Analgesia & Resuscitation : Current ResearchISSN: 2324-903X

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Case Report, Analg Resusc Curr Res Vol: 4 Issue: 2

An Emergency Coronary Artery bypass Grafting after Out-of-Hospital Cardio Pulmonary Arrest

Akihisa Furuta Dr1*, Hiroyuki Saito MD1, YutaKume Dr1, Satoshi Saito MD2 and Kenji Yamazaki MD2
1Department of Cardiovascular Surgery, Tokyo Women’s Medical University Yachiyo Medical Center 477-96 Owadashinden, Yachiyo-shi, Chiba, 276-0035, Japan
2Department of Cardiovascular Surgery, Tokyo Women’s Medical University, 8-1, Kawadacho, Shinjuku-ku, Tokyo, 162-0054, Japan
Corresponding author : Akihisa Furuta Dr
Department of Cardiovascular Surgery, Tokyo Women’s Medical University Yachiyo Medical Center, 477-96 Owadashinden, Yachiyo-shi, Chiba, 276-0035, Japan
Tel: +81-80-1911-7627
E-mail: [email protected]
Received: June 06, 2015 Accepted: August 27, 2015 Published: August 31, 2015
Citation: Furuta DrA, Saito MDH, YutaKume Dr, Saito MDS, Yamazaki MDK (2015) An Emergency Coronary Artery bypass Grafting after Out-of-Hospital Cardio Pulmonary Arrest. Analg Resusc: Curr Res 4:2. doi:10.4172/2324-903X.1000136

Abstract

Survival from out-of-hospital cardiac arrest is influenced by various factors. We performed an emergency coronary artery bypass grafting for unstable angina immediately after an out of hospital cardiopulmonary arrest. A 73-year-old man with a history of percutaneous coronary intervention who experienced an out of hospital cardiopulmonary arrest was transported to our hospital. He received an emergency coronary artery bypass graft after bystander cardiopulmonary resuscitation, and transferred to the emergency department and catheter laboratory within 7h from the initial event. Successful bystander cardiopulmonary resuscitation with automated external defibrillation and cooperation among the emergency physicians, cardiologists and surgeons were paramount to the successful outcome.

Keywords: Cardiopulmonary arrest; Unstable angina; Percutaneous cardiopulmonary support

Keywords

Cardiopulmonary arrest; Unstable angina; Percutaneous cardiopulmonary support

Introduction

With the increase in number of cardiovascular diseases in the aging society, the number of out-of-hospital cardiopulmonary arrest (OHCPA) is also continuing to increase. Various factors, such as early detection, initial cardiopulmonary resuscitation (CPR) with an automatic external defibrillator (AED), implementation of percutaneous cardiopulmonary support (PCPS), and time to revascularization, influence the survival rate and cerebral complications [1-4]. We report a successful emergency coronary artery bypass graft (CABG) for unstable angina immediately after an OHCPA. We also analyzed the factors that determined the successful of the emergency CABG for the OHCPA patient.

Case

A 73-year-old man with a history of percutaneous coronary intervention for an old myocardial infarction who experienced an OHCPA was transported to the emergency department of our hospital. When he was 70 years old, a diagnosis of old myocardial infarction was confirmed through angiography, which showed coronary occlusion in the left circumflex branch and right coronary artery and an aberrant right coronary artery. He had undergone percutaneous catheter intervention three times; however, those did not restored the patency of his coronary artery because of severe calcifications. He also has a history of hypertension, hyperlipidemia, old cerebral infarction, and bilateral carotid artery stenosis and bladder carcinoma. He received only orally administered drugs, including aspirin, clopidogrel, nicorandil, carvedilol, and lovastatin in an outpatient basis.
While swimming in a gym at age 73 years, he suddenly experienced heart and lung arrest. After confirming CPA, CPR was started immediately by a bystander and the patient was transported to our hospital. On the way to the hospital, he underwent cardio version after ventricular fibrillation appeared. However, ventricular fibrillation was not terminated on arrival and CPR was continued.
His vital signs on arrival included a temperature of 36.0°C, no breathing and no pulse in his femoral artery. On physical examination, his consciousness scores on the Glasgow coma scale were as follow: eye opening-1; best verbal response-1; best motor response-1. Blood cell count and biochemical examination demonstrated high levels of white blood cell count (13050 /μL), brain natriuretic peptide (183.8 pg/mL) and hepatic enzymes (aspartate aminotransferase, 194 IU/L, alkaline phosphatase, 140 IU/L; lactase dehydrogenase 525 IU/L). The initial serum level of cardiac enzymes and electrolytes were normal; however, the coagulation test demonstrated prolongation of the international normalized ratio and activated partial thromboplastin time and high level of fibrin degradation product and D-dimer (international normalized ratio - 4.49; activated partial thromboplastin time - >150 s; fibrin degradation product - 8 μg/dL; D-dimer - 4.96 μg/dL). A chest X radiograph showed cardiomegaly with displacement of the heart to the left lateral wall.
Despite several cardio version attempts and the administration of inotropes including adrenaline by the emergency physicians, ventricular fibrillation continued. Then, we decided to implement PCPS. The cardiologists established an initial flow of 2.5 L/min through the left femoral artery and vein percutaneously by using a modified Seldinger technique 36 min after arrival. Chest compression was then discontinued, and the patient was brought to the catheter laboratory. The cardiologists performed an emergency angiography and found 75% stenosis of the left anterior descending coronary artery (#6 and #7) and complete occlusion of the right coronary artery and left circumflex branch (#1 and #13) (Figure 1A an 1B). Intra-aortic balloon pumping was applied. The patient underwent computed tomography before he was brought to the operating room for the emergency CABG (Figure 2).
Figure 1A: Emergency angiographpy demonstrated 75% stenosis of left anterior descending coronary artery (#6 and #7) and complete occlusion of left circumflex artery (#13).
Figure 1B: Emergency angiographpy also revealed complete occlusion of right coronary artery.
Figure 2: A computed tomography demonstrated the abnormal cardiac location to the left wall and aberrant RCA.
The operation was started with a median sternotomy, and the flow of the PCPS was changed to a minimum flow after establishing cardiopulmonary bypass. An emergency on-pump beating CABG (left internal thoracic artery-left anterior descending artery and ascending aorta-great saphenous vein- posterolateral branchposterior descending artery) was carried out without any serious complications such as massive bleeding and ventricular fibrillation. At the end of the operation we removed the PCPS after confirming a stable circulatory dynamics without the PCPS.
We removed the intra-aortic balloon pump on postoperative day 2 and extubated on postoperative day 6. Postoperative angiography revealed sufficient flow distal to the anastomosed side without anastomotic stenosis. Electrophysiological study on postoperative day 37 revealed that an implantable cardiac defibrillator is needed to prevent ventricular tachycardia from occurring and the patient was transferred to another hospital for the implantation of a cardiac defibrillator.

Discussion

A successful emergency CABG for unstable angina immediately after an OHCPA is described. In cases of OHCPA various factors such as time from detection to CPR, initiation of CPR with AED, shorter emergency medical services response interval, implementation of PCPS, and time to reperfusion, could influence the survival rate and cerebral complications of patients [1-4].
The location where CPA occurs also has the life-saving treatment and survival rate because it is associated with the time to detection and initial CPR and the ease of access to AED [2]. The patient was found in the gym, which is a public location. Because of this, the times to detection and ambulance arrival were short. Moreover, CPR was started immediately after the detection and the AED was readily available in the gym for use in the patient. Thus, the location of detection in this case could have led to the good course and the absence of complications after CABG.
Rapid initiation of CPR for CPA has a large influence on the life prognosis. It is reported that bystander CPR improves the 30- day and 1-year survival rate [4]. In Japan, 43% of patients with CPA transported to hospitals had received bystander CPR, and the number is increasing yearly as the number of participants of lectures in life support is increasing. In 2013, the 30-day survival rate of patients who had received initiation of CPR from a bystander was 11.5% and their rehabilitation rate was 7.2% [5]. In this case, a non-elderly started the good-quality CPR with AED by stander immediately after detection of the patient; this bystander was a young instructor who had undertaken a course in life support [6]. The good-quality CPR that the patient received could have maintained his circulatory dynamics during CPA and led to good results.
Although the indication of PCPS for cases of CPA is still controversial, using PCPS for patients with cardiogenic shock could lead to an improved survival rate [7-9]. The time to implementation of PCPS leads to shortening of the hours of brain ischemia. It is possible to introduce PCPS rapidly; others have reported starting PCPS within 7-25 min after arrival [10]. In this case, the time from arrival and the decision making to the actual implementation of PCPS was 36 and 27 min respectively. This was due to rapid decision making and the cooperation between the emergency physicians and the cardiologists. Although these times were comparatively short and have contributed to good results, further training to reduce the time is needed to improve the survival rate and to reduce complications.

Conclusion

A successful emergency CABG graft for unstable angina immediately after OHCPA is reported. Rapid and proper introduction of CPR with AED and a sufficient multidisciplinary approach are paramount to improving the survival rate of OHCPA patients.

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