**4. Emergency PCI with complete coronary revascularization or treatment of the coronary "culprit lesion" only?**

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 disease [28]. In cardiogenic shock, early coronary revascularization was associated with improved long-term survival compared to drug therapy [29, 30]. However, early PCI in cardiogenic shock or in patients with aborted cardiac arrest is applied in 50–70% of patients only [31], although most of these patients reveal coronary multivessel disease being associated with significantly higher mortality compared to coronary one-vessel disease [32, 33]. Depending on hemodynamic instability and complexity of multivessel coronary disease according to the SYNTAX level, either a PCI or CABG may be the recommended treatment option in cardiogenic shock (Grade I, Level B evidence) [22]. The "CULPRIT-SHOCK" study recently demonstrated a prognostic benefit for a staged PCI of the "culprit lesion" at first in patients with cardiogenic shock and coronary multivessel disease compared to "ad-hoc" multivessel PCI directly at presentation. 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]. Comparative studies evaluating CABG versus PCI in patients suffering from cardiac arrest or cardiogenic shock are lacking [36]. 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. This has led to an almost lower prevalence of emergency CABG in post-cardiac arrest patients of less than 5% [31].

of cardiac function with the lowest myocardial infarction size [39]. This experimental evidence confirms the disadvantage of delayed coronary revascularization and limits the ben-

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

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

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In contrast, Mooney et al. demonstrated that delayed initiation of TTM in patients with outof-hospital cardiac arrest was associated with a 20% increase of mortality. However, the rate of invasive coronary angiography was 72% with a PCI rate of 40% only [40]. It is well documented from several cohort studies that a combined PCI plus TTM improves survival and

TTM consists of controlled intravenous infusion systems (e.g., Bogard XP® Temperature Management System, ZOLL Medical Corporation, Asahi Kasei Corp, Japan) in combination with cool packs. TTM may not be initiated out-of-hospital only in order to achieve potentially best possible prognostic and neurological outcome [41, 42]. The target temperature is aimed between 32 and 36°C, whereas even lower target temperatures were shown to have no additional prognostic or neurological benefit [37, 43, 44]. Regardless of the documented primary arrhythmia, TTM is always recommended for at least 24 h duration in patients with persistent

Despite successful CPR and consecutive ROSC, there are still 30–40% of patients revealing hemodynamic instability and prolonged cardiogenic shock. 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

○ LV to aorta: non-pulsatile axial Impella® 2.5/5.0 (Abiomed Europe, Aachen, Germany;

○ Left atrium (LA) to aorta: TandemHeart® LVAD KIT (CardiacAssist, Inc., Pittsburgh,

○ Vena cava inferior (VCI) to pulmonary artery (PA): non-pulsatile axial Impella RP®

Currently available VAD systems for percutaneous access include the following:

neurological outcome in patients with cardiac arrest and persistent coma [6].

**5.2. Cardiac assist devices for extracorporeal life support (ECLS)**

efit of sole TTM after cardiac arrest.

coma [37].

support.

• LVAD – central:

Abb. 3a),

• RVAD – central:

USA; Abb. 3b);

• Intra-aortic balloon pump (IABP);

(Abiomed Europe, Aachen, Germany; 3a),
