JonJuiMD,MPH

¡ Whatistheop3malelectricaltherapyforrefractoryventricularfibrilla3on?

Strategies Effect

Highperformance+vasopressorsCPR

Op:mizecoronarybloodflow

An:-arrhythmics Decreaseirritabilityofmyocardium

Defibrilla:onStrategies Op:mizedefibrilla:on

Fixtheischemia:AKACoronarycatheteriza:on

Defini:vetreatmentforischemicVF

E-CPR/ECMO Keepspa:entaliveun:ldefini:vetherapycanbeadministered

¡ RefractoryVF/VTACH§ RhythmNEVERconvertedwithdefibrilla3on§ Example:VF,VF,VF,VF

¡ RecurrentVF/VTACH§ Rhythmconvertedsuccessfullywithdefibrilla3onbutrecurred§ Example:VF,PEA,VF,Asystole,VF

¡  Vectors§ Changingtheorienta3onofelectricalvectorwithinthemyocardium

¡  Coverage§ Sequen3alpulsesmayapplyalargercurrentdensityandmoreevendistribu3onoverthefibrilla3ngmyocardium.

¡  Dura3onofshock§ Doublesequen3alprolongsshockdura3onthusdeplorizingmoremyocytesindifferentelectricalphases

¡ MoreEnergy

Date Author Study Conclusion

1994 Hoch 2,990consecu3vepa3entsundergoingproceduresinEPlabover3years.

5pa3entswithrefractoryVFwithmul3pleshocksbysingledefibrillator.All5successfullydefibrillatedon1staYemptwithdoublesequen3alandall5survived.

2014 Cabanas(WakeCo,NC)

Retrospec3vecaseseries10pa3entswithOHCA(6-10singleshocks)

Successfulconversiontonormalrhythmin7/10pa3ents.Nonesurvivedhowever.

2014 Gerstein DSDinIHCA Successfuldefibrilla3onwithDSDaber74minutesofresuscita3on

2015 Lybeck(St.Louis,Mo)

40yoOHCAaberstrikingagainstpoleplayingbasketball

DSDon8thaYemptinED.CTcardiaccontusiontoapexanddistallateralwall.Cardiaccatheteriza3onrevealednormalcoronaryanatomy.DCwithfullneurologicalfunc3on.

Date Author Study Conclusion

2104 Leacock(St.Louis,Mo)

51yomale,STEMI,cardiacarrest,witnessbyEMS,BMI40

5normalenergyshocks,DSDx1,conversion,VTsecondDSDsuccessful,CathLAD,stent,balloonpump,DCalivewithfullneurologicalrecovery

2016 Johnston(Toronto,Ca)

28yofemale,witnessedarrestbyhusband,DSDon#7shock,aber6normalshocks,withROSC

Remainedstableinhospital,normalCathwithnormalcoronaryangiogram,withseverehypokinesisandEF<10%(laternormalized),foundtohaveprolongedQTc594milliseconds.DCtoSNFwithmodifiedRankinscore2(butlaterimprovedto1).Nowcaringfor16montholddaughter.

Date Author Study Conclusion

2016 Cortez(Columbus,Ohio)

Retrospec3vecaseseries12pa3entswithOHCA2010to2014

Successfulelectricalconversion9/12,ROSC3/12,3DCalive(2/3withCPCscoreof1(goodperformance)

¡ Shock§ EPI

¡ Shock§ Amiodarone300mg

¡ Shock§ Amiodarone150mg

¡ Shock

¡  Ifrefractory,Doublesequen3al¡  (usually5thor6thshock)

Outcomes Number Percent

Unsuccessful 19 53%

ElectricalSuccess 23 47%

ROSC 15 31%

Total 48 100%

INCDATE SEX AGE FirstKnownRhythmElectricalSuccess ROSC

lastknownBloodPressure Comments

1/9/2014Female 54PulselessElectricalAc3vity yes YES 75/56 8shockstotal,6,7,8DSSuccessPEA

5/15/2014Female 27VentricularFibrilla3on yes YES 6shockstotal,#5,6DSconvertedtoSVTSurvivor

8/16/2014Male 79 Asystole yes YES 111/76 7totalshocks,#6,7DS,SuccessfROSC

9/29/2014Male 78VentricularFibrilla3on yes YES 195/94 7Total,#5.6DS,7SSSuccessPEAbutbacktoVT

1/8/2015Female 81VentricularFibrilla3on yes YES 8totalshocks,#7,8DS,VFtoidioventtoNSRSurvivor

4/20/2015Male 47VentricularFibrilla3on yes YES 106/84 7totalshocks,#7DS,immediateorganizedrhythmSurvivor

4/22/2015Male 71VentricularFibrilla3on yes YES 84/54 9totalshocks,#8,9DSbradycardiawithROSC

5/21/2015Female 62VentricularFibrilla3on yes YES 161/128 4totalshocks,#4dsVFtoaccelleratedjunc3onalROSC

11/12/2015Male 78VentricularFibrilla3on yes YES 8totalshocks,#7DS,#8SS,PEAwithROSC

1/21/2016Male 75VentricularFibrilla3on yes YES 135/101 8totalshocks,#8asystoleconver3ngtoperfusingrhythmwithBP

5/12/2016Male 74VentricularFibrilla3on yes YES DS#5toPEA,toROSC,diedinED

6/17/2016Female 50VentricularFibrilla3on yes YES 121/95 5SS1DSsuccessfulDischargealivemoderatecerebralperformance

6/29/2016Male 51VentricularFibrilla3on yes YES 106/-

5totalshocks,DS4and5,NSRaber#5.Lucas,Dischargealivegoodcerebralperformance

7/3/2016Male 87VentricularFibrilla3on yes yes 93/30 DS#8withROSC,howevertransientPEAaber#3AdmiYedtohospitalmadeDNR

12/6/2016Male 80VentricularFibrilla3on yes yes VFarrest,DSD#6toPEA,ROSCinED,diedinhospital

Ini:alRhythm

DefibSequence ROSC Outcome

27yoF VF 4singleshocks,2DSD,convertedon2nd

Yes Dischargealive,CathnormalICD

81yoF VF 6singleshocks,2DSDconvertedon2nd

Yes DCalive,K=2.0,normalcoronaryarteries

47yoM VF 6singleshocks,1DSDshockconvertedon1stshock

Yes DCalive,non“obstruc3veCAD”

Ini:alRhythm

DefibSequence ROSC Outcome

50yoF VF 5singleshocks,1DSD,convertedon1st

Yes Dischargealive(moderateCNS)CathnormalICD,ICD

51yoM VT 3singleshocks,2DSDconvertedon2nd

Yes DCalive,normalcoronaryarteries,arrhythmogenicRVcardiomyopathy,ICD

¡ DoubleSequen3alDefibrilla3onmaybeaviabletherapyop3onforpa3entsinrefractoryVFcardiacarrest.

¡ Ourdatacurrentlyindicatethatmostpa3entswhowillconvertwillconvertbythe2ndshock.

¡ Thevastmajorityofourpa3entswhosurvivedwereyoung,witnessedcardiacarrestandhadnormalcoronaryarteries.

¡ DSDshouldbeintegratedwithaggressivedefini:veinterven:on(CardiacCath/E-CPR)whenappropriate.