**3. Value of early invasive coronary diagnostics and therapies after cardiac arrest**

angiography may lead to increasing one-year survival in up to 60%. Still 58% of patients without ST-segment elevation reveal a critical coronary arterial stenosis ("culprit lesion") [6, 9, 24, 25]. Again, most studies investigating patients suffering from acute coronary syndrome and malignant arrhythmia were observational and heterogeneous including both patients with STEMI and NSTEMI [26]. Invasive coronary angiography with PCI should be performed either immediately or as early as possible based on careful clinical assessment [6]. This concept is also supported by animal studies demonstrating an improvement of both survival and neurological function after immediate reperfusion therapy in pigs with induced ischemiadriven ventricular fibrillation [27]. A fortiori, further clinical parameters become considerably

Interventional Therapies for Post-Cardiac Arrest Patients Suffering from Coronary Artery Disease

http://dx.doi.org/10.5772/intechopen.75045

47

important, which in turn may limit the use of an early PCI in the individual (**Table 2**).

• lactate value >7 mmol/L, pH value <7.2 both being associated with severe tissue hypoxia

• Lactate value >7 mmol/L, pH value <7.2 both being associated with severe tissue hypoxia and multiple organ

**Table 2.** Important clinical parameters limiting prognosis and the additional benefit of an early aggressive invasive

These parameters include the following: [6]

• absence of ventricular fibrillation as primary arrhythmia;

• terminal renal failure requiring renal replacement therapy; and

• presence of noncardiac causes leading to cardiac arrest.

• Absence of ventricular fibrillation as primary arrhythmia

• terminal renal failure requiring renal replacement therapy • Presence of noncardiac causes leading to cardiac arrest • Patients with noncardiac causes of cardiac arrest

• unwitnessed cardiac arrest;

• absence of bystander CPR; • prolonged or repeated CPR; • CPR period longer than 30 min;

and multiple organ failure;

• age > 85 years;

• Unwitnessed cardiac arrest

• Absence of bystander CPR • Prolonged or repeated CPR • CPR period longer than 30 min

failure • Age > 85 years

• Frailty

• Advanced dementia • Persistent ventilation

• Multisystem disorders

treatment strategy by PCI.

The biological processes that cause an arrested heart either to regain a regulated sinus rhythm with sufficient myocardial contraction and stroke volume or not to recover adequately after an acute myocardial infarction are still unclear [4]. The reperfusion-damage theory is often debated, which has to be prevented by coronary revascularization and reperfusion. Still vital myocardium is threatened not only by cell death under circumstances of ongoing ischemia, but also by changes in cell metabolism and the sudden resupply of oxygen and other substrates after reperfusion [14]. Whether re-exposure to normal concentrations of oxygen, calcium or a balanced pH value may have beneficial or even fatal effects following successful reperfusion of a closed coronary artery is poorly understood and very controversial [15, 16]. It is assumed that the reperfusion damage is subject to temporal dynamics. After a prolonged ischemic phase, there is a critical time frame in which reperfusion may cause even more harm than benefit [17]. This has been proven in studies investigating ischemic preconditioning. Here, repetitive periods of iatrogenic induced complete ischemia may reveal myocardial protection and may reduce the reperfusion damage [18].

Today, emergency PCI combined with an extracorporeal bypass is one of the favored revascularization strategies. Emergency bypass requires rapid cannulation of a large central artery and vein, typically femoral artery and vein, and can be inserted out-of-hospital already [12, 19]. Since 2000, those concepts have been pushed forward. For instance, more than 30 cardiac arrest centers were created in Japan to establish full cardiovascular support and emergency PCI support within 15 min, achieving a survival rate of more than 15% in cardiac arrest patients with good neurological function [7]. The administration of additional intravenous drug combinations as a so-called "anti-perfusion-damage cocktail" is another concept that has so far only been evaluated in experimental work [4, 20].

In case of an established emergency bypass protected emergency PCI can be performed safer. Emergency PCI represents the decisive therapy in cardiac arrest patients, which may prevent ongoing myocardial necrosis. In addition, the baseline neurological status of each individual patient is directly related to mortality after cardiac arrest. About two-thirds of all patients with out-of-hospital cardiac arrest caused by ST segment elevation myocardial infarction (STEMI) are in a comatose state. In particular, this group of patients is associated with a significantly higher mortality of 50%, compared with a mortality of only 5% in awake patients after being successfully resuscitated [21].

About 50% of patients surviving out-of-hospital cardiac arrest and with proven CAD reveal acute coronary artery occlusion [7]. Therefore, European guidelines recommend primary PCI in patients with a successfully restored spontaneous circulation (ROSC) after cardiac arrest, cardiopulmonary resuscitation (CPR) in the presence of STEMI, regardless of baseline neurological status (recommendation class I, level of evidence B) [1, 7, 9]. In contrast, coronary angiography should also be performed independently of ECG findings in survivors of cardiac arrest with an intermediate pretest probability, which is estimated on the basis of age, gender and symptoms (recommendation grade IIa, level of evidence B-C [1, 22, 23]. This also includes patients with "ventricular storming" (recommendation grade IIa, level of evidence C [22]). According to various mostly nonrandomized studies, early invasive coronary angiography may lead to increasing one-year survival in up to 60%. Still 58% of patients without ST-segment elevation reveal a critical coronary arterial stenosis ("culprit lesion") [6, 9, 24, 25]. Again, most studies investigating patients suffering from acute coronary syndrome and malignant arrhythmia were observational and heterogeneous including both patients with STEMI and NSTEMI [26]. Invasive coronary angiography with PCI should be performed either immediately or as early as possible based on careful clinical assessment [6]. This concept is also supported by animal studies demonstrating an improvement of both survival and neurological function after immediate reperfusion therapy in pigs with induced ischemiadriven ventricular fibrillation [27]. A fortiori, further clinical parameters become considerably important, which in turn may limit the use of an early PCI in the individual (**Table 2**).

These parameters include the following: [6]


**3. Value of early invasive coronary diagnostics and therapies after** 

tection and may reduce the reperfusion damage [18].

has so far only been evaluated in experimental work [4, 20].

successfully resuscitated [21].

The biological processes that cause an arrested heart either to regain a regulated sinus rhythm with sufficient myocardial contraction and stroke volume or not to recover adequately after an acute myocardial infarction are still unclear [4]. The reperfusion-damage theory is often debated, which has to be prevented by coronary revascularization and reperfusion. Still vital myocardium is threatened not only by cell death under circumstances of ongoing ischemia, but also by changes in cell metabolism and the sudden resupply of oxygen and other substrates after reperfusion [14]. Whether re-exposure to normal concentrations of oxygen, calcium or a balanced pH value may have beneficial or even fatal effects following successful reperfusion of a closed coronary artery is poorly understood and very controversial [15, 16]. It is assumed that the reperfusion damage is subject to temporal dynamics. After a prolonged ischemic phase, there is a critical time frame in which reperfusion may cause even more harm than benefit [17]. This has been proven in studies investigating ischemic preconditioning. Here, repetitive periods of iatrogenic induced complete ischemia may reveal myocardial pro-

Today, emergency PCI combined with an extracorporeal bypass is one of the favored revascularization strategies. Emergency bypass requires rapid cannulation of a large central artery and vein, typically femoral artery and vein, and can be inserted out-of-hospital already [12, 19]. Since 2000, those concepts have been pushed forward. For instance, more than 30 cardiac arrest centers were created in Japan to establish full cardiovascular support and emergency PCI support within 15 min, achieving a survival rate of more than 15% in cardiac arrest patients with good neurological function [7]. The administration of additional intravenous drug combinations as a so-called "anti-perfusion-damage cocktail" is another concept that

In case of an established emergency bypass protected emergency PCI can be performed safer. Emergency PCI represents the decisive therapy in cardiac arrest patients, which may prevent ongoing myocardial necrosis. In addition, the baseline neurological status of each individual patient is directly related to mortality after cardiac arrest. About two-thirds of all patients with out-of-hospital cardiac arrest caused by ST segment elevation myocardial infarction (STEMI) are in a comatose state. In particular, this group of patients is associated with a significantly higher mortality of 50%, compared with a mortality of only 5% in awake patients after being

About 50% of patients surviving out-of-hospital cardiac arrest and with proven CAD reveal acute coronary artery occlusion [7]. Therefore, European guidelines recommend primary PCI in patients with a successfully restored spontaneous circulation (ROSC) after cardiac arrest, cardiopulmonary resuscitation (CPR) in the presence of STEMI, regardless of baseline neurological status (recommendation class I, level of evidence B) [1, 7, 9]. In contrast, coronary angiography should also be performed independently of ECG findings in survivors of cardiac arrest with an intermediate pretest probability, which is estimated on the basis of age, gender and symptoms (recommendation grade IIa, level of evidence B-C [1, 22, 23]. This also includes patients with "ventricular storming" (recommendation grade IIa, level of evidence C [22]). According to various mostly nonrandomized studies, early invasive coronary

**cardiac arrest**

46 Myocardial Infarction



**Table 2.** Important clinical parameters limiting prognosis and the additional benefit of an early aggressive invasive treatment strategy by PCI.

<sup>•</sup> 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.

**Figures 1** and **2** show two emergency complex multiple PCIs in two patients in cardiogenic shock after impending or survived cardiac arrest using two different cardiac/ventricular assist devices (VAD) as extracorporeal life support (ECLS).

**Figure 1.** Emergency coronary angiography of a 82-year-old female patient surviving out-of-hospital cardiac arrest with immediate nonprofessional resuscitation. Ventricular fibrillation was documented as primary arrhythmia, with consecutive 15-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). The left coronary artery shows a critical 99% stenosis at the distal main trunk (LMT), progressing into the central left circumflex (CX) (B) and left artery descending (LAD). LAD additionally shows sequential high-grade 99% proximal and mid-stenoses (C). 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 (1.25 mm burr) from the LMT into the middle LAD (E). Secondly, single PCI/DES implantation was performed at mid-LAD (Boston Syndrome II 2.5/16 mm). Finally, bifurcational PCI of LMT-CX-RIVA T-stenting with antegrade protrusion (TAP) technique and final balloon kissing was performed (LMT in CX, Boston Synergy 4.0 / 24 mm; LMT in LAD protruded, Boston Synergy II 3.0/16 mm; final kissing with non-compliant balloons, Boston Emerge 4.0/20 and 3.5/15 mm) (F). Weaning from VA-ECMO and mechanical ventilation succeeds on the following day and the patient could have been discharged from hospital at day 9 in stable neurological and cardiopulmonary status.

**4. Emergency PCI with complete coronary revascularization or** 

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]). On the other hand, the SYNTAX trial demonstrated that complete compared to incomplete coronary revascularization (either by PCI or CABG) significantly improves long-term survival of patients with coronary three-vessel

**Figure 2.** Severe coronary artery disease of a 50-year-old male patient with ST segment elevation myocardial infarction (STEMI) of the anterior wall, consecutive cardiogenic shock and prolonged cardiac arrest. Coronary angiography showed a subtotal stenosis of the mid and distal LMT, LAD showed long and critical stenosis, CX and first marginal branch were also highly stenosed (A&B). Right coronary artery was normal (not shown). Firstly, percutaneous and central intracardiac LVAD (Impella 2.5) was inserted into the left ventricle (C). Secondly, the LMT-LAD-CX bifurcation was predilated by a kissing balloon technique (D). Thirdly, rotablation (1.25 mm burr) of the mid CX was performed (E). Finally, complex multivessel PCI of marginal branch, CX and LAD. Final result showed sufficient TIMI-III flow with complete emergency revascularization (F). Impell device was removed after PCI due to

Interventional Therapies for Post-Cardiac Arrest Patients Suffering from Coronary Artery Disease

http://dx.doi.org/10.5772/intechopen.75045

49

**treatment of the coronary "culprit lesion" only?**

recovery of circulation.

Interventional Therapies for Post-Cardiac Arrest Patients Suffering from Coronary Artery Disease http://dx.doi.org/10.5772/intechopen.75045 49

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 inva-

**Figures 1** and **2** show two emergency complex multiple PCIs in two patients in cardiogenic shock after impending or survived cardiac arrest using two different cardiac/ventricular assist

**Figure 1.** Emergency coronary angiography of a 82-year-old female patient surviving out-of-hospital cardiac arrest with immediate nonprofessional resuscitation. Ventricular fibrillation was documented as primary arrhythmia, with consecutive 15-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). The left coronary artery shows a critical 99% stenosis at the distal main trunk (LMT), progressing into the central left circumflex (CX) (B) and left artery descending (LAD). LAD additionally shows sequential high-grade 99% proximal and mid-stenoses (C). 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 (1.25 mm burr) from the LMT into the middle LAD (E). Secondly, single PCI/DES implantation was performed at mid-LAD (Boston Syndrome II 2.5/16 mm). Finally, bifurcational PCI of LMT-CX-RIVA T-stenting with antegrade protrusion (TAP) technique and final balloon kissing was performed (LMT in CX, Boston Synergy 4.0 / 24 mm; LMT in LAD protruded, Boston Synergy II 3.0/16 mm; final kissing with non-compliant balloons, Boston Emerge 4.0/20 and 3.5/15 mm) (F). Weaning from VA-ECMO and mechanical ventilation succeeds on the following day and the patient could have been discharged from hospital at day

sive diagnostics and therapies.

48 Myocardial Infarction

devices (VAD) as extracorporeal life support (ECLS).

9 in stable neurological and cardiopulmonary status.

**Figure 2.** Severe coronary artery disease of a 50-year-old male patient with ST segment elevation myocardial infarction (STEMI) of the anterior wall, consecutive cardiogenic shock and prolonged cardiac arrest. Coronary angiography showed a subtotal stenosis of the mid and distal LMT, LAD showed long and critical stenosis, CX and first marginal branch were also highly stenosed (A&B). Right coronary artery was normal (not shown). Firstly, percutaneous and central intracardiac LVAD (Impella 2.5) was inserted into the left ventricle (C). Secondly, the LMT-LAD-CX bifurcation was predilated by a kissing balloon technique (D). Thirdly, rotablation (1.25 mm burr) of the mid CX was performed (E). Finally, complex multivessel PCI of marginal branch, CX and LAD. Final result showed sufficient TIMI-III flow with complete emergency revascularization (F). Impell device was removed after PCI due to recovery of circulation.
