Real-Time Ventricular Fibrillation Amplitude-Spectral Area Analysis to Guide Timing of Shock Delivery Improves Defibrillation Efficacy During Cardiopulmonary Resuscitation in Swine
Salvatore Aiello, Michelle Perez, Chad Cogan, Alvin Baetiong, Steven A Miller, Jeejabai Radhakrishnan, Christopher L Kaufman, Raúl J Gazmuri, Salvatore Aiello, Michelle Perez, Chad Cogan, Alvin Baetiong, Steven A Miller, Jeejabai Radhakrishnan, Christopher L Kaufman, Raúl J Gazmuri
Abstract
Background: The ventricular fibrillation amplitude spectral area (AMSA) predicts whether an electrical shock could terminate ventricular fibrillation and prompt return of spontaneous circulation. We hypothesized that AMSA can guide more precise timing for effective shock delivery during cardiopulmonary resuscitation.
Methods and results: Three shock delivery protocols were compared in 12 pigs each after electrically induced ventricular fibrillation, with the duration of untreated ventricular fibrillation evenly stratified into 6, 9, and 12 minutes: AMSA-Driven (AD), guided by an AMSA algorithm; Guidelines-Driven (GD), according to cardiopulmonary resuscitation guidelines; and Guidelines-Driven/AMSA-Enabled (GDAE), as per GD but allowing earlier shocks upon exceeding an AMSA threshold. Shocks delivered using the AD, GD, and GDAE protocols were 21, 40, and 62, with GDAE delivering only 2 AMSA-enabled shocks. The corresponding 240-minute survival was 8/12, 6/12, and 2/12 (log-rank test, P=0.035) with AD exceeding GDAE (P=0.026). The time to first shock (seconds) was (median [Q1-Q3]) 272 (161-356), 124 (124-125), and 125 (124-125) (P<0.001) with AD exceeding GD and GDAE (P<0.05); the average coronary perfusion pressure before first shock (mm Hg) was 16 (9-30), 10 (6-12), and 3 (-1 to 9) (P=0.002) with AD exceeding GDAE (P<0.05); and AMSA preceding the first shock (mV·Hz, mean±SD) was 13.3±2.2, 9.0±1.6, and 8.6±2.0 (P<0.001) with AD exceeding GD and GDAE (P<0.001). The AD protocol delivered fewer unsuccessful shocks (ie, less shock burden) yielding less postresuscitation myocardial dysfunction and higher 240-minute survival.
Conclusions: The AD protocol improved the time precision for shock delivery, resulting in less shock burden and less postresuscitation myocardial dysfunction, potentially improving survival compared with time-fixed, guidelines-driven, shock delivery protocols.
Keywords: amplitude spectral area; animal model; defibrillation; resuscitation; sudden cardiac arrest; ventricular fibrillation; ventricular fibrillation waveform analysis; waveform analysis.
© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
Figures
References
- Travers AH, Perkins GD, Berg RA, Castren M, Considine J, Escalante R, Gazmuri RJ, Koster RW, Lim SH, Nation KJ, Olasveengen TM, Sakamoto T, Sayre MR, Sierra A, Smyth MA, Stanton D, Vaillancourt C. Part 3: adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132:S51–S83.
- Valenzuela TD, Spaite DW, Meislin HW, Clark LL, Wright AL, Ewy GA. Emergency vehicle intervals versus collapse‐to‐CPR and collapse‐to‐defibrillation intervals: monitoring emergency medical services system performance in sudden cardiac arrest. Ann Emerg Med. 1993;22:1678–1683.
- Ekstrom L, Herlitz J, Wennerblom B, Axelsson A, Bang A, Holmberg S. Survival after cardiac arrest outside hospital over a 12‐year period in Gothenburg. Resuscitation. 1994;27:181–187.
- Spearpoint KG, McLean CP, Zideman DA. Early defibrillation and the chain of survival in ‘in‐hospital’ adult cardiac arrest; minutes count. Resuscitation. 2000;44:165–169.
- Valenzuela TD, Roe DJ, Nichol G, Clark LL, Spaite DW, Hardman RG. Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. N Engl J Med. 2000;343:1206–1209.
- Gazmuri RJ, Weil MH, von Planta M, Gazmuri RR, Shah DM, Rackow EC. Cardiac resuscitation by extracorporeal circulation after failure of conventional CPR. J Lab Clin Med. 1991;118:65–73.
- Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out‐of‐hospital ventricular fibrillation. JAMA. 1999;281:1182–1188.
- Menegazzi JJ, Wang HE, Lightfoot CB, Fertig KC, Chengelis NL, Sherman LD, Callaway CW. Immediate defibrillation versus interventions first in a swine model of prolonged ventricular fibrillation. Resuscitation. 2003;59:261–270.
- Eftestol T, Wik L, Sunde K, Steen PA. Effects of cardiopulmonary resuscitation on predictors of ventricular fibrillation defibrillation success during out‐of‐hospital cardiac arrest. Circulation. 2004;110:10–15.
- Meier P, Baker P, Jost D, Jacobs I, Henzi B, Knapp G, Sasson C. Chest compressions before defibrillation for out‐of‐hospital cardiac arrest: a meta‐analysis of randomized controlled clinical trials. BMC Med. 2010;8:52.
- Niemann JT, Cairns CB, Sharma J, Lewis RJ. Treatment of prolonged ventricular fibrillation. Immediate countershock versus high‐dose epinephrine and CPR preceding countershock. Circulation. 1992;85:281–287.
- Tang W, Weil MH, Sun S, Yamaguchi H, Povoas HP, Pernat AM, Bisera J. The effects of biphasic and conventional monophasic defibrillation on postresuscitation myocardial function. J Am Coll Cardiol. 1999;34:815–822.
- Leng CT, Paradis NA, Calkins H, Berger RD, Lardo AC, Rent KC, Halperin HR. Resuscitation after prolonged ventricular fibrillation with use of monophasic and biphasic waveform pulses for external defibrillation. Circulation. 2000;101:2968–2974.
- Marn‐Pernat A, Weil MH, Tang W, Pernat A, Bisera J. Optimizing timing of ventricular defibrillation. Crit Care Med. 2001;29:2360–2365.
- Povoas HP, Weil MH, Tang W, Bisera J, Klouche K, Barbatsis A. Predicting the success of defibrillation by electrocardiographic analysis. Resuscitation. 2002;53:77–82.
- Indik JH, Allen D, Shanmugasundaram M, Zuercher M, Hilwig RW, Berg RA, Kern KB. Predictors of resuscitation in a swine model of ischemic and nonischemic ventricular fibrillation cardiac arrest: superiority of amplitude spectral area and slope to predict a return of spontaneous circulation when resuscitation efforts are prolonged. Crit Care Med. 2010;38:2352–2357.
- Firoozabadi R, Nakagawa M, Helfenbein ED, Babaeizadeh S. Predicting defibrillation success in sudden cardiac arrest patients. J Electrocardiol. 2013;46:473–479.
- Indik JH, Conover Z, McGovern M, Silver AE, Spaite DW, Bobrow BJ, Kern KB. Association of amplitude spectral area of the ventricular fibrillation waveform with survival of out‐of‐hospital ventricular fibrillation cardiac arrest. J Am Coll Cardiol. 2014;64:1362–1369.
- Coult J, Sherman L, Kwok H, Blackwood J, Kudenchuk PJ, Rea TD. Short ECG segments predict defibrillation outcome using quantitative waveform measures. Resuscitation. 2016;109:16–20.
- Ristagno G, Mauri T, Cesana G, Li Y, Finzi A, Fumagalli F, Rossi G, Grieco N, Migliori M, Andreassi A, Latini R, Fornari C, Pesenti A. Amplitude spectrum area to guide defibrillation: a validation on 1617 patients with ventricular fibrillation. Circulation. 2015;131:478–487.
- Noc M, Weil MH, Gazmuri RJ, Sun S, Bisera J, Tang W. Ventricular fibrillation voltage as a monitor of the effectiveness of cardiopulmonary resuscitation. J Lab Clin Med. 1994;124:421–426.
- Salcido DD, Menegazzi JJ, Suffoletto BP, Logue ES, Sherman LD. Association of intramyocardial high energy phosphate concentrations with quantitative measures of the ventricular fibrillation electrocardiogram waveform. Resuscitation. 2009;80:946–950.
- Li Y, Ristagno G, Bisera J, Tang W, Deng Q, Weil MH. Electrocardiogram waveforms for monitoring effectiveness of chest compression during cardiopulmonary resuscitation. Crit Care Med. 2008;36:211–215.
- Reynolds JC, Salcido DD, Menegazzi JJ. Correlation between coronary perfusion pressure and quantitative ECG waveform measures during resuscitation of prolonged ventricular fibrillation. Resuscitation. 2012;83:1497–1502.
- Kolarova J, Ayoub IM, Yi Z, Gazmuri RJ. Optimal timing for electrical defibrillation after prolonged untreated ventricular fibrillation. Crit Care Med. 2003;31:2022–2028.
- Sun S, Weng Y, Wu X, Tang K, Ye S, Chen W, Weil MH, Tang W. Optimizing the duration of CPR prior to defibrillation improves the outcome of CPR in a rat model of prolonged cardiac arrest. Resuscitation. 2011;82(suppl 2):S3–S7.
- Salcido DD, Kim YM, Sherman LD, Housler G, Teng X, Logue ES, Menegazzi JJ. Quantitative waveform measures of the electrocardiogram as continuous physiologic feedback during resuscitation with cardiopulmonary bypass. Resuscitation. 2012;83:505–510.
- Gazmuri RJ, Kaufman CL, Baetiong A, Radhakrishnan J. Ventricular fibrillation waveform changes during controlled coronary perfusion using extracorporeal circulation in a swine model. PLoS One. 2016;11:e0161166.
- Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S414–S435.
- Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O'Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW. Part 7: adult advanced cardiovascular life support: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S444–S464.
- Kelley KW, Curtis SE, Marzan GT, Karara HM, Anderson CR. Body surface area of female swine. J Anim Sci. 1973;36:927–930.
- Faybik P, Lahner D, Schramm W. A longstanding error by Ernest Henry Starling (author reply 1584‐5). Resuscitation. 2010;81:1584–1585.
- Gazmuri RJ, Whitehouse K, Wittinghill K, Baetiong A, Radhakrishnan J. Vasopressin infusion with small‐volume fluid resuscitation during hemorrhagic shock promotes hemodynamic stability and survival in swine. PLoS One. 2015;10:e0130134.
- Gazmuri RJ, Whitehouse K, Whittinghill K, Baetiong A, Shah K, Radhakrishnan J. Early and sustained vasopressin infusion augments the hemodynamic efficacy of restrictive fluid resuscitation and improves survival in a liver laceration model of hemorrhagic shock. J Trauma Acute Care Surg. 2017;82:317–327.
- Wang Z, Goonewardene LA. The use of MIXED models in the analysis of animal experiments with repeated measures data. Can J Anim Sci. 2004;84:1–11.
- Fitzmaurice GM, Ravichandran C. A primer in longitudinal data analysis. Circulation. 2008;118:2005–2010.
- Ayoub IM, Kolarova J, Gazmuri RJ. Cariporide given during resuscitation promotes return of electrically stable and mechanically competent cardiac activity. Resuscitation. 2010;81:106–110.
- Borovnik‐Lesjak V, Whitehouse K, Baetiong A, Artin B, Radhakrishnan J, Gazmuri RJ. High‐dose erythropoietin during cardiac resuscitation lessens postresuscitation myocardial stunning in swine. Transl Res. 2013;162:110–121.
- Freese JP, Jorgenson DB, Liu PY, Innes J, Matallana L, Nammi K, Donohoe RT, Whitbread M, Silverman RA, Prezant DJ. Waveform analysis‐guided treatment versus a standard shock‐first protocol for the treatment of out‐of‐hospital cardiac arrest presenting in ventricular fibrillation: results of an international randomized, controlled trial. Circulation. 2013;128:995–1002.
- Cheng Y, Mowrey KA, Nikolski V, Tchou PJ, Efimov IR. Mechanisms of shock‐induced arrhythmogenesis during acute global ischemia. Am J Physiol Heart Circ Physiol. 2002;282:H2141–H2151.
- Nikolski VP, Efimov IR. Electroporation of the heart. Europace. 2005;7(suppl 2):146–154.
- Guensch DP, Yu J, Nadeshalingam G, Fischer K, Shearer J, Friedrich MG. Evidence for acute myocardial and skeletal muscle injury after serial transthoracic shocks in healthy swine. PLoS One. 2016;11:e0162245.
- Gazmuri RJ, Deshmukh S, Shah PR. Myocardial effects of repeated electrical defibrillations in the isolated fibrillating rat heart. Crit Care Med. 2000;28:2690–2696.
- Kato R, Foex P. Myocardial protection by anesthetic agents against ischemia‐reperfusion injury: an update for anesthesiologists. Can J Anaesth. 2002;49:777–791.
- Xu P, Wang J, Kodavatiganti R, Zeng Y, Kass IS. Activation of protein kinase C contributes to the isoflurane‐induced improvement of functional and metabolic recovery in isolated ischemic rat hearts. Anesth Analg. 2004;99:993–1000.
- Chiari PC, Bienengraeber MW, Pagel PS, Krolikowski JG, Kersten JR, Warltier DC. Isoflurane protects against myocardial infarction during early reperfusion by activation of phosphatidylinositol‐3‐kinase signal transduction: evidence for anesthetic‐induced postconditioning in rabbits. Anesthesiology. 2005;102:102–109.
Source: PubMed