Relationship between duration of prehospital resuscitation and favorable prognosis in ventricular fibrillation.

OBJECTIVE: There appears to be an optimal point in balancing the relative benefits of extending the resuscitation time to obtain return of spontaneous circulation in the prehospital setting and the initiation of therapies such as extracorporeal cardiopulmonary resuscitation (CPR). This study investigated how prehospital CPR duration is related to survival and neurologic outcome in ventricular fibrillation (VF) and tried to find the tolerable time for prehospital resuscitation. MATERIALS AND METHODS: Out-of-hospital cardiac arrest patients with VF in Funabashi City, Japan, from January 2009 to December 2013 were reviewed. Resuscitation teams that included physicians were dispatched to incident sites. Survival rate at 24 hours and neurologic outcome at 30 days were analyzed with respect to prehospital CPR duration. RESULTS: A total of 172 patients were evaluated. Seventy-three patients were alive at 24 hours. Thirty-four patients had favorable neurologic outcomes after 30 days. Of the 69 patients who required prolonged prehospital CPR (>30 minutes), 6 were alive at 24 hours, and only 1 had a favorable neurologic outcome at 30 days. Logistic regression model showed that both survival rate at 24 hours and neurologic outcome at 30 days deteriorated with the increase in prehospital CPR duration (both P < .001). CONCLUSION: The prognosis of out-of-hospital cardiac arrest patients with VF deteriorated with the increase in prehospital CPR duration. Favorable results are less likely especially in cases of prolonged prehospital CPR (>30 minutes). Therefore, it may be necessary to consider transportation to a more definitive treatment facility rather than extending conventional CPR in the prehospital setting.

Successful treatment of Panton-Valentine leukocidin-expressing Staphylococcus aureus-associated pneumonia co-infected with influenza using extracorporeal membrane oxygenation.

BACKGROUND: Panton-Valentine leukocidin (PVL) is a cytotoxin that causes leukocyte destruction and lung necrosis. Managing respiratory failure and acute respiratory distress syndrome secondary to PVL-expressing Staphylococcus aureus pneumonia and its associated lung necrosis with mechanical ventilation is challenging. We report a patient with life-threatening PVL-expressing S. aureus-associated pneumonia who was rescued using extracorporeal membrane oxygenation (ECMO). CASE REPORT: We examined the case of a woman who presented to our Emergency Department with septic shock due to PVL-expressing S. aureus-associated pneumonia. A 27-year-old Filipino woman was transferred to our hospital due to severe dyspnea, hemosputum, and high-grade fever. She had a medical history of osteosarcoma of the leg and hyperthyroidism. On arrival, her vital signs indicated septic shock, with a white blood cell count of 3.5×10(3)/µl. Because a Gram stain of her sputum indicated SA, therapy with antibiotics, including meropenem and vancomycin, was started. Hypoxemia necessitated intubation and ventilation. Because the patient's PaO2/FiO2 remained less than 60 mmHg and her blood pressure was unstable despite aggressive conventional management, venoarterial ECMO was administered approximately 11 h after her arrival. The ECMO circuit was changed to veno-venous ECMO on day 7 and the patient was successfully weaned off ECMO after 12 days of treatment. She was discharged from the hospital 104 days after admission. CONCLUSION: This case demonstrates that early induction of ECMO support can be a reasonable therapeutic option for PVL-S. aureus-associated pneumonia. This patient's successful outcome might be attributable to early establishment of ECMO to prevent ventilation-induced lung injury.

Effectiveness of bystander-initiated cardiac-only resuscitation for patients with out-of-hospital cardiac arrest.

BACKGROUND: Previous animal and clinical studies suggest that bystander-initiated cardiac-only resuscitation may be superior to conventional cardiopulmonary resuscitation (CPR) for out-of-hospital cardiac arrests. Our hypothesis was that both cardiac-only bystander resuscitation and conventional bystander CPR would improve outcomes from out-of-hospital cardiac arrests of < or = 15 minutes' duration, whereas the addition of rescue breathing would improve outcomes for cardiac arrests lasting > 15 minutes. METHODS AND RESULTS: We carried out a prospective, population-based, observational study involving consecutive patients with emergency responder resuscitation attempts from May 1, 1998, through April 30, 2003. The primary outcome measure was 1-year survival with favorable neurological outcome. Multivariable logistic regression analysis was performed to evaluate the relationship between type of CPR and outcomes. Among the 4902 witnessed cardiac arrests, 783 received conventional CPR, and 544 received cardiac-only resuscitation. Excluding very-long-duration cardiac arrests (> 15 minutes), the cardiac-only resuscitation yielded a higher rate of 1-year survival with favorable neurological outcome than no bystander CPR (4.3% versus 2.5%; odds ratio, 1.72; 95% CI, 1.01 to 2.95), and conventional CPR showed similar effectiveness (4.1%; odds ratio, 1.57; 95% CI, 0.95 to 2.60). For the very-long-duration arrests, neurologically favorable 1-year survival was greater in the conventional CPR group, but there were few survivors regardless of the type of bystander CPR (0.3% [2 of 624], 0% [0 of 92], and 2.2% [3 of 139] in the no bystander CPR, cardiac-only CPR, and conventional CPR groups, respectively; P<0.05). CONCLUSIONS: Bystander-initiated cardiac-only resuscitation and conventional CPR are similarly effective for most adult out-of-hospital cardiac arrests. For very prolonged cardiac arrests, the addition of rescue breathing may be of some help.

Circadian variation of endothelial function in idiopathic dilated cardiomyopathy.

This study measured flow-mediated dilation (FMD) of the brachial artery 3 times a day (6:30 a.m., 11:30 a.m., and 9 p.m.) in 7 normal subjects and 14 patients with idiopathic dilated cardiomyopathy (7 in New York Heart Association [NYHA] functional class I or II and 7 in NYHA functional class III or IV). FMD in normal subjects and patients in NYHA class I or II showed a circadian variation, being lowest in the morning and highest at night. Compared with them, FMD in patients in NYHA class III or IV was lower and almost constant during the day, showing loss of significant circadian variation in endothelial function in patients with congestive heart failure.

[Fulminant myocarditis causing severe left heart failure and massive thrombus formation following cardiac tamponade: a case report].

A woman aged middle thirties presented with common cold-like symptoms, and was hospitalized due to hypotension and tachycardia. Echocardiography revealed pericardial effusion and preserved left ventricular fractional shortening (28%). Cardiac index, pulmonary capillary wedge and right atrial pressure were 1.8 l/min/m2, 15 and 13 mmHg, respectively. After drainage of pericardial effusion, cardiac index increased to 3.4 l/min/m2. On the fifth hospital day, left ventricular dysfunction developed (fractional shortening: 16%, cardiac index: 1.5 l/min/m2, pulmonary capillary wedge pressure: 18 mmHg, right atrial pressure: 12 mmHg), so percutaneous cardiopulmonary support was introduced. However, the heart failed in asystole and the cavity was occupied by massive thrombus, probably related to heparin-induced thrombocytopenia. This case of fulminant myocarditis passed through various clinical features of heart failure. She died on the 12th hospital day.

Favourable clinical outcome in patients with cardiogenic shock due to fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation.

AIMS: The clinical outcome of severe acute myocarditis patients with cardiogenic shock who require circulatory support devices is not well known. We studied the survival and clinical courses of patients with fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation (ECMO) and compared them with those of patients with acute non-fulminant myocarditis. METHODS AND RESULTS: Patients with acute myocarditis were divided into the following two groups. Fourteen patients who required ECMO for cardiogenic shock were defined as having fulminant myocarditis (F group), whereas 13 patients who had an acute onset of symptoms, but did not have compromised, were defined as having acute non-fulminant myocarditis (NF group). In the F group, 10 patients were weaned successfully from percutaneous ECMO. Therefore, the overall acute survival rate was 71%. Patients who were not weaned from ECMO showed smaller left ventricular end-diastolic and end-systolic dimensions, thicker left ventricular wall, and higher creatine phosphokinase MB isoform levels than those who were weaned from ECMO. When compared with patients in the NF group, the fractional shortening in the F group was more severely decreased in the acute phase [F: 10+/-4 vs. NF: 23+/-8% (mean+/-SD), P<0.001], but recovered in the chronic phase (F: 33+/-7 vs. NF: 34+/-6%). The prevalence of adverse clinical events in both groups was similar during the follow-up period of 50 months. CONCLUSION: In patients with fulminant myocarditis, percutaneous ECMO is a highly effective form of a haemodynamic support. Once a patient recovers from inflammatory myocardial damage, the subsequent clinical outcome is favourable, similar to that observed in patients with acute non-fulminant myocarditis.

Cardiac tumor as an initial manifestation of acquired immunodeficiency syndrome.

A cardiac tumor was the first manifestation of acquired immunodeficiency syndrome (AIDS) in a female patient in a state of severe immunodeficiency caused by human immunodeficiency virus (HIV) infection. The extensive cardiac and extracardiac involvement shown by various imaging modalities, including echocardiography and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), suggested that she was in the critical stage of non-Hodgkin's lymphoma (NHL). AIDS was treated by highly active-antiretroviral therapy and the NHL was treated by a combination of rituximab-cyclophosphamide-vincristine-doxorubicine-predonisolone. After 6 cycles of chemotherapy, she was in complete remission. Her cardiac tumor dramatically reduced in size and FDG-PET showed no positive uptake on whole body imaging. Generally, an AIDS-related cardiac tumor tends to be diagnosed at the late stage of the disease because of its nonspecific clinical findings, resulting in an extremely poor prognosis. In the present case, the cardiac tumor was detected by echocardiography and treated with appropriate chemotherapy. Early diagnosis and prompt treatment may improve a patient's prognosis.