Reversible myocardial dysfunction after cardiopulmonary resuscitation☆
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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A Spanish translated version of the Abstract and Keywords of this article appears as Appendix at 10.1016/j.resuscitation.2005.01.012.