Quantitative characterization of left ventricular function during pulseless electrical activity using echocardiography during out-of-hospital cardiac arrest

Felipe Teran; Norman A Paradis; Anthony J Dean; M Kit Delgado; Kristin A Linn; Jeffrey A Kramer; Ryan W Morgan; Robert M Sutton; Romolo Gaspari; Anthony Weekes; Srikar Adhikari; Vicki Noble; Jason T Nomura; Daniel Theodoro; Michael Y Woo; Nova L Panebianco; Wilma Chan; Claire Centeno; Oscar Mitchell; Mary Ann Peberdy; Benjamin S Abella

doi:10.1016/j.resuscitation.2021.05.016

Quantitative characterization of left ventricular function during pulseless electrical activity using echocardiography during out-of-hospital cardiac arrest

Resuscitation. 2021 Oct:167:233-241. doi: 10.1016/j.resuscitation.2021.05.016. Epub 2021 Jun 1.

Authors

Felipe Teran¹, Norman A Paradis², Anthony J Dean³, M Kit Delgado⁴, Kristin A Linn⁵, Jeffrey A Kramer³, Ryan W Morgan⁶, Robert M Sutton⁶, Romolo Gaspari⁷, Anthony Weekes⁸, Srikar Adhikari⁹, Vicki Noble¹⁰, Jason T Nomura¹¹, Daniel Theodoro¹², Michael Y Woo¹³, Nova L Panebianco³, Wilma Chan³, Claire Centeno³, Oscar Mitchell¹⁴, Mary Ann Peberdy¹⁵, Benjamin S Abella¹⁶

Affiliations

¹ Center for Resuscitation Science, University of Pennsylvania School of Medicine, University of Pennsylvania Blockley Hall, 423 Guardian Drive, Room 414A, Philadelphia, PA 19104, USA; Division of Emergency Ultrasound, Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA. Electronic address: felipe.teran-merino@pennmedicine.upenn.edu.
² Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH 03756, USA.
³ Division of Emergency Ultrasound, Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
⁴ Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA.
⁵ Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA.
⁶ Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
⁷ Department of Emergency Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA.
⁸ Department of Emergency Medicine, Carolinas Medical Center, 1000 Blythe Blvd, Charlotte, NC 28203, USA.
⁹ Department of Emergency Medicine, School of Medicine University of Arizona Tucson, 1501 N. Campbell Ave, Tucson, AZ 85724, USA.
¹⁰ Department of Emergency Medicine, University Hospitals, Cleveland Medical Center, Case Western Reserve School of Medicine, 11100 Euclid Ave, Cleveland, OH 44106, USA.
¹¹ Department of Emergency Medicine, Christiana Care, 4755 Ogletown Stanton Road, Newark, DE 19718, USA.
¹² Department of Emergency Medicine, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO 63110, USA.
¹³ Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, Ontario K1Y4E9, Canada.
¹⁴ Center for Resuscitation Science, University of Pennsylvania School of Medicine, University of Pennsylvania Blockley Hall, 423 Guardian Drive, Room 414A, Philadelphia, PA 19104, USA; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
¹⁵ Division of Cardiology, Department of Internal Medicine, Weil Institute of Emergency and Critical Care, Department of Emergency Medicine, University Virginia Commonwealth University, 1101 E. Marshall Street, Richmond, VA 23298, USA.
¹⁶ Center for Resuscitation Science, University of Pennsylvania School of Medicine, University of Pennsylvania Blockley Hall, 423 Guardian Drive, Room 414A, Philadelphia, PA 19104, USA.

PMID: 34087419
PMCID: PMC10694851
DOI: 10.1016/j.resuscitation.2021.05.016

Abstract

Background: Several prospective studies have demonstrated that the echocardiographic detection of any myocardial activity during PEA is strongly associated with higher rates of return of spontaneous circulation (ROSC). We hypothesized that PEA represents a spectrum of disease in which not only the presence of myocardial activity, but more specifically that the degree of left ventricular (LV) function would be a predictor of outcomes. The purpose of this study was to retrospectively assess the association between LV function and outcomes in patients with OHCA.

Materials and methods: Using prospectively obtained data from an observational cohort of patients receiving focused echocardiography during cardiopulmonary resuscitation (CPR) in the Emergency Department (ED) setting, we analyzed 312 consecutive subjects with available echocardiography images with initial rhythm of PEA. We used left ventricular systolic fractional shortening (LVFS), a unidimensional echocardiographic parameter to perform the quantification of LV function during PEA. Regression analyses were performed independently to evaluate for relationships between LVFS and a primary outcome of ROSC and secondary outcome of survival to hospital admission. We analyzed LVFS both as a continuous variable and as a categorial variable using the quartiles and the median to perform multiple different comparisons and to illustrate the relationship of LVFS and outcomes of interest. We performed survival analysis using Cox proportional hazards model to evaluate the hazard corresponding to length of resuscitation.

Results: We found a positive association between LVFS and the primary outcome of ROSC (OR 1.04, 95%CI 1.01-1.08), but not with the secondary outcome of survival to hospital admission (OR 1.02, 95%CI 0.96-1.08). Given that the relationship was not linear and that we observed a threshold effect in the relationship between LVFS and outcomes, we performed an analysis using quartiles of LVFS. The predicted probability of ROSC was 75% for LVFS between 23.4-96% (fourth quartile) compared to 47% for LVFS between 0-4.7% (first quartile). The hazard of not achieving ROSC was significantly greater for subjects with LVFS below the median (13.1%) compared to the subgroup with LVFS greater than 13.1% (p < 0.05), with the separation of the survival curves occurring at approximately 40 min of resuscitation duration.

Conclusions: Left ventricular function measured by LVFS is positively correlated with higher probability of ROSC and may be associated with higher chances of survival in patients with PEA arrest.

Keywords: Cardiac arrest; Echocardiography; Point-of-care ultrasound; Resuscitation; Ultrasound.

MeSH terms

Cardiopulmonary Resuscitation*
Echocardiography
Humans
Out-of-Hospital Cardiac Arrest* / diagnostic imaging
Out-of-Hospital Cardiac Arrest* / therapy
Prospective Studies
Retrospective Studies
Ventricular Function, Left

Grants and funding

T32 HL007891/HL/NHLBI NIH HHS/United States