Department of Anesthesiology, Medical Faculty, RWTH University Hospital Aachen, RWTH Aachen University, 52074, Aachen, Germany.
Abiomed Europe GmbH, Aachen, Germany.
BMC Cardiovasc Disord. 2021 Apr 17;21(1):189. doi: 10.1186/s12872-021-01992-w.
Resuscitation using a percutaneous mechanical circulatory support device (iCPR) improves survival after cardiac arrest (CA). We hypothesized that the addition of inhaled nitric oxide (iNO) during iCPR might prove synergistic, leading to improved myocardial performance due to lowering of right ventricular (RV) afterload, left ventricular (LV) preload, and myocardial energetics. This study aimed to characterize the changes in LV and RV function and global myocardial work indices (GWI) following iCPR, both with and without iNO, using 2-D transesophageal echocardiography (TEE) and GWI evaluation as a novel non-invasive measurement.
In 10 pigs, iCPR was initiated following electrically-induced CA and 10 min of untreated ventricular fibrillation (VF). Pigs were randomized to either 20 ppm (20 ppm, n = 5) or 0 ppm (0 ppm, n = 5) of iNO in addition to therapeutic hypothermia for 5 h following ROSC. All animals received TEE at five pre-specified time-points and invasive hemodynamic monitoring.
LV end-diastolic volume (LVEDV) increased significantly in both groups following CA. iCPR alone led to significant LV unloading at 5 h post-ROSC with LVEDV values reaching baseline values in both groups (20 ppm: 68.2 ± 2.7 vs. 70.8 ± 6.1 mL, p = 0.486; 0 ppm: 70.8 ± 1.3 vs. 72.3 ± 4.2 mL, p = 0.813, respectively). LV global longitudinal strain (GLS) increased in both groups following CA. LV-GLS recovered significantly better in the 20 ppm group at 5 h post-ROSC (20 ppm: - 18 ± 3% vs. 0 ppm: - 13 ± 2%, p = 0.025). LV-GWI decreased in both groups after CA with no difference between the groups. Within 0 ppm group, LV-GWI decreased significantly at 5 h post-ROSC compared to baseline (1,125 ± 214 vs. 1,835 ± 305 mmHg%, p = 0.011). RV-GWI was higher in the 20 ppm group at 3 h and 5 h post-ROSC (20 ppm: 189 ± 43 vs. 0 ppm: 108 ± 22 mmHg%, p = 0.049 and 20 ppm: 261 ± 54 vs. 0 ppm: 152 ± 42 mmHg%, p = 0.041). The blood flow calculated by the Impella controller following iCPR initiation correlated well with the pulsed-wave Doppler (PWD) derived pulmonary flow (PWD vs. controller: 1.8 ± 0.2 vs. 1.9 ± 0.2L/min, r = 0.85, p = 0.012).
iCPR after CA provided sufficient unloading and preservation of the LV systolic function by improving LV-GWI recovery. The addition of iNO to iCPR enabled better preservation of the RV-function as determined by better RV-GWI. Additionally, Impella-derived flow provided an accurate measure of total flow during iCPR.
使用经皮机械循环支持设备（iCPR）进行复苏可提高心搏骤停（CA）后的生存率。我们假设，在 iCPR 期间添加吸入性一氧化氮（iNO）可能会产生协同作用，通过降低右心室（RV）后负荷、左心室（LV）前负荷和心肌能量代谢，从而改善心肌性能。本研究旨在使用二维经食管超声心动图（TEE）和 GWI 评估，通过测量左心室（LV）和右心室（RV）功能以及整体心肌做功指数（GWI），来描述 iCPR 后 LV 和 RV 功能以及整体心肌做功指数（GWI）的变化，iNO 的使用可导致 LV 和 RV 功能的变化，而 GWI 则是一种新的非侵入性测量方法。
在 10 头猪中，在电诱导 CA 后和未经治疗的心室颤动（VF）持续 10 分钟后开始 iCPR。将猪随机分为两组：20ppm（20ppm，n=5）或 0ppm（0ppm，n=5），除了在 ROSC 后 5 小时内接受治疗性低温外，还添加了 iNO。所有动物在五个预设时间点接受 TEE 检查和有创血流动力学监测。
CA 后两组 LV 舒张末期容积（LVEDV）均显著增加。单独的 iCPR 在 ROSC 后 5 小时内导致 LV 明显卸载，两组 LVEDV 值均达到基线值（20ppm：68.2±2.7 vs. 70.8±6.1 mL，p=0.486；0ppm：70.8±1.3 vs. 72.3±4.2 mL，p=0.813）。CA 后两组 LV 整体纵向应变（GLS）均增加。在 ROSC 后 5 小时，20ppm 组的 LV-GLS 恢复明显更好（20ppm：-18±3% vs. 0ppm：-13±2%，p=0.025）。CA 后两组 LV-GWI 均降低，两组之间无差异。在 0ppm 组中，与基线相比，LV-GWI 在 ROSC 后 5 小时显著降低（1,125±214 vs. 1,835±305 mmHg%，p=0.011）。在 ROSC 后 3 小时和 5 小时，20ppm 组的 RV-GWI 更高（20ppm：189±43 vs. 0ppm：108±22 mmHg%，p=0.049 和 20ppm：261±54 vs. 0ppm：152±42 mmHg%，p=0.041）。Impella 控制器在 iCPR 启动后计算的血流量与脉冲波多普勒（PWD）衍生的肺血流量高度相关（PWD 与控制器：1.8±0.2 vs. 1.9±0.2 L/min，r=0.85，p=0.012）。
CA 后的 iCPR 通过改善 LV-GWI 恢复，为 LV 提供了足够的卸载和收缩功能的保护。在 iCPR 中添加 iNO 可更好地保护 RV 功能，这可通过更好的 RV-GWI 来确定。此外，Impella 衍生的流量可提供 iCPR 期间总流量的准确测量。
