Christine Gasperetti, MD, FSCAI; Jayant Bagai, MD, FSCAI

Cardiac arrest in the cardiac cath lab (CCL), while infrequent, represents a significant management challenge due to the need to provide both CPR and treat the underlying cause of cardiac arrest simultaneously. The majority of patients who sustain cardiac arrest are undergoing urgent/emergent procedures for ST elevation myocardial infarction (MI) and cardiogenic shock.1 Patients with poor cardiac reserve undergoing high-risk percutaneous coronary intervention (PCI) and structural interventions are also at risk for cardiac arrest.2,3 This Tip of the Month will provide considerations for the management of refractory cardiac arrest in the CCL.

1. Identifying patients at an increased risk for cardiac arrest in the CCL

    a. ST elevation MI

    b. Severe cardiogenic shock (SCAI shock  stages C, D, and E)

    c. High-risk PCI

    d. Transcatheter aortic valve replacement (TAVR)

    e. PCI complications such as class III perforation, severe no-reflow, left main dissection resulting in abrupt closure, and severe air embolism

    f. Very severe left ventricular (LV)/right ventricular (RV)/biventricular systolic dysfunction

    g. History of cardiac arrest outside the CCL

2. Preventative planning in patients at a high risk for cardiac arrest

a. Provide an early notification to anesthesia; perfusion; and, if needed, advanced heart failure and cardiac  surgery prior to the arrival of the patient in the CCL or the start of the procedure if there is a high likelihood of cardiac arrest requiring extracorporeal membrane oxygenation (ECMO). Telephone numbers for these teams should be displayed clearly in the CCL.

     b. Ensure all patients have defibrillator pads placed prior to the procedure.

     c. Perform early insertion of mechanical circulatory support (MCS)/ECMO in patients who are prearrest/rapidly declining. The MCS type should be specific for the ventricle that is contributing predominantly to the severe hemodynamic compromise. For example, RV support may be of greater value than LV support in patients with severe acute RV failure from proximal occlusion of a large dominant right coronary artery (RCA).

     d. If possible, delay intubation in patients with severe hypotension and tachycardia until vascular access/MCS is in place, as these patients may arrest during induction.

3. Tips for the management of refractory in-lab cardiac arrest

      a. Instruct staff to start immediate high-quality CPR, perform defibrillation, and administer drugs based on current advanced cardiac life support (ACLS) guidelines. Attach the arterial access sheath to pressure to ensure a systolic blood pressure of 90-100 mmHg during chest compressions. 

      b. Consider mechanical compression devices (MCDs). In a case series, MCDs allowed for the performance of PCI during CPR with a 25 percent survival to discharge.4 MCDs ensure fatigue-free CPR following guideline-recommended frequency, depth, and recoil parameters. They also free staff to perform other tasks and reduce their exposure to radiation, injury, and communicable infection.

     c. Ensure the interventional cardiologist delegates responsibility of running the code blue to another team member so that he or she can focus on interventional aspects of the procedure.

     d. Call for help from another interventional cardiologist, if available. Notify cardiac surgery for extensive coronary or aortic dissection and refractory perforation.

     e. Mechanical Circulatory Support—there is limited data to support the efficacy of MCS devices such as Impella and intra-aortic balloon pump, for cardiac arrest.5 ECMO, if available, is the preferred device for refractory cardiac arrest and should be considered earlier (within 10–20 minutes) rather than later (after 30 minutes) after the start of CPR.6 ECMO generates high mean arterial pressure, provides oxygenation, and results in high rates of return of spontaneous circulation. Survival to hospital discharge, however, depends on whether the underlying condition can be reversed (such as with revascularization).7,8,9 The 2019 American Heart Association (AHA) Focused Update on ACLS states that there is insufficient evidence to recommend the routine use of ECMO during CPR (ECPR) for patients with cardiac arrest. ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD [limited data]).10 Absolute contraindications for ECMO, based on guidelines published by the Extracorporeal Life Support Organization (ELSO), include an unrecoverable heart and not a candidate for transplant or ventricular assist device (VAD), advanced age, chronic organ dysfunction (emphysema, cirrhosis, renal failure), compliance limitations, and prolonged CPR without adequate tissue perfusion.11

4. Process/system measures

      a. For CCLs performing complex and high-risk procedures, use a multidisciplinary approach (anesthesia, perfusion, advanced heart failure and cardiac surgery) for the management of refractory cardiac arrest in the CCL. 

      b. Perform mock drills to keep staff prepared and identify knowledge and process gaps. ACLS certification should be up to date for all staff and operators.

      c. Develop an algorithm for management of in-lab refractory cardiac arrest and tailor it to the specific environment and structure of the CCL and hospital. This should include criteria to determine patient candidacy for ECMO, which vary among institutions and programs. An example of an algorithm is provided in Figure 1. 

Conclusion
The rapid application of a team-based approach, focusing on the maintenance of vital organ perfusion coupled with efforts to correct the underlying cause, is key to patient survival during cardiac arrest in the CCL. The role of ECMO and MCS devices is evolving, and survival to hospital discharge depends significantly on the ability to correct the underlying cause. 

References

1. Webb JG, Solankhi NK, Chugh SK, et al. Incidence, correlates, and outcome of cardiac arrest associated with percutaneous coronary intervention. Am J Cardiol. 2002 Dec 1;90(11):1252‐1254.
2. O'Neill WW, Kleiman NS, Moses J, et al. A prospective, randomized clinical trial of hemodynamic support with Impella 2.5 versus intra-aortic balloon pump in patients undergoing high-risk percutaneous coronary intervention: the PROTECT II study. Circulation. 2012 Oct 2;126(14):1717-1727. 
3. Makkar RR, Jilaihawi H, Chakravarty T, et al. Determinants and outcomes of acute transcatheter valve-in-valve therapy or embolization: a study of multiple valve implants in the U.S. PARTNER trial (Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve). J Am Coll Cardiol. 2013 Jul 30;62(5):418-430. 
4. 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. Scand J Trauma Resusc Emerg Med. 2016; 24:4.
5. Vase H, Christensen S, Christiansen A, et al. The Impella CP device for acute mechanical circulatory support in refractory cardiac arrest. Resuscitation. 2017 Mar; 112:70-74.
6. Hardig BM, 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 Cardiovasc Disord. 2019;19:134. 
7. 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. J Invasive Cardiol. 2011 Apr;23(4):141-147.
8.  Arlt M, Philipp A, Voelkel S, et al. Early experiences with miniaturized extracorporeal life-support in the catheterization laboratory. Eur J Cardiothorac Surg. 2012 Nov;42(5):858-863.
9. 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 Jun; 115:56-60.
10. Panchal AR, Berg KM, Hirsch KG, et al. 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019 Dec 10;140(24): e881-e894.
11.  Extracorporeal Life Support Organization (ELSO). “Patient Specific Supplements to the ELSO General Guidelines.”

Figure 1: Proposed algorithm for the management of refractory in-lab cardiac arrest. (ACLS: advanced cardiac life support, MCD: mechanical compression device, MCS: mechanical circulatory support, ECMO: extracorporeal membrane oxygenation, IC: interventional cardiologist, ROSC: return of spontaneous circulation, VA: venoarterial.)