Kimio Kikushima

Cardiopulmonary cerebral resuscitation using emergency cardiopulmonary bypass, coronary reperfusion therapy and mild hypothermia in patients with cardiac arrest outside the hospital

OBJECTIVES The purpose of this study was to evaluate the efficacy of an alternative cardiopulmonary cerebral resuscitation (CPCR) using emergency cardiopulmonary bypass (CPB), coronary reperfusion therapy and mild hypothermia. BACKGROUND Good recovery of patients with out-of-hospital cardiac arrest is still inadequate. An alternative therapeutic method for patients who do not respond to conventional CPCR is required. METHODS A prospective preliminary study was performed in 50 patients with out-of-hospital cardiac arrest meeting the inclusion criteria. Patients were treated with standard CPCR and, if there was no response, by emergency CPB plus intra-aortic balloon pumping. Immediate coronary angiography for coronary reperfusion therapy was performed in patients with suspected acute coronary syndrome. Subsequently, in patients with systolic blood pressure above 90 mm Hg and Glasgow coma scale score of 3 to 5, mild hypothermia (34 C for at least two days) was induced by coil cooling. Neurologic outcome was assessed by cerebral performance categories at hospital discharge. RESULTS Thirty-six of the 50 patients were treated with emergency CPB, and 30 of 39 patients who underwent angiography suffered acute coronary artery occlusion. Return of spontaneous circulation and successful coronary reperfusion were achieved in 92% and 87%, respectively. Mild hypothermia could be induced in 23 patients, and 12 (52%) of them showed good recovery. Factors related to a good recovery were cardiac index in hypothermia and the presence of serious complications with hypothermia or CPB. CONCLUSIONS The alternative CPCR demonstrated an improvement in the incidence of good recovery. Based upon these findings, randomized studies of this hypothermia are needed.

Relationship between the hemoglobin level at hospital arrival and post-cardiac arrest neurologic outcome

BACKGROUND The hemoglobin (Hb) level is an essential determinant of oxygen delivery. The restoration of blood perfusion to vital organs and the capacity for oxygen delivery may be associated with ischemia and reperfusion injuries during cardiac arrest and after cardiac arrest. However, whether the Hb level is associated with neurologic outcome in post-cardiac arrest patients remains unclear. METHODS Emergency medical service information and clinical demographics were compiled for witnessed out-of-hospital cardiac arrest patients with coma after the restoration of spontaneous circulation. The study end point was defined as a favorable neurologic outcome at 28 days. We evaluated the relationship between the Hb level at the time of hospital arrival and the neurologic outcome using univariate analyses and a multivariate logistic regression analysis. RESULTS There were 137 witnessed cardiac arrest patients: 49 (35.7%) survived and 34 (24.8%) achieved a favorable neurologic outcome. Univariate analyses showed that the favorable outcome group was characterized as having a higher Hb level, a younger age, a higher percentage of male patients, and ventricular fibrillation as the initial cardiac rhythm. In a multivariate analysis adjusting for potential confounding factors, the Hb level at the time of hospital arrival (odds ratio, 1.26; 95% confidence interval, 1.00-1.58) was an independent predictor of a favorable neurologic outcome. CONCLUSION A higher Hb level at the time of hospital arrival was associated with a favorable short-term neurologic outcome among post-cardiac arrest patients with a presumed cardiac etiology.

Diffuse pulmonary hemorrhage as a fatal complication of Schönlein-Henoch purpura

We report a case of a 69‐year‐old man with Schönlein–Henoch purpura who developed diffuse pulmonary hemorrhage. He complained of dyspnea and hemoptysis while he was treated with steroids for gastroenteropathy associated with Schönlein–Henoch purpura. The drop in his hemoglobin levels and diffuse ground‐glass opacity at all levels of the lung fields on chest computed tomography were a significant clue to diagnosis. Despite pulse therapy, no clinical improvement of the lung was achieved, and he died on the 36th day after the admission. Although the combination of the corticosteroid and immunosuppressive agents is normally recommended, diffuse pulmonary hemorrhage could become a fatal complication in elderly Schönlein–Henoch patients.

Changes of cerebral oxygen metabolism and hemodynamics during ECPR with hypothermia measured by near-infrared spectroscopy: a pilot study.

BACKGROUND The 2010 CPR Guidelines recommend that extracorporeal cardiopulmonary resuscitation (ECPR) using an emergency cardiopulmonary bypass (CPB) should be considered for patients with cardiac arrest. However, it is not yet clear whether this therapy can improve cerebral circulation and oxygenation in these patients. To clarify this issue, we evaluated changes of cerebral blood oxygenation (CBO) during ECPR using near-infrared spectroscopy (NIRS). METHODS We employed NIRS to measure CBO in the bilateral frontal lobe in patients transported to the emergency room (ER) after out-of-hospital cardiac arrest between November 2009 and June 2011. RESULTS Fifteen patients met the above criteria. The tissue oxygenation index (TOI) on arrival at the ER was 36.5 %. This increased to 67.8 % during ECPR (P < 0.001). The one patient whose TOI subsequently decreased had a favorable neurological outcome. CONCLUSION Increase of TOI during ECPR might reflect an improvement in cerebral blood flow, while decrease of TOI after ECPR might reflect oxygen utilization by the brain tissue as a result of neuronal cell survival. NIRS may be useful for monitoring cerebral hemodynamics and oxygen metabolism during CPR.

Efficacy of Calcium Channel Blocker in the Secondary Prevention of Myocardial Infarction

BACKGROUND Calcium channel blockers (CCBs) may have a positive influence on the long-term prognosis of Japanese patients with ischemic heart disease. METHODS AND RESULTS The effect of nifedipine-retard (NR) (n=202) compared with that of non-CCB treatment (n=92) on the secondary prevention of myocardial infarction (MI) was retrospectively investigated in patients who had survived acute MI between 1987 and 1996. The primary endpoint was the occurrence of cardiac death or non-fatal MI. The median follow-up was 6.3+/-2.4 years. The incidence of cardiac events was 8.9% in the NR group and 14.1% in the non-CCBs group (p=0.14, odds ratio (OR): 0.584, 95% confidence interval (CI): 0.286-1,193). However, subanalysis revealed that NR significantly reduced the incidence of cardiac events in patients aged less than 55 years (4.2 vs 18.2%, p=0.016, OR: 0.180, 95%CI: 0.045-0.721) and those who did not smoke (8.6 vs 16.4%, p=0.048, OR: 0.462, 95%CI: 0.203-0.999). CONCLUSION Although this was a retrospective analysis, it showed that NR did not cause an increase in the incidence of cardiac events in post-MI patients; it even prevented cardiac events, especially in those who were less than 55 years of age and in non-smokers, suggesting the potential usefulness of CCBs in the secondary prevention of MI in Japan.

Takotsubo cardiomyopathy in two patients with microvascular angina

We present two cases in which takotsubo cardiomyopathy (TC) developed immediately after a diagnosis of microvascular angina had been established. One patient who had been diagnosed as having endothelium-dependent microvascular angina (microvascular spasm) developed TC three weeks after the initial admission. The other patient was diagnosed as having endothelium-independent microvascular angina (decreased coronary flow reserve) and subsequently developed TC after the discontinuation of nicorandil treatment. These cases may provide insight into the possible mechanisms underlying the pathophysiological findings of TC. <Learning objective: Impaired coronary microcirculation has been recently reported in many cases during the acute phase of takotsubo cardiomyopathy. However, the exact mechanism responsible for the coronary microvascular dysfunction associated with this entity remains unclear. This report highlights the importance of microvascular angina, which may play a role in the development of this cardiomyopathy.>.

Resuscitative Hypothermia in Comatose Survivors After Prolonged Cardiopulmonary Resuscitation and B-type Natriuretic Peptide for the Advanced Challenge

Although two randomized studies of mild hypothermia after out-of-hospital cardiac arrest showed a neurologic benefit with a low risk of complications, few studies are available for patients with return of spontaneous circulation (ROSC) after prolonged cardiopulmonary resuscitation (CPR). A prospective study was performed on 109 comatose survivors treated with mild hypothermia (34°C for 2 days or more) by extracorporeal cooling methods whose ROSC could be achieved by standard and/or invasive CPR. We then compared our study with the European study (n = 137) and the Australian study (n = 43), and investigated the relationship between the B-type natriuretic peptide (BNP) on arrival at the emergency room and neurologic outcomes. Criteria for entry into mild hypothermia were generally similar in the three studies. Although the time interval from collapse to ROSC took about twice as much time as that in the two randomized studies, no significant difference was observed among the three studies regarding a favorable neurologic outcome (41.3% vs 55% vs 49%, P = 0.85). In a multiple logistic-regression analysis, the time interval from ROSC to attainment of 34°C was one of the independent predictors for neurologic outcomes. The BNP level in patients with a favorable neurologic outcome was significantly lower than in those with an unfavorable neurologic outcome (30 vs 243pg/ml, P < 0.001). Mild hypothermia (34°C for 2 days or more) by extracorporeal cooling methods may have improved the chances of favorable neurologic recovery in comatose survivors after prolonged CPR, and the BNP levels were related to the neurologic outcomes.

Fatal pulmonary renal syndrome and treatment in adults with Schönlein–Henoch purpura: Reply

Dear Editor, We reported a 69-year-old man with Schönlein– Henoch purpura (SHP) who developed diffuse pulmonary hemorrhage as a fatal complication. Although the pulmonary involvement in SHP with subclinical symptoms is not rare, severe pulmonary hemorrhage is unusual. The pathogenesis of the alveolar hemorrhage in the case of SHP remains to be clarified. Kathuria et al. reported that microscopic examination of the alveolar hemorrhage with SHP showed leukocytoclastic vasculitis with immunoglobulin (Ig)A deposition, and postulated that the involvement was caused by a similar immunopathogenic mechanism found in other organs such as the skin and kidney. Most of the severe cases with pulmonary hemorrhage of SHP had severe renal disorders. The ages in the patients showed two peaks; one was under 20 years and the other was over 61 years. These patients were treated with a various combination of corticosteroids and/or immunosuppressive agents, such as cyclophosphamide and azathioprine whose regimens were effective for some pediatric patients, but not for adult cases. None of the cases over 61 years of age recovered except for one. At present, the treatment of elderly patients with pulmonary hemorrhage of SHP is an issue that needs further examination. Recent studies have shown that plasmapheresis has been tried in various renal disorders such as SHP glomerulonephritis or Goodpasture’s syndrome, and its efficacy is controversial. Kauffmann et al. described two adult patients with SHP and rapidlyprogressive renal failure, who showed a decrease of circulating IgA immune complexes and improvement of renal function after the application of plasmapheresis. Although we were unable to find any reports in which the pulmonary hemorrhage with SHP benefited from plasmapheresis, early plasmapheresis in addition to methylprednisolone pulse therapy may be recommended as the therapeutic option. New strategies are needed for preventing fatal complications in the case of SHP.

Mild Hypothermia for Cerebral Resuscitation in Survivors of Out-of­ Hospital Ventricular Fibrillation

As emergency and intensive care medicine progresses, brain hypothermia is attracting attention as a therapeutic method that overcomes the hmitations of cerebral protection and resuscitation. We conducted a preliminary study by preparing a protocol of mild hypothermia by coil cooling at 34°C in patients who returned to spontaneous circulation via standard advanced cardiac life support and had experienced out-of-hospital ventricular fibrillation (VF) due to suspected cardiac arrest. Primary endpoints were survival at hospital discharge and good recovery using the Glasgow Outcome Scale. This study was performed in 15 patients meeting the inclusion criteria of mild hypothermia. The average core temperature during mild hypothermia at the cooling stage was 34.4°C, and the average duration was 83.9h. Survival rate at hospital discharge was 80%, and the good recovery rate was 67%. Multivariate analysis revealed that systemic oxygen delivery at the cooling stage was an indepedent predictor of good recovery. In conclusion, brain hypothermia (at a temperature of 34°C for 3 days and by coil cooling) in comatose survivors with out-of-hospital VF may have improved the outcome.