Cardiac Arrest in the Cardiac Catheterization Suite (“Cath Lab”): ALS 3406 TF ScR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None applicable

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None applicable

Task Force Synthesis Citation

Nolan JP, Ohshimo S, Nabecker S, Nikolaou N, Kudenchuk P, Deakin CD, Dunning J, Gonzalez Salvado V, Nicholson T, Bichmann A, Morley P, Drennan I. on behalf of the International Liaison Committee on Resuscitation Advanced Life Support Task Force. Cardiac arrest in the Cardiac Intervention Laboratory a Scoping Review: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2024 November XX. Available from: http://ilcor.org

Methodological Preamble and Link to Published Scoping Review

A scoping review was conducted by members of the ILCOR Advanced Lire Support Task Force. Evidence for adult resuscitation occurring in the cardiac intervention suite (“cath lab”) was identified.

Scoping Review

Webmaster to insert the Scoping Review citation and link to Pubmed using this format when/if it is available.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Adults (Aged 18 years and over) who experience a cardiac arrest in the cardiac intervention laboratory.

Intervention: Patient management other than national/international resuscitation guidelines.

Comparators: Patient management using national/international resuscitation guidelines.

Outcomes: Return of spontaneous circulation (ROSC)

Survival status at hospital discharge, 30 days and longer-term

Functional outcome (modified Rankin scale score or Cerebral Performance Category) at hospital discharge, 30 days and longer-term.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) Unpublished studies (e.g., conference abstracts, trial protocols) and case series with ≤ 5 cases are excluded. All relevant publications in any language are included as long as there is an English abstract.

Timeframe: All years.

Literature search updated 12 March 2024.

Search Strategies

The search strategy was created in coordination with an information scientist. Two databases (PubMed and Embase) were searched to identify all potentially relevant publications. The full search terms can be found below. Each identified title and abstract were reviewed by two authors and any disagreements adjudicated by consensus or a third reviewer. Full text articles were then reviewed and relevant data abstracted using a standardized spreadsheet. Data abstraction was conducted by pairs of authors – for each domain one author undertook the initial abstraction and this was reviewed by a second author.

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Inclusion and Exclusion criteria

Adults with cardiac arrest in the cardiac intervention laboratory. Where possible the data were separated into those cardiac arrests that started in the cardiac intervention laboratory and those in refractory cardiac arrest at the time of entry to the cardiac intervention laboratory.

PRISMA: ALS 3406 PRISMA

Data tables

The studies were categorized into 6 domains:

1. Incidence and outcome of cardiac arrest in the cardiac intervention laboratory
2. Incidence and outcome from cardiac arrest during PCI in the cardiac intervention laboratory among patients with and without acute ST-elevation MI
3. Mechanical chest compression CPR in the cardiac intervention laboratory.
4. ECPR in the cardiac intervention laboratory.
5. Mechanical circulatory support in the cardiac intervention laboratory.

Intracoronary epinephrine in the cardiac intervention laboratory

Attachment: ALS 3406 Data Tables

Task Force Insights

1. Why this topic was reviewed.

• An increasing number and complexity of procedures are being undertaken in the cardiac intervention laboratory. Should cardiac arrest occur the circumstances are very different to cardiac arrest occurring elsewhere in the hospital: patients are frequently already monitored with defibrillation readily available; many are also invasively and noninvasively instrumented allowing for continuous assessment of hemodynamics and other parameters during the resuscitation attempt. Pharmacologic treatments may also be efficiently administered via established central arterial and venous access as well as peripheral vascular access. If refractory VF/VT results from acute ischemia, this may be resolved by angioplasty and stenting of an occluded coronary artery. Cardiac arrest may also occur during transcatheter structural cardiac interventions, which are increasingly frequent in this setting, and its management may require special considerations. Conversely, an emphasis on corrective invasive procedures (such as angioplasty) in the cardiac interventional laboratory creates potential challenges, should these serve as a distraction that detracts from high-quality CPR, or CPR itself detracts from what is technically required for procedural success. Thus, the optimal management of, and outcome from, cardiac arrest in the cardiac intervention laboratory may be very different to elsewhere in hospital.

• This topic has not previously been reviewed by ILCOR

2. Narrative summary of evidence identified

We identified 35 observational studies but no randomized controlled trials.^1-35

2a. Incidence and outcome of cardiac arrest in the cardiac intervention laboratory

We identified 3 observational studies (2 retrospective cohort studies^1,2 and 1 prospective cohort study³) that described the incidence and outcome from cardiac arrest in the cardiac intervention laboratory among patients undergoing a variety of interventions. In 2 studies, the incidence rate was 0.2% and 0.5% and 77% and 67% respectively survived the event.^1,2 Two studies^2,3 reported survival to discharge (56.1% and 38.1%) and one study reported a 1-year survival of 37%.¹

2b. Incidence and outcome from cardiac arrest during PCI in the cardiac intervention laboratory

We identified 3 observational studies (1 prospective^6,7 and 2 retrospective^4,5) that described the incidence and outcome from cardiac arrest in the cardiac intervention laboratory among patients (elective and non-elective) undergoing percutaneous coronary intervention (PCI). Two studies concerned the incidence and outcome of ventricular fibrillation (VF),^4,6,7 while the 3^rd reported all-rhythm cardiac arrests.⁵ The incidence of VF cardiac arrest was 0.84% to 2% and the one study reporting outcomes documented successful defibrillation within 1 minute and survival to hospital discharge in all 164 (100%) VF cardiac arrests.⁴ Three studies documented that VF was more common during right coronary artery (RCA) PCI compared with LCA PCI.^4,6,7

2c. Incidence and outcome from cardiac arrest during Primary PCI in the cardiac intervention laboratory during treatment of ST elevation acute myocardial infarction (STEMI)

We identified 5 observational studies (2 prospective^7,11 and 3 retrospective^8-10) that described the incidence and outcome from VF/VT cardiac arrest in the cardiac intervention laboratory among patients undergoing primary PCI for ST-elevation acute myocardial infarction (STEMI) within 12 hours of symptom onset. The incidence of VF/VT cardiac arrest ranged from 1.9% to 5.5% and the rate of survival to hospital discharge ranged from 81.7% to 99.2%.

2d. Mechanical chest compression devices to manage cardiac arrest in the cardiac intervention laboratory

We identified 7 observational studies (1 prospective¹² and 6 retrospective^13-18) that described outcomes following use of a mechanical chest compression to manage cardiac arrest in the cardiac intervention laboratory. Six of these studies involved use of a mechanical piston device (LUCAS) device and 1 using a load-distributing band ( Autopulse).¹⁸ Two of these studies involved exclusively cardiac arrests that started in the intervention laboratory and that were treated with the LUCAS device.^12,13 Among the 75 patients in these two studies, 19 (25.3%) survived to hospital discharge with favourable neurological function (CPC 1-2). The remaining studies included patients who were in cardiac arrest on arrival at the cardiac intervention laboratory as well those whose cardiac arrest occurred in the laboratory – in only one of these cases was it possible to separate the outcomes in these two cohorts,¹⁷ but it is unclear whether these same patients had been included in the two previous studies by the same group.^12,13 In many cases the mechanical chest compression device was used while simultaneously performing coronary angiography and PCI and in some cases the mechanical chest compression device was used a bridge to mechanical circulatory support or ECPR.

2e. Extracorporeal CPR in the cardiac intervention laboratory

We identified 9 observational studies (2 prospective studies,^22,26 5 retrospective studies,^21,23-25,35 and 2 case series^19,20) involving the use of ECPR to treat patients in the cardiac intervention laboratory. By far the largest study that provided data specifically on ECPR for cardiac arrests that occurred in the cardiac intervention laboratory came from the ELSO registry.³⁵ In this study some of the 602 patients were receiving other mechanical circulatory support before being placed on ECPR and 39% of patients survived to hospital discharge. The remaining studies included a total of 164 patients in cardiac arrest who were placed on ECPR in the cardiac intervention laboratory. However, significant variability among the included studies was noted. First, five studies included mixed cohorts, including patients who were already in cardiac arrest on arrival in the laboratory or who suffered cardiac arrest in the catheterization laboratory, with outcomes not always documented separately for these groups.^{20,22,23,25,26} In contrast, three studies focused exclusively patients whose cardiac arrest started in the cardiac intervention laboratory.^19,21,24 Second, two studies explicitly included patients who experienced cardiac arrest and were placed on ECPR in locations other than the cardiac intervention laboratory.^20,23 Additionally, four studies did not only include patients with cardiac arrest but also with cardiogenic shock, although outcomes were generally reported separately.^21,23,24,26 Overall, with the exception of the ELSO study, the heterogeneity of patient samples, settings and procedures across the studies makes it very challenging to draw definitive conclusions from the data.

2f. Mechanical circulatory support in the cardiac intervention laboratory

We identified 5 retrospective observational studies^28-32 and a case series²⁷ that describe the use of mechanical circulatory support in the cardiac intervention laboratory. Four studies included use of Impella, ^28,29,31,32 1 study described 8 patients treated with a multifunctional percutaneous heart (MPH)²⁷ and a further study included 16 cardiac arrest patients undergoing transcatheter aortic valve replacement who were placed on ‘heart-lung circulatory support’ but their outcomes are not reported separately.³⁰ Whether cardiac arrest occurred in the cardiac intervention laboratory or before transfer to the laboratory is not clear in most of these studies and interpretation is also made difficult because of inclusion of patients of patients in cardiogenic shock but not cardiac arrest.

2g. Intracoronary epinephrine

We identified 2 prospective cohort studies^33,34 that compared intracoronary epinephrine with either peripheral intravenous or central venous epinephrine in a total of 320 patients developing cardiac arrest. One study enrolled 158 acute myocardial infarction patients and in the event of cardiac arrest epinephrine 1 mg was injected via a central venous catheter if one was already in situ or, in the absence of a central line 1 mg epinephrine was injected via peripheral IV or intracoronary at the physicians discretion.³⁴ Return of spontaneous circulation, survival to discharge and survival with favourable functional outcome were all higher in the central venous and intracoronary groups than the peripheral intravenous group.

In the second study, 162 patients undergoing cardiac catheterization and who developed cardiac arrest were enrolled in the study if a catheter was already in a coronary artery at the time of cardiac arrest. These patients were then given epinephrine 1 mg either intracoronary or intravenously at the physician’s discretion.³³ Return of spontaneous circulation, survival to discharge and survival with favourable functional outcome were all significantly higher in the intracoronary group.

3. Narrative Reporting of the task force discussions

• Interpretation of these studies is very difficult because it is often unclear whether cardiac arrest occurred in the cardiac intervention laboratory or beforehand. Many studies included patients in cardiogenic shock as well as cardiac arrest but in most cases, it was not possible to extract outcome data for the cardiac arrest cases alone.
• The performance and quality of standard resuscitative measures (e.g. CPR) performed in the cardiac interventional laboratory were not characterized in the surveyed studies.
• Further study of the use of intracoronary epinephrine to treat cardiac arrest in cardiac intervention laboratory should be considered.

Knowledge Gaps

• There are no randomized controlled trials of interventions to treat cardiac arrest in the cardiac intervention laboratory.
• The outcomes for patients developing cardiac arrest in the cardiac intervention laboratory and then treated with mechanical chest compression devices or mechanical circulatory support, or centrally-administered pharmacologic therapies are unclear.

References

1. Sharma R, Bews H, Mahal H, et al. In-Hospital Cardiac Arrest in the Cardiac Catheterization Laboratory: Effective Transition from an ICU- to CCU-Led Resuscitation Team. Journal of interventional cardiology 2019;2019(8907826):1686350.

2. Sprung J, Ritter MJ, Rihal CS, et al. Outcomes of cardiopulmonary resuscitation and predictors of survival in patients undergoing coronary angiography including percutaneous coronary interventions. Anesthesia and analgesia 2006;102(1):217-24.

3. Elkaryoni A, Tran AT, Saad M, et al. Patient characteristics and survival outcomes of cardiac arrest in the cardiac catheterization laboratory: Insights from get with the Guidelines-Resuscitation registry. Resuscitation 2022;180((Elkaryoni, Darki, Lopez) Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, United States(Tran, Chan) Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, MO, U):121-127.

4. Addala S, Kahn JK, Moccia TF, et al. Outcome of ventricular fibrillation developing during percutaneous coronary interventions in 19,497 patients without cardiogenic shock. The American journal of cardiology 2005;96(6):764-5.

5. Webb JG, Solankhi NK, Chugh SK, et al. Incidence, correlates, and outcome of cardiac arrest associated with percutaneous coronary intervention. The American journal of cardiology 2002;90(11):1252-4.

6. Huang JL, Ting CT, Chen YT, Chen SA. Mechanisms of ventricular fibrillation during coronary angioplasty: Increased incidence for the small orifice caliber of the right coronary artery. International Journal of Cardiology 2002;82(3):221-228.

7. Henriques JP, Gheeraert PJ, Ottervanger JP, et al. Ventricular fibrillation in acute myocardial infarction before and during primary PCI. Int J Cardiol 2005;105(3):262-6.

8. Mehta RH, Starr AZ, Lopes RD, et al. Incidence of and outcomes associated with ventricular tachycardia or fibrillation in patients undergoing primary percutaneous coronary intervention. 2009;301(17):1779‐1789.

9. Demidova MM, Carlson J, Erlinge D, Platonov PG. Predictors of ventricular fibrillation at reperfusion in patients with acute ST-elevation myocardial infarction treated by primary percutaneous coronary intervention. The American journal of cardiology 2015;115(4):417-22.

10. Gigliolli C, Margheri M, Valente S, et al. Timing, setting and incidence of cardiovascular complications in patients with acute myocardial infarction submitted to primary percutaneous coronary intervention. Canadian Journal of Cardiology 2006;22(12):1047-1052.

11. Mehta RH, Harjai KJ, Grines L, et al. Sustained ventricular tachycardia or fibrillation in the cardiac catheterization laboratory among patients receiving primary percutaneous coronary intervention - Incidence, predictors, and outcomes. Journal of the American College of Cardiology 2004;43(10):1765-1772.

12. Wagner H, Hardig BM, Rundgren M, et al. Mechanical chest compressions in the coronary catheterization laboratory to facilitate coronary intervention and survival in patients requiring prolonged resuscitation efforts. Scandinavian journal of trauma, resuscitation and emergency medicine 2016;24(101477511):4.

13. Wagner H, Terkelsen CJ, Friberg H, et al. Cardiac arrest in the catheterisation laboratory: a 5-year experience of using mechanical chest compressions to facilitate PCI during prolonged resuscitation efforts. Resuscitation 2010;81(4):383-7.

14. Larsen AI, Hjornevik AS, Ellingsen CL, Nilsen DWT. Cardiac arrest with continuous mechanical chest compression during percutaneous coronary intervention. A report on the use of the LUCAS device. Resuscitation 2007;75(3):454-459.

15. Venturini JM, Retzer E, Estrada JR, et al. Mechanical chest compressions improve rate of return of spontaneous circulation and allow for initiation of percutaneous circulatory support during cardiac arrest in the cardiac catheterization laboratory. Resuscitation 2017;115(r8q, 0332173):56-60.

16. Chyrchel M, Halubiec P, Duchnevic O, et al. Prognostic Factors in Patients with Sudden Cardiac Arrest and Acute Myocardial Infarction Undergoing Percutaneous Interventions with the LUCAS-2 System for Mechanical Cardiopulmonary Resuscitation. Journal of Clinical Medicine 2022;11(13):3872.

17. Madsen Hardig B, Kern KB, Wagner H. Mechanical chest compressions for cardiac arrest in the cath-lab: When is it enough and who should go to extracorporeal cardio pulmonary resuscitation? BMC Cardiovascular Disorders 2019;19(1):134.

18. Spiro JR, White S, Quinn N, et al. Automated cardiopulmonary resuscitation using a load-distributing band external cardiac support device for in-hospital cardiac arrest: a single centre experience of AutoPulse-CPR. Int J Cardiol 2015;180:7-14.

19. Shawl FA, Domanski MJ, Wish MH, Davis M, Punja S, Hernandez TJ. Emergency cardiopulmonary bypass support in patients with cardiac arrest in the catheterization laboratory. Catheterization and cardiovascular diagnosis 1990;19(1):8-12.

20. Mooney MR, Arom KV, Joyce LD, et al. Emergency cardiopulmonary bypass support in patients with cardiac arrest. The Journal of thoracic and cardiovascular surgery 1991;101(3):450-4.

21. Grambow DW, Deeb GM, Pavlides GS, Margulis A, O'Neill WW, Bates ER. Emergent percutaneous cardiopulmonary bypass in patients having cardiovascular collapse in the cardiac catheterization laboratory. American Journal of Cardiology 1994;73(12):872-875.

22. Nagao K, Hayashi N, Arima K, et al. Effects of combined emergency percutaneous cardiopulmonary support and reperfusion treatment in patients with refractory ventricular fibrillation complicating acute myocardial infarction. Internal medicine (Tokyo, Japan) 1999;38(9):710-6.

23. Goslar T, Knafelj R, Radsel P, et al. Emergency percutaneous implantation of veno-arterial extracorporeal membrane oxygenation in the catheterisation laboratory. EuroIntervention 2016;12(12):1465-1472.

24. Parr CJ, Sharma R, Arora RC, Singal R, Hiebert B, Minhas K. Outcomes of extracorporeal membrane oxygenation support in the cardiac catheterization laboratory. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2020;96(3):547-555.

25. Hryniewicz K, Hart M, Raile D, et al. Multidisciplinary shock team is associated with improved outcomes in patients undergoing ECPR. International Journal of Artificial Organs 2021;44(5):310-317.

26. Radsel P, Goslar T, Bunc M, Ksela J, Gorjup V, Noc M. Emergency veno-arterial extracorporeal membrane oxygenation (VA ECMO)-supported percutaneous interventions in refractory cardiac arrest and profound cardiogenic shock. Resuscitation 2021;160((Radsel, Goslar, Gorjup, Noc) Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia(Radsel, Goslar, Bunc, Ksela, Gorjup, Noc) Faculty of Medicine, University of Ljubljana, Slovenia(Goslar) Cardiovascular Division and Cente):150-157.

27. Bagai J, Webb D, Kasasbeh E, et al. Efficacy and safety of percutaneous life support during high-risk percutaneous coronary intervention, refractory cardiogenic shock and in-laboratory cardiopulmonary arrest. The Journal of invasive cardiology 2011;23(4):141-7.

28. Loehn T, O'Neill WW, Lange B, et al. Long term survival after early unloading with Impella CP in acute myocardial infarction complicated by cardiogenic shock. European Heart Journal: Acute Cardiovascular Care 2020;9(2):149-157.

29. Vase H, Christensen S, Christiansen A, et al. The Impella CP device for acute mechanical circulatory support in refractory cardiac arrest. Resuscitation 2017;112((Vase, Therkelsen, Christiansen, Eiskjaer, Poulsen) Department of Cardiology, Aarhus University Hospital, Denmark(Christensen, Christiansen) Department of Intensive Care Medicine, Aarhus University Hospital, Denmark):70-74.

30. Gerfer S, Kuhn EW, Gablac H, et al. Outcomes and Characteristics of Patients with Intraprocedural Cardiopulmonary Resuscitation during TAVR. Thoracic and Cardiovascular Surgeon 2023;71(2):101-106.

31. Almajed MR, Mahmood S, Obri M, et al. Application of Impella Mechanical Circulatory Support Devices in Transcatheter Aortic Valve Replacement and Balloon Aortic Valvuloplasty: A Single-Center Experience. Cardiovascular Revascularization Medicine 2023;53((Almajed, Mahmood, Obri) Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, United States(Nona, Gonzalez, Chiang, Wang, Frisoli, Lee, Basir, O'Neill, O'Neill, Villablanca) Center for Structural Heart Disease, Henry Ford Hospital, Detroit):1-7.

32. Orvin K, Perl L, Landes U, et al. Percutaneous mechanical circulatory support from the collaborative multicenter Mechanical Unusual Support in TAVI (MUST) Registry. Catheterization and Cardiovascular Interventions 2021;98(6):E862-E869.

33. Tantawy M, Selim G, Saad M, Tamara M, Mosaad S. Outcomes with intracoronary vs. intravenous epinephrine in cardiac arrest. European heart journal Quality of care & clinical outcomes 2024;10(1):99-103.

34. Aldujeli A, Haq A, Tecson KM, et al. A prospective observational study on impact of epinephrine administration route on acute myocardial infarction patients with cardiac arrest in the catheterization laboratory (iCPR study). Critical Care 2022;26(1):393.

35. Mazzeffi M, Zaaqoq A, Curley J, et al. Survival After Extracorporeal Cardiopulmonary Resuscitation Based on In-Hospital Cardiac Arrest and Cannulation Location: An Analysis of the Extracorporeal Life Support Organization Registry. Crit Care Med 2024