[Organ Donation in Victims of Non-Traumatic Out-of-Hospital Cardiac Arrest]. / Organspende bei Patienten nach nicht traumatischem außerklinischem Herzstillstand.

INTRODUCTION: The out-of-hospital cardiac-arrest (OHCA) is one of the leading causes of death. However, although previous studies showed the possibility to transplant organs from resuscitated donors, organ donation following OHCA remains seldom. We therefore initiated this study to investigate the current percentage of organ donation in victims of OHCA in a german university hospital. MATERIAL AND METHODS: We analyzed data from all victims of OHCA who were admitted to our hospital between January 1st 2008 and May 31st 2017. RESULTS: Altogether, there were 385 victims of OHCA admitted to our hospital. 126 victims of OHCA (32.8 %) survived until hospital discharge, 259 died (67.2 %), hereunder 7 victims of OHCA (1.8 %) with proven brain death. 5 victims of OCHA (1.5 %) donated their organs, and altogether 14 organs could be transplanted successfully. DISCUSSION: Organ donation following OHCA is seldom. We therefore would appreciate a more frequent diagnostics of brain death as currently not even all victims of OHCA with proven signs of brain damage in the computed tomography receive further diagnostics to confirm the diagnosis of brain death.

[Relevance of Living Wills During Post-Resuscitation Care]. / Stellenwert der Patientenverfügung in der Postreanimationsbehandlung.

Background There is hardly any evidence about the influence of living wills on acute life-threatening disease like out-of-hospital cardiac-arrest (OHCA). We therefore initiated this study to quantify the percentage of victims of OHCA who's living wills are available during post-resuscitation care. Methods All victims of OHCA who were admitted to our hospital between January 1st 2008 and July 31th 2016 were identified by analysis of our central admission register. Data from individual patients were collected from the patient's health records and anonymously stored on a central database. Results Altogether, there were 343 victims of OHCA admitted to our hospital between January 1st 2008 and July 31th 2016, including 16 patients (4.7 %) with living wills and 18 patients (5.2 %) with legal health care proxy. Survival rates were 31.2 % in patients with living wills, 27.8 % in patients with legal health care proxy and 33.3 % in patients without such a document. Conclusion In this study, the percentage of victims of OHCA with available living wills during post-resuscitation care was low. The presentation of living wills or legal health care proxies during post-resuscitation care of victims from OHCA was not equivalent to the patient`s death. Most often, discussion with relatives led to the decision to withdraw further therapy.

[ECG score to predict ICD therapies in patients with nonischemic cardiomyopathy and primary prophylactic CRT-D]. / EKG-Score zur Vorhersage von ICD-Therapien bei nichtischämischer Kardiomyopathie und primärprophylaktischem CRT-D.

BACKGROUND AND PROBLEM: Recently published results of the DANISH study raise concerns, if primary prophylactic ICD implantations in patients with nonischemic cardiomyopathy (NICM) and severe reduced left ventricular ejection fraction (LVEF) should be performed without further risk stratification. There was no significant difference in the overall mortality of patients with or without ICD and CRT defibrillator (CRT-D) or CRT pacemaker (CRT-P), respectively. Clinical risk scores to identify patients with ischemic cardiomyopathy (ICM) who benefit most from an ICD have been recommended. The need for risk stratification systems concerning patients with NICM has been emphasized. STUDY DESIGN AND METHODS: A retrospective study of 434 consecutive patients with CRT-D implantation was performed. Patients with no regular follow-up at our institution (n = 132), secondary prophylactic ICD indication (n = 61), and upgrade to CRT (n = 95) were excluded. The occurrence of an adequate ICD therapy was defined as the endpoint. Left ventricular ejection fraction (LVEF), genesis of the cardiomyopathy as well as the modified Selvester ECG score (MSES) for evaluation of the left ventricular scar burden were documented among other characteristics. RESULTS: Within a median follow-up of 605 days, 24% of the patients experienced an adequate ICD therapy. These patients had significantly lower LVEF (20% vs. 23%), and the MSES was higher (7 vs. 3 points). There was no significant difference in patients suffering from ICM vs NICM. A receiver-operating-characteristic (ROC) analysis revealed a sensitivity of 0.914 and a specifity of 0.586 for MSES ≥4 to predict the occurrence of an ICD therapy. None of 35 patients suffering from NICM with MSES <4 experienced an ICD therapy. INTERPRETATION: The evaluation of the left ventricular scar burden using MSES can be useful for the decision between CRT-D and CRT-P in patients suffering from NICM.

[Predictors for need of antibradycardia and antitachycardia pacing after ICD implantation : Implications for the subcutaneous ICD]. / Prädiktoren für die Notwendigkeit antibradykarder und antitachykarder Stimulation nach ICD-Implantation : Implikationen für den subkutanen ICD.

BACKGROUND: Little is known about the incidence and risk factors for progression to pacemaker dependency or the need for cardiac resynchronization in typical patients with an implanted defibrillator with regard to an alternative implantation of a subcutaneous ICD (S-ICD). STUDY DESIGN AND METHODS: After retrospective analysis of 291 patients with first implantation of a transvenous single chamber ICD (VVI-ICD) from 2010-2016 and excluding those with an indication for pacemaker or lack of follow-up data, 121 patients were included and investigated with regard to the following endpoints: need for pacemaker stimulation, upgrade for cardiac resynchronization (CRT), and secondary occurrence and effectiveness of antitachycardia pacing (ATP). We compared the results with those of fundamental S­ICD studies and tried to determine risk factors on the basis of medical history and pre-implant data. RESULTS: The study population and the rate of endpoints were significantly different to those of fundamental S­ICD studies. Within a 2.2-year follow-up, 14.9 % of the patients developed a need for pacemaker stimulation and 0.8 % the need for cardiac resynchronization. Excluding patients who at implantation were already at high risk for pacemaker dependency, 7.4 % remained with a reached endpoint. We identified atrial fibrillation and bundle-branch-block as risk factors. All episodes of ventricular tachycardia (VT) could be terminated by ATP in 9.9 % of the patients. They more often had ischemic heart disease and a secondary prophylactic indication for an ICD. CONCLUSION: The low rate of conversions from S­ICD to a transvenous ICD in case of pacemaker-dependency as stated in fundamental S­ICD studies should not be transferred to other typical collectives of ICD recipients. The latter group is at significantly higher risk for developing pacemaker-dependency.

Using vascular closure devices following out-of-hospital cardiac arrest?

OBJECTIVES AND BACKGROUND: Despite a generally broad use of vascular closure devices (VCDs), it remains unclear whether they can also be used in victims from out-of-hospital cardiac arrest (OHCA) treated with mild therapeutic hypothermia (MTH). METHODS: All victims from OHCA who received immediate coronary angiography after OHCA between January 1(st) 2008 and December 31(st) 2013 were included in this study. The operator decided to either use a VCD (Angio-Seal™) or manual compression for femoral artery puncture. The decision to induce MTH was based on the clinical circumstances. RESULTS: 76 patients were included in this study, 46 (60.5%) men and 30 (39.5%) women with a mean age of 64.2 ± 12.8 years. VCDs were used in 26 patients (34.2%), and 48 patients (63.2%) were treated with MTH. While there were significantly more overall vascular complications in the group of patients treated with MTH (12.5% versus 0.0%; p=0.05), vascular complications were similar between patients with VCD or manual compression, regardless of whether or not they were treated with MTH. CONCLUSION: In our study, the overall rate of vascular complications related to coronary angiography was higher in patients treated with mild therapeutic hypothermia, but was not affected by the application of a vascular closure device. Therefore, our data suggest that the use of VCDs in victims from OHCA might be feasible and safe in patients treated with MTH as well, at least if the decision to use them is individually carefully determined.

Cardiac arrest teams and time of day: effects on surviving in-hospital resuscitation.

OBJECTIVES: Little is known about the factors that influence survival following in-hospital resuscitation, but previous investigations have suggested that in-hospital resuscitations outside of regular working hours are associated with worse survival rates. MATERIAL AND METHODS: In-hospital cardiac arrest teams at our hospital were instructed to complete a questionnaire following every emergency call between July 2011 and June 2013. Data on all resuscitation attempts were collected and analyzed. RESULTS: A total of 65 in-hospital resuscitations were recorded in 42 males (64.6%) and 23 females (35.4%) (mean age 72.0±14.3 years). A total of 54 (83.1%) cardiac arrests were witnessed; seven (10.8%) showed a shockable rhythm at the time of the first ECG. Resuscitation attempts lasted 29.3±41.3 minutes, and 4.1±3.1 mg epinephrine was given. Return of spontaneous circulation could be achieved in 38 patients (58.5%); 29 (44.6%) survived the first day, 23 (35.4%) the seventh day, and 15 patients (23.1%) were discharged alive. Significantly more in-hospital resuscitations were obtained for those performed during non-regular working hours (P<0.001), with higher neuron-specific enolase levels at 72 hours after resuscitation during nonregular working hours (P=0.04). Patients who were discharged alive were significantly younger (P=0.01), presented more often with an initial shockable rhythm (P=0.04), and had a shorter duration of resuscitation (P<0.001) with the need of a lower dose of epinephrine (P<0.001). DISCUSSION: Survival rates following in-hospital resuscitation were poor at any time, but appear to depend less on time-dependent effects of the quality of resuscitation and more on time-dependent effects of recognition of cardiac arrests.