Echocardiographic patterns of postresuscitation myocardial dysfunction

doi:10.1016/j.resuscitation.2018.01.019

Resuscitation

Volume 124, March 2018, Pages 90-95

https://doi.org/10.1016/j.resuscitation.2018.01.019 Get rights and content

Abstract

Background

Postresuscitation myocardial dysfunction (PRMD) can develop after successful resuscitation from cardiac arrest. However, echocardiographic patterns of PRMD remain unknown. This study aimed to investigate PRMD manifestations with serial echocardiography during the post-cardiac arrest period.

Methods

We enrolled non-traumatic out-of-hospital cardiac arrest patients older than 19 years who underwent successful cardiopulmonary resuscitation (CPR). We excluded patients with myocardial infarction or pre-existing cardiac disease, including heart failure or myocardial disease. Transthoracic echocardiography (TTE) was performed within 24 h, between 24 and 48 h, and between 72 and 96 h after restoration of spontaneous circulation (ROSC).

Results

Of 280 patients, 138 (93 men) were analysed. PRMD was observed in 45 patients (33%), including global dysfunction in 28 patients (20%), regional wall motion abnormalities (RWMA) in 10 (7%), and Takotsubo pattern in 7 (5%). There were no differences in clinical characteristics, laboratory findings, or hospital mortality according to PRMD pattern. Global left ventricular (LV) systolic function gradually improved with time and had recovered to normal by Day 3 in all patients except one with the Takotsubo pattern, which remained on follow-up echocardiography two weeks after ROSC.

Conclusions

PRMD occurs in about one-third of patients resuscitated from cardiac arrest. Echocardiographic patterns of post-cardiac arrest LV dysfunction include global hypokinesia, regional wall motion abnormalities, and Takotsubo pattern.

Introduction

Global ischaemia during cardiac arrest and resuscitation often produces post-cardiac arrest syndrome (PCAS), which is manifested by multiple organ dysfunction, including neurological dysfunction, postresuscitation myocardial dysfunction (PRMD), systemic ischaemic/reperfusion injury, and persistent precipitating pathology [1]. PCAS is associated with significant morbidity and mortality during the post-cardiac arrest period in patients with prolonged cardiac arrest that occurs outside a medical facility [[2], [3]]. PRMD is a phenomenon of myocardial dysfunction caused by the global ischaemia that occurs during cardiac arrest, which is very different from focal ischaemia. PRMD occurs after return of spontaneous circulation (ROSC) and disappears with recovery of ventricular function to the baseline level after 24–48 h without specific treatment [4]. The occurrence of PRMD is not a universal phenomenon following cardiac arrest. The incidence of PRMD has been reported to range from 34 to 75% according to echocardiographic or angiographic observations [[5], [6], [7], [8]]. The occurrence of PRMD is associated with low cardiac output from the reduced LV ejection fraction (EF) and hypotension that typically requires vasopressor support [7]. Therefore, it is important to evaluate myocardial function to maintain optimal haemodynamics in the early post-cardiac arrest phase.

Myocardial stunning from focal ischaemia is manifested by regional wall motion abnormality. However, myocardial stunning from global ischaemia, such as that which occurs in PRMD, can be manifested by various patterns. Manifestations of PRMD include global LV systolic dysfunction with reduced EF, LV diastolic dysfunction, or right ventricular dysfunction [[4], [9], [10]]. Among these, global LV systolic dysfunction is the most significant manifestation of PRMD. However, the detailed patterns of PRMD in human have not yet been investigated. In this study, we examined the manifestations of PRMD with serial echocardiographic observations during the post-cardiac arrest period in patients resuscitated from cardiac arrest with a non-cardiac aetiology.

Section snippets

Study design and setting

This was a prospective cohort study of cardiac arrest patients who were admitted to the emergency department (ED) of a tertiary university hospital (Wonju Severance Christian Hospital) between January 2009 and March 2016. The study protocol was approved by the Institutional Review Board of Wonju Severance Christian Hospital.

In the Wonju area, patients who experience out-of-hospital cardiac arrest (OHCA) are managed by emergency medical technicians (EMTs) who are dispatched from a fire

General characteristics

During the study period, 280 patients who regained spontaneous circulation following cardiac arrest underwent TTE in the ED. Among them, 142 patients were excluded from the analysis owing to a previous history of myocardial infarction (23 patients), acute myocardial infarction (21 patients), congestive heart failure (CHF) (12 patients), cardiomyopathy (12 dilated cardiomyopathies, 2 hypertrophic cardiomyopathies, 1 postpartum cardiomyopathy), aortic dissection (1 patient), atrial septal defect

Discussion

Our observations showed that the echocardiographic manifestations of PRMD in patients resuscitated from OHCA included global dysfunction, RWMA, and Takotsubo pattern. Global myocardial dysfunction (myocardial stunning) was the most frequent echocardiographic pattern of PRMD. PRMD developed in approximately one-third of the patients, and it was a reversible process that returned to normal global LV systolic function 72 h after ROSC.

Global myocardial dysfunction is a representative type of PRMD.

Conclusions

Echocardiographic patterns of PRMD presented as three different types: global dysfunction, regional wall motion abnormalities, and the Takotsubo pattern in a single-center cohort-based study.

Conflict of interest

All authors have no conflicts of interest to declare.

References (27)

K.B. Kern et al.
Myocardial dysfunction after resuscitation from cardiac arrest: an example of global myocardial stunning
J Am Coll Cardiol
(1996)
I. Laurent et al.
Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest
J Am Coll Cardiol
(2002)
M. Ruiz-Bailen et al.
Reversible myocardial dysfunction after cardiopulmonary resuscitation
Resuscitation
(2005)
R.M. Lang et al.
Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology
J Am Soc Echocardiogr
(2005)
R.T. Hurst et al.
3rd, Sengupta PP, Tajik AJ. Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology
JACC Cardiovasc Imaging
(2010)
K. Klouche et al.
Evolution of the stone heart after prolonged cardiac arrest
Chest
(2002)
J.M. Schoffstall et al.
Endogenous and exogenous plasma catecholamine levels in cardiac arrest in swine
Resuscitation
(1990)
B. Pinamonti et al.
Echocardiographic findings in myocarditis
Am J Cardiol
(1988)
S.W. Sharkey et al.
Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy
J Am Coll Cardiol
(2010)
R.W. Neumar et al.
Post-cardiac arrest syndrome: epidemiology, pathophysiology, treatment, and prognostication a consensus statement from the international liaison committee on resuscitation (American heart association, australian and New Zealand council on resuscitation, european resuscitation council, heart and stroke foundation of Canada, Inter American heart foundation, resuscitation council of asia, and the resuscitation council of southern africa); the american heart association emergency cardiovascular care committee; the council on cardiovascular surgery and anesthesia; the council on cardiopulmonary, perioperative, and critical care; the council on clinical cardiology; and the stroke council
Circulation
(2008)

S.P. Keenan et al.

Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are

Crit Care Med

(2007)

J.P. Nolan et al.

Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database

Anaesthesia

(2007)

J. Bro-Jeppesen et al.

Hemodynamics and vasopressor support during targeted temperature management at 33 degrees C Versus 36 degrees C after out-of-hospital cardiac arrest: a post hoc study of the target temperature management trial

Crit Care Med

(2015)

Cited by (53)

Contribution and therapeutic value of mitophagy in cerebral ischemia-reperfusion injury after cardiac arrest
2023, Biomedicine and Pharmacotherapy
Cardiopulmonary resuscitation and related life support technologies have improved substantially in recent years; however, mortality and disability rates from cardiac arrest (CA) remain high and are closely associated with the high incidence of cerebral ischemia-reperfusion injury (CIRI), which is explained by a “double-hit” model (i.e., resulting from both ischemia and reperfusion). Mitochondria are important power plants in the cell and participate in various biochemical processes, such as cell differentiation and signaling in eukaryotes. Various mitochondrial processes, including energy metabolism, calcium homeostasis, free radical production, and apoptosis, are involved in several important stages of the progression and development of CIRI. Mitophagy is a key mechanism of the endogenous removal of damaged mitochondria to maintain organelle function and is a critical target for CIRI treatment after CA. Mitophagy also plays an essential role in attenuating ischemia-reperfusion in other organs, particularly during post-cardiac arrest myocardial dysfunction. Regulation of mitophagy may influence necroptosis (a programmed cell death pathway), which is the main endpoint of organ ischemia-reperfusion injury. In this review, we summarize the main signaling pathways related to mitophagy and their associated regulatory proteins. New therapeutic methods and drugs targeting mitophagy in ischemia-reperfusion animal models are also discussed. In-depth studies of the mechanisms underlying the regulation of mitophagy will enhance our understanding of the damage and repair processes in CIRI after CA, thereby contributing to the development of new therapeutic strategies.
Harnessing the therapeutic potential of mesenchymal stem cell-derived exosomes in cardiac arrest: Current advances and future perspectives
2023, Biomedicine and Pharmacotherapy
Cardiac arrest (CA), characterized by sudden onset and high mortality rates, is one of the leading causes of death globally, with a survival rate of approximately 6–24%. Studies suggest that the restoration of spontaneous circulation (ROSC) hardly improved the mortality rate and prognosis of patients diagnosed with CA, largely due to ischemia-reperfusion injury.
Mesenchymal stem cells (MSCs) exhibit self-renewal and strong potential for multilineage differentiation. Their effects are largely mediated by extracellular vesicles (EVs). Exosomes are the most extensively studied subgroup of EVs. EVs mainly mediate intercellular communication by transferring vesicular proteins, lipids, nucleic acids, and other substances to regulate multiple processes, such as cytokine production, cell proliferation, apoptosis, and metabolism. Thus, exosomes exhibit significant potential for therapeutic application in wound repair, tissue reconstruction, inflammatory reaction, and ischemic diseases.
Based on similar pathological mechanisms underlying post-cardiac arrest syndrome involving various tissues and organs in many diseases, the review summarizes the therapeutic effects of MSC-derived exosomes and explores the prospects for their application in the treatment of CA.
Cardiac arrest centres: What do they add?
2023, Resuscitation
There are wide regional variations in outcome following resuscitated out of hospital cardiac arrest. These geographical differences appear to be due to hospital infrastructure and provider experience rather than baseline characteristics. It is proposed that post-arrest care be delivered in a systematic fashion by concentrating services in Cardiac Arrest Centres, with greater provider experience, 24-hour access to diagnostics, and specialist treatment to minimise the impact of ischaemia–reperfusion injury and treat the causative pathology. These cardiac arrest centres would provide access to targeted critical care, acute cardiac care, radiology services and appropriate neuro-prognostication. However implementation of cardiac arrest networks with specialist receiving hospitals is complex and requires alignment of pre-hospital care services with those delivered in hospital. Furthermore there are no randomised trial data currently supporting pre-hospital delivery to a Cardiac Arrest Centre and definitions are heterogeneous. In this review article, we propose a universal definition of a Cardiac Arrest Centre and review the current observational data evidence and the potential impact of the ARREST trial.
Post-Cardiac Arrest Care
2023, Emergency Medicine Clinics of North America
Scoping review of echocardiographic parameters associated with diagnosis and prognosis after resuscitated sudden cardiac arrest
2023, Resuscitation
Current international guidelines recommend early echocardiography after resuscitated sudden death despite limited data. Our aim was to analyze published data on early post-resuscitation echocardiography to identify cardiac causes of sudden death and prognostic implications.
We reviewed MEDLINE, EMBASE, and CENTRAL databases to December 2021 for echocardiographic studies of adult patients after resuscitation from non-traumatic sudden death. Studies were included if echocardiography was performed <48 hours after resuscitation and reported (1) diagnostic accuracy to detect cardiac etiologies of sudden death or (2) prognostic outcomes. Diagnostic endpoints were associations of regional wall motion abnormalities (RWMA), ventricular function, and structural abnormalities with cardiac etiologies of arrest. Prognostic endpoints were associations of echocardiographic findings with survival to hospital discharge and favorable neurological outcome.
Of 2877 articles screened, 16 (0.6%) studies met inclusion criteria, comprising 2035 patients. Two of six studies formally reported diagnostic accuracy for echocardiography identifying cardiac etiology of arrest; RWMA (in 5 of 6 studies) were associated with presumed cardiac ischemia in 17–89% of cases. Among 12 prognostic studies, there was no association of reduced left ventricular ejection fraction with hospital survival (v10) or favorable neurologic status (n = 5). Echocardiographic high mitral E/e′ ratio (n = 1) and right ventricular systolic dysfunction (n = 2) were associated with poor survival.
This scoping review highlights the limited data on early echocardiography in providing etiology of arrest and prognostic information after resuscitated sudden death. Further research is needed to refine the clinical application of early echocardiographic findings in post arrest care.
Carbon monoxide-releasing molecule-2 ameliorates postresuscitation myocardial dysfunction in rat via mitochondrial-mediated apoptosis pathway and the regulation of mitochondrial dynamics
2022, European Journal of Pharmacology
Citation Excerpt :
PRMD is characterized by systolic and diastolic dysfunction, and the underlying mechanism is associated with myocardial stunning and myocardial tissue damage (Yang et al., 2020). The incidence of PRMD following CA ranges from 34% to 75%, depending on the observation method (echocardiography or angiography) (Bro-Jeppesen et al., 2015; Cha et al., 2018); and, despite extensive research, there is still no effective treatment. Mitochondria play an important role in maintaining cellular homeostasis by generating energy and by regulating key signaling pathways involved in cell survival (Tahrir et al., 2019).
Mitochondrial dysfunction plays a significant role in the development of postresuscitation myocardial dysfunction (PRMD). Endogenous carbon monoxide (CO) has obvious protective effects on cardiomyocytes and that mitochondria are considered to be the main targets of CO action. This study aimed to investigate whether exogenous CO (carbon monoxide releasing molecule 2, CORM-2) could protect against PRMD, and improve cardiac function in rats via the mitochondria pathway. Forty male Sprague-Dawley rats were randomly divided into five groups: sham group, model cardiopulmonary resuscitation (CPR) group, CORM-2 treatment group, inactivated CORM-2 group, and DMSO (Dimethyl sulfoxide, CORM-2 vehicle) group. Excluding the sham group, all groups underwent CPR 4 min after cardiac arrest (CA), animals in every group underwent surgery for catheter insertion before the CA-CPR. In the treatment groups, CORM-2 and inactivated CORM-2 (both 4 mg/kg, dissolved in 2% dimethyl sulfoxide and diluted in normal saline) were intraperitoneally injected 12 h before CPR was started. In the sham, model CPR, and vehicle groups, animals were administered normal saline or vehicle as appropriate. The results demonstrated that the mitochondrial ultrastructure abnormalities in CORM-2 group was less severe than CPR rats. CORM-2 alleviated myocardial contractile and diastolic dysfunction after CPR, decreased caspase-3 and caspase-9 expression in myocardial tissues, and meanwhile suppressed cytochrome c release from mitochondria. Furthermore, CORM-2 lessen the production of reactive oxygen species (ROS) and increased myocardial mitochondrial respiratory complex IV enzyme activity after CPR. Dynamin-related protein 1（Drp1) was significantly less expressed in CORM-2 group with high expression of mitofusion-2 (Mfn2), suggesting that CORM-2 can promote mitochondrial fusion and reduce mitochondrial fission. Collectively, we provide the evidence that CORM-2 effectively relieved myocardial injury after CPR in rats, protected myocardial mitochondria, and preserved cardiac function after resuscitation. The proposed mechanisms of action were improved mitochondrial respiratory function, maintained mitochondrial dynamics balance, and suppressed the mitochondrial-mediated apoptosis.

View all citing articles on Scopus

View full text

Clinical paperEchocardiographic patterns of postresuscitation myocardial dysfunction

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study design and setting

General characteristics

Discussion

Conclusions

Conflict of interest

J Am Coll Cardiol

J Am Coll Cardiol

Resuscitation

J Am Soc Echocardiogr

JACC Cardiovasc Imaging

Chest

Resuscitation

Am J Cardiol

J Am Coll Cardiol

Circulation

Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are

Crit Care Med

Outcome following admission to UK intensive care units after cardiac arrest: a secondary analysis of the ICNARC Case Mix Programme Database

Anaesthesia

Hemodynamics and vasopressor support during targeted temperature management at 33 degrees C Versus 36 degrees C after out-of-hospital cardiac arrest: a post hoc study of the target temperature management trial

Crit Care Med

Clinical paper
Echocardiographic patterns of postresuscitation myocardial dysfunction

Hemodynamics and vasopressor support during targeted temperature management at 33 degrees C Versus 36 degrees C after out-of-hospital cardiac arrest: a post hoc study of the target temperature management trial