, Registered 19 January 2012.

• Klíčová slova
• Extracorporeal cardiopulmonary resuscitation, Extracorporeal membrane oxygenation, Long-term, Out-of-hospital cardiac arrest, Quality of life,
• MeSH
• časové faktory MeSH
• kardiopulmonální resuscitace * MeSH
• kvalita života MeSH
• lidé MeSH
• následné studie MeSH
• retrospektivní studie MeSH
• zástava srdce mimo nemocnici * terapie   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• randomizované kontrolované studie MeSH

Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.

• Klíčová slova
• Arrhythmia, Consensus document, Electrical storm, Sudden cardiac death, Ventricular fibrillation, Ventricular tachycardia,
• MeSH
• defibrilátory implantabilní * MeSH
• incidence MeSH
• komorová tachykardie * diagnóza   terapie   komplikace   MeSH
• lidé MeSH
• rizikové faktory MeSH
• srdeční arytmie diagnóza   terapie   MeSH
• srdeční selhání * komplikace   MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• konsensus - konference MeSH
• Geografické názvy
• Asie epidemiologie   MeSH

INTRODUCTION: Failure to restore spontaneous circulation remains a major cause of death for cardiac arrest (CA) patients. Mechanical circulatory support, specifically extracorporeal cardiopulmonary resuscitation (ECPR), has emerged as a feasible and efficacious rescue strategy for selected refractory CA patients. METHODS: Mechanical Circulatory Support was one of six focus topics for the Wolf Creek XVII Conference held on June 14-17, 2023 in Ann Arbor, Michigan, USA. Conference invitees included international thought leaders and scientists in the field of CA resuscitation from academia and industry. Participants submitted via online survey knowledge gaps, barriers to translation and research priorities for each focus topic. Expert panels used the survey results and their own perspectives and insights to create and present a preliminary unranked list for each category that was debated, revised and ranked by all attendees to identify the top 5 for each category. RESULTS: Top 5 knowledge gaps included optimal patient selection, pre-ECPR treatments, logistical and programmatic characteristics of ECPR programs, generalizability and effectiveness of ECPR, and prevention of reperfusion injury. Top 5 barriers to translation included cost/resource limitations, technical challenges, collaboration across multiple disciplines, limited patient population, and early identification of eligible patients. Top 5 research priorities focused on comparing the outcomes of prehospital/rapid transport strategies vs in-hospital ECPR initiation, implementation of high-performing ECPR system vs standard care, rapid patient identification tools vs standard clinical judgment, post-cardiac arrest bundled care vs no bundled care, and standardized ECPR clinical protocol vs routine care. CONCLUSION: This overview can serve as an innovative guide to transform the care and outcome of patients with refractory CA.

• Klíčová slova
• Cardiac arrest, Extracorporeal cardiopulmonary resuscitation, Mechanical circulatory support, Wolf Creek Conference,
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH