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Cardiac arrest with refractory ventricular fibrillation: a successful resuscitation using extracorporeal membrane oxygenation

      Extracorporeal membrane oxygenation (ECMO) is a form of a mechanical cardiopulmonary life-support system and an adjunct to prolonged cardiac resuscitation. The ECMO results in good outcomes for patients with in-hospital cardiac arrest. We present a case of a 52-year-old man with out-of-hospital cardiac arrest caused by refractory ventricular fibrillation. The patient was referred to our emergency department with suspected acute coronary syndrome. Cardiac arrest with ventricular fibrillation was refractory to conventional cardiopulmonary resuscitation. In this case, the ECMO–cardiopulmonary resuscitation provided cardiopulmonary life support for out-of-hospital cardiac arrest, achieving a sustained return of spontaneous circulation that allowed prompt percutaneous coronary intervention and a good recovery.
      A 52-year-old man was referred to our emergency department with suspected acute coronary syndrome. On arrival, he was unconscious, pulseless, and in cardiac arrest for which he received advanced cardiopulmonary life support. Electrocardiography revealed ventricular fibrillation; thus, immediate defibrillation and standard cardiopulmonary resuscitation (CPR) were performed. The patient received defibrillation with 200 × 21 J (biphasic shock), minimal interruption of chest compressions, intravenous administration of epinephrine (1 × 15 ]mg), mechanical ventilation, and intravenous administration of amiodarone (300 × 1 mg and 150 × 8 mg). Five episodes of asystole occurred during resuscitation. The duration of CPR was approximately 59 minutes, and first return of spontaneous circulation (ROSC) was achieved. His blood pressure was 58/32 mm Hg, and heart rate was 122 beats per minute. Cardiac enzymes were elevated, and echocardiography demonstrated severe diffuse hypokinesia of the left ventricle with a left ventricular ejection fraction of 10% (Table 1). Ventricular fibrillation repeatedly developed during echocardiography, and sustained ROSC was not achieved. The patient was pulseless without defibrillation or chest compressions for approximately 95 minutes. We failed to reverse this life-threatening ventricular rhythm. A decision was made to use extracorporeal membrane oxygenation (ECMO)-CPR for cardiopulmonary life support.
      Table 1Summary of the laboratory data
      At the EDPost CPRDay 2Day 3Day 12
      CPK (μ/L)99648163180
      CPK-MB (ng/mL)598.9324.65.6
      ABG
      pH6.9297.2107.4097.406
      PCO2 (mm Hg)>82.531.934.737.2
      PO2 (mm Hg)40.470.4116.693.3
      Base excess (mmol/L)15.313.21.50.5
      HCO3 (mmol/L)14.215.522.223.4
      O2 saturation43.392.599.097.6
      LVEF (%)104560
      ED indicates emergency department; ABG, arterial blood gas; LVEF, left ventricular ejection fraction; CPK-MB, creatine phosphokinase-MB.
      Venoarterial ECMO catheters were inserted into his right femoral vessels for resuscitation. The pump flow was set at 2.5 L/min with a fraction of inspired oxygen of 1.0. Sustained ROSC was dramatically achieved, and spontaneous movement of extremities was noted. Prompt percutaneous coronary intervention (PCI) was performed, which revealed total occlusion of the left anterior descending coronary artery. After successful PCI with thrombosuction and direct stenting of left anterior descending coronary artery, he was admitted to the intensive care unit. Serial echocardiography revealed gradual recovery of heart contractility (left ventricular ejection fraction increased from 10% to 45% in 3 days), and the patient was successfully weaned off ECMO on day 3. Pneumonia developed on day 4, which required a prolonged course of antibiotic administration. Mechanical ventilation support was discontinued on day 12 because of his improved clinical condition and laboratory data (Table); the patient was transferred from the intensive care unit to the cardiovascular ward. He was discharged on day 23 without any serious complications or neurological deficits.
      Ventricular fibrillation is a life-threatening rhythm because it rapidly transforms into sudden cardiac death without immediate defibrillation or CPR. In this case, ventricular fibrillation repeatedly developed, and ROSC could not be maintained despite successful defibrillation with chest compressions. If the patient had not been resuscitated with ECMO, it would have been very difficult to reverse the refractory ventricular fibrillation to sinus rhythm and to maintain ROSC. It was obvious that the refractory ventricular fibrillation was reversible using ECMO, although it persisted for 95 minutes. Previous reports indicate that extracorporeal life support as an adjunct to cardiac resuscitation can produce good outcomes for patients with in-hospital cardiac arrest, but it is not recommended to use ECMO as an adjunct to cardiac resuscitation in the emergency department for patients with out-of-hospital cardiac arrest (OHCA) [
      • Chen Y.S.
      • Lin J.W.
      • Yu H.Y.
      • et al.
      Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.
      ]. Our patient was successfully resuscitated from OHCA because of ventricular fibrillation in the setting of ST-segment elevation myocardial infarction. A cardiologist was consulted for PCI after ROSC was noted, but the duration of ROSC was less than 20 minutes, and sustained ROSC was not achieved, which did not allow adequate time for transfer and to perform emergency PCI. Sustained ROSC was achieved with ECMO-CPR, hemodynamic status was stabilized, and emergency PCI was performed. After advanced postcardiac arrest treatment, PCI may result in improved survival to the time of hospital discharge [
      • Sunde K.
      • Pytte M.
      • Jacobsen D.
      • et al.
      Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest.
      ,
      • Reynolds J.C.
      • Callaway C.W.
      • El Khoudary S.R.
      • Moore C.G.
      • Alvarez R.J.
      • Rittenberger J.C.
      Coronary angiography predicts improved outcome following cardiac arrest: propensity-adjusted analysis..
      ]. Although acute myocardial infarction–induced ventricular fibrillation refractory to conventional CPR is a good indication for ECMO, only 1 case of OHCA due to recurrent ventricular fibrillation has been reportedly treated with ECMO as a resuscitation tool in the emergency department [
      • Shin J.S.
      • Lee S.W.
      • Han G.S.
      • Jo W.M.
      • Choi S.H.
      • Hong Y.S.
      Successful extracorporeal life support in cardiac arrest with recurrent ventricular fibrillation unresponsive to standard cardiopulmonary resuscitation.
      ].
      In the present case, conventional CPR failed to maintain ROSC and prevent a recurrence of ventricular fibrillation, and ECMO was successful for a patient with OHCA due to refractory ventricular fibrillation in the setting of acute coronary syndrome.

      References

        • Chen Y.S.
        • Lin J.W.
        • Yu H.Y.
        • et al.
        Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.
        Lancet. 2008; 372: 554-561
        • Sunde K.
        • Pytte M.
        • Jacobsen D.
        • et al.
        Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest.
        Resuscitation. 2007; 73: 29-39
        • Reynolds J.C.
        • Callaway C.W.
        • El Khoudary S.R.
        • Moore C.G.
        • Alvarez R.J.
        • Rittenberger J.C.
        Coronary angiography predicts improved outcome following cardiac arrest: propensity-adjusted analysis..
        J Intensive Care Med. 2009; 24: 179-186
        • Shin J.S.
        • Lee S.W.
        • Han G.S.
        • Jo W.M.
        • Choi S.H.
        • Hong Y.S.
        Successful extracorporeal life support in cardiac arrest with recurrent ventricular fibrillation unresponsive to standard cardiopulmonary resuscitation.
        Resuscitation. 2007; 73: 309-313