Elsevier

Resuscitation

Volume 66, Issue 2, August 2005, Pages 175-181
Resuscitation

Reversible myocardial dysfunction after cardiopulmonary resuscitation

https://doi.org/10.1016/j.resuscitation.2005.01.012Get rights and content

Abstract

Objective:

Myocardial stunning frequently has been described in patients with an acute coronary syndrome. Recently, it has also been described in critically ill patients without ischaemic heart disease. It is possible that the most severe form of any syndrome, leading to cardio-respiratory arrest, may cause myocardial stunning. Myocardial stunning appears to have been demonstrated in experimental studies, though this phenomenon has not been sufficiently studied in human models. The aim of the present work has been to study and describe the possible development of myocardial dysfunction in patients resuscitated after cardio-respiratory arrest, in the absence of acute or previous coronary artery disease.

Design:

Descriptive study of a case series.

Setting:

The intensive care unit (ICU) of a provincial hospital.

Patients and participants:

The study period was from April 1999 to June 2001. All patients admitted to the ICU with critical, non-coronary artery pathology, with no past history of cardiac disease, and those who were resuscitated after cardio-respiratory arrest, were included in the study.

Measurements and results:

Transthoracic and transoesophageal echocardiography was used to assess left ventricular ejection fraction (LVEF) and disturbances of segmental contractility. This study was carried out within the first 24 h after admission, during the first week, during the second or third week, after 1 month, and between 3 and 6 months. Twenty-nine patients with a median age of 65 years (range 24–76) were included in the study. Twelve patients died. Twenty patients developed myocardial dysfunction; the initial LVEF in these patients was 0.28 (0.12–0.51), showing improvement over time in the patients who survived. All of these patients presented disturbances of segmental contractility which also became normal over time.

Conclusions:

After successful CPR, reversible myocardial dysfunction, consisting of systolic myocardial dysfunction and disturbances of segmental contractility, may occur.

Introduction

In 1975, Heyndrickx and colleagues were the first to describe the phenomenon of reversible post-ischaemic left ventricular dysfunction [1]. In 1982, Braunwald and Kloner [2] called this syndrome “myocardial stunning”, and since that time it has been extensively documented [3]. Myocardial stunning is defined as the reversible myocardial dysfunction (RMD), which persists after myocardial reperfusion, in the absence of an irreversible lesion, after the restoration of normal or near-normal coronary artery flow. Since its initial description, it has been widely reported and is recognised in patients with various forms of ischaemic heart disease. Phenomena of reversible myocardial dysfunction, consisting of systolic dysfunction, altered segmental contractility and electrocardiographic changes have been described in patients with critical, non-coronary pathology such as sepsis, trauma, stress, acute neurological pathology, asthma and pancreatitis [4].

It is easy to imagine that in a pathology that leads to cardio-respiratory arrest (CA), the phenomena of post-resuscitation myocardial dysfunction could occur. Furthermore, in the post-resuscitation syndrome described after cardiopulmonary resuscitation, with multi-organ failure, including renal insufficiency, acute pulmonary or cerebral lesions, myocardial dysfunction could easily exist within this context [5]. Experimentally, many studies have investigated this hypothesis, all demonstrating variable degrees of myocardial dysfunction after cardiopulmonary resuscitation (CPR) [6], [7], [8], [9]. However, there are very few studies using human models, most of these being case series in which no convincing results on the existence or absence of post-resuscitation myocardial dysfunction following CPR have been found [10], [11], [12], [13]. In view of these findings, the objective of the present study has been to investigate the existence of myocardial dysfunction in patients following successful resuscitation after cardio-respiratory arrest.

Section snippets

Material and methods

A descriptive study carried out on a series of cases gathered prospectively from the patients admitted to a nine-bed medico-surgical ICU in a provincial hospital during the study period running from April 1999 to June 2001.

The inclusion criteria for the study were respiratory or cardio-respiratory arrest with survival for at least 72 h. Any patient with a past history of cardiovascular pathology was excluded, except for those with, or having treatment for, arterial hypertension. Patients were

Results

During the study period, 113 CA occurred in, or were admitted to, the ICU. Of these patients, 29 suffered CA, which was not of cardiovascular origin nor caused by any condition known to induce myocardial dysfunction and, with no past history of heart disease, developed reversible myocardial dysfunction. The reasons for admission to the unit are listed in Table 1. The site of the cardio-respiratory arrest was: pre-hospital, 8 (27.6%) patients, intensive care unit, 9 (31.1%) patients, emergency

Discussion

Suspicion of myocardial dysfunction, based fundamentally on experimental animal models, has been confirmed by our results in more than half of the patients surviving respiratory or cardio-respiratory arrest [6], [7], [8], [9], [10], [13], [15], [16], [17]. Our findings not only show a fall in the LVEF, but also alterations in segmental contractility in the different cardiac chambers, findings which change over time. The myocardial dysfunction is therefore characterised by: (1) systolic

Study limitations

Despite the interesting results, which appear to demonstrate the onset of a post-resuscitation myocardial dysfunction in patients resuscitated after CA, there are limitations to this study which mean that these results must be viewed with caution. This is a descriptive study with no control group and the long-term effects of this reversible myocardial dysfunction could not be studied. Due to the great difficulty in studying all 16 segments in the left ventricle in patients on mechanical

Conclusions

In summary, in our setting, myocardial dysfunction developed in patients with no previous coronary artery pathology who were resuscitated after CA, and this dysfunction was reversible in the survivors. The syndrome presents with systolic myocardial dysfunction and disturbances of segmental contractility. Although it may be inferred that this will worsen the clinical course of the patient, it is not known to what extent it may modify the prognosis of the primary pathology.

Conflict of interest

The authors warrant that there is no conflict of interests neither any financial and personal relationships with other people or organisations.

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