Resuscitative endovascular occlusion of the aorta (REBOA) as a mechanical method for increasing the coronary perfusion pressure in non-traumatic out-of-hospital cardiac arrest patients

doi:10.1016/j.resuscitation.2022.07.020

Resuscitation

Volume 179, October 2022, Pages 277-284

https://doi.org/10.1016/j.resuscitation.2022.07.020 Get rights and content

Abstract

Aim of the study

Resuscitative endovascular balloon occlusion of the aorta (REBOA), originally designed to block blood flow to the distal part of the aorta by placing a balloon in trauma patients, has recently been shown to increase coronary perfusion in cardiac arrest patients. This study evaluated the effect of REBOA on aortic pressure and coronary perfusion pressure (CPP) in non-traumatic out of-hospital cardiac arrest (OHCA) patients.

Methods

Adult OHCA patients with cerebral performance category 1 or 2 prior to cardiac arrest, and without evidence of aortic disease, were enrolled from January to December 2021. Aortic pressure and right atrial pressure were measured before and after balloon occlusion. The CPP was calculated using the measured aortic and right atrial pressures, and the values before and after the balloon occlusion were compared.

Results

Fifteen non-traumatic OHCA patients were enrolled in the study. The median call to balloon time was 46.0 (IQR, 38.0–54.5) min. The median CPP before and after balloon occlusion was 13.5 (IQR, 5.8–25.0) and 25.2 (IQR, 12.0–44.6) mmHg, respectively (P = 0.001). The median increase in the estimated CPP after balloon occlusion was 86.7%.

Conclusions

The results of this study suggest that REBOA may increase the CPP during cardiopulmonary resuscitation in patients with non-traumatic OHCA. Additional studies are needed to investigate the effect on clinical outcomes.

Introduction

The primary goal of cardiopulmonary resuscitation (CPR) performed on cardiac arrest patients is to deliver oxygen to vital organs by generating blood flow. In particular, the achievement of a return of spontaneous circulation (ROSC) depends on providing sufficient oxygen delivery to the heart by maintaining the myocardial blood flow. The coronary perfusion pressure (CPP), the pressure gradient between the aorta and right atrium, is a major determinant of the myocardial blood flow.1., 2. Consequently, generating a high CPP by providing high-quality chest compression during CPR is one of the most critical factors for achieving ROSC in cardiac arrest patients.

A resuscitative endovascular balloon occlusion of the aorta (REBOA) was designed originally for use in trauma patients.³ The positive effect of the use a REBOA is to generate a high CPP during CPR in a non-traumatic cardiac arrest has been reported in several animal studies. In addition, some clinical studies have also been conducted, based on the theoretical background that an aortic occlusion may increase the CPP and the cerebral perfusion pressure in out-of-hospital cardiac arrest (OHCA) patients.4., 5., 6., 7., 8., 9., 10. However, there is still no direct evidence that REBOA can affect the CPP in patients with OHCA.

We hypothesised that REBOA may affect the CPP in cardiac arrest patients and conducted this pilot study to evaluate the effect of use of REBOA on CPP in non-traumatic OHCA patients.

Section snippets

Study design and setting

This pilot study was conducted from January to December 2021 in the emergency department (ED) of a tertiary teaching hospital with approximately 90,000 annual visits. All the adult patients (aged ≥ 18 years) with non-traumatic OHCA were eligible. The exclusion criteria were: 1) patients who had a ROSC at ED presentation; 2) patients with a cerebral performance category (CPC) of 3–4 before cardiac arrest; 3) patients with a history of aortic diseases, such as aortic dissection or aneurysm, or

Results

During the study period, 149 adult patients with non-traumatic OHCA visited the ED, of whom 15 were included in the study (Fig. 1). Table 1 shows the clinical characteristics of the enrolled patients, and Supplementary Table 1 shows the detailed information for each patient. The median call to balloon time was 46.0 (IQR, 38.0–54.5) min. Of the enrolled patients, 6 (40.0%) achieved a ROSC and 1 (6.7%) was admitted to the ICU with a sustained ROSC. However, none of the enrolled patients survived

Discussion

The results of this study suggest that REBOA may increase the aortic pressure and CPP in patients with non-traumatic OHCA. The mean aortic pressure and CPP showed a statistically significant increase after the balloon occlusion using a REBOA, and the median CPP increase was approximately 86.7%, from 13.5 to 25.2 mmHg.

The CPP, the difference between the aortic and right atrial pressure, is a major mechanism that drives the coronary blood flow.²⁰ During CPR, a CPP of 15 mmHg or greater is

Conclusion

The results of this study suggest that REBOA may increase the CPP during CPR in patients with non-traumatic OHCA. Additional studies are needed to investigate the effect on clinical outcomes.

CRediT authorship contribution statement

Dong-Hyun Jang: Data curation, Formal analysis, Visualization, Writing – original draft. Dong Keon Lee: Conceptualization, Methodology, Investigation, Formal analysis, Writing – review & editing. You Hwan Jo: Conceptualization, Methodology, Investigation, Supervision. Seung Min Park: Supervision. Young Taeck Oh: Investigation. Chang Woo Im: Investigation.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

This work was supported by the Seoul National University Bunding Hospital Research Fund (No. 06-2020-0358). The study sponsors had no involvement in this study.

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Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) and ultrasound-guided left stellate ganglion block to rescue out of hospital cardiac arrest due to refractory ventricular fibrillation: A case report
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Out of hospital cardiac arrest from shockable rhythms that is refractory to standard treatment is a unique challenge. Such patients can achieve neurological recovery even with long low-flow times if perfusion can somehow be restored to the heart and brain. Extracorporeal cardiopulmonary resuscitation is an effective treatment for refractory cardiac arrest if applied early and accurately, but often cannot be directly implemented by frontline providers and has strict inclusion/exclusion criteria. We present the case of a novel treatment strategy for out of hospital cardiac arrest due to refractory ventricular fibrillation utilizing Resuscitative Endovascular Balloon Occlusion of the Aorta-assisted cardiopulmonary resuscitation and intra-arrest left stellate ganglion blockade to achieve return of spontaneous circulation and eventual good neurological outcome after 101 minutes of downtime.
Resuscitative endovascular balloon occlusion of the aorta in out-of-hospital cardiac arrest – A Delphi consensus study for uniform data collection
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Evolving research on resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct treatment for out-of-hospital cardiac arrest mandates uniform recording and reporting of data. A consensus on which variables need to be collected may enable comparing and merging data from different studies. We aimed to establish a standard set of variables to be collected and reported in future REBOA studies in out-of-hospital cardiac arrest.
A four-round stepwise Delphi consensus process first asked experts to propose without restraint variables for future REBOA research in out-of-hospital cardiac arrest. The experts then reviewed the variables on a 5-point Likert scale and ≥75% agreement was defined as consensus. First authors of published papers on REBOA in out-of-hospital cardiac arrest over the last five years were invited to join the expert panel.
The data were collected between May 2022 and December 2022. A total of 28 experts out of 34 primarily invited completed the Delphi process, which developed a set of 31 variables that might be considered as a supplement to the Utstein style reporting of research in out-of-hospital cardiac arrest.
This Delphi consensus process suggested 31 variables that enable future uniform reporting of REBOA in out-of-hospital cardiac arrest.
Left rib fractures during cardiopulmonary resuscitation are associated with hemodynamic variations in a pig model of cardiac arrest
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Chest compressions (CC) are the cornerstone of cardiopulmonary resuscitation (CPR). But CC are also known to cause injuries, specifically rib fractures. The effects of such fractures have not been examined yet. This study aimed to investigate hemodynamic effects of rib fractures during mechanical CPR in a porcine model of cardiac arrest (CA).
We conducted a retrospective hemodynamic study in 31 pigs that underwent mechanical CC. Animals were divided into three groups based on the location of rib fractures: No Broken Ribs group (n = 11), Left Broken Ribs group (n = 13), and Right Broken Ribs group (n = 7). Hemodynamic measurements were taken at 10 seconds before and 10, 30, and 60 seconds after rib fractures.
Baseline hemodynamic parameters did not differ between the three groups. Systolic aortic pressure was overall higher in the Left Broken Ribs group than in the No Broken Ribs group at 10, 30, and 60 seconds after rib fracture (p = 0.02, 0.01, and 0.006, respectively). The Left Broken Ribs group had a significantly higher right atrial pressure compared to the No Broken Rib group after rib fracture (p = 0.02, 0.01, and 0.03, respectively). There was no significant difference for any parameter for the Right Broken Ribs group, when compared to the No Broken Ribs group.
An increase in main hemodynamic parameters was observed after left rib fractures while right broken ribs were not associated with any change in hemodynamic parameters. Reporting fractures and their location seems worthwhile for future experimental studies.
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¹: Contributed equally to this work.

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Clinical paperResuscitative endovascular occlusion of the aorta (REBOA) as a mechanical method for increasing the coronary perfusion pressure in non-traumatic out-of-hospital cardiac arrest patients

Abstract

Aim of the study

Methods

Results

Conclusions

Introduction

Section snippets

Study design and setting

Results

Discussion

Conclusion

CRediT authorship contribution statement

Declaration of Competing Interest

Acknowledgements

Best Practice Res Clin Anaesthesiol

Resuscitation

Resuscitation

Resusc Plus

Resuscitation

Resuscitation

Resuscitation

Am J Cardiol

Am J Emerg Med

Sci Rep

Continuing Educ Anaesthesia Critical Care Pain

J Emerg Med

Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association

Circulation

Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man

Surgery.

Clinical paper
Resuscitative endovascular occlusion of the aorta (REBOA) as a mechanical method for increasing the coronary perfusion pressure in non-traumatic out-of-hospital cardiac arrest patients