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Case Reports  |   November 2003
Successful Resuscitation from Prolonged Ventricular Fibrillation Using a Portable Percutaneous Cardiopulmonary Support System
Author Affiliations & Notes
  • Hiroshi Sunami, M.D.
    *
  • Yoshihisa Fujita, M.D.
  • Tomoko Okada, M.D.
    *
  • Satoshi Wada, M.D.
    *
  • Motoko Kimura, M.D.
  • Atsuo Sari, M.D.
    §
  • Kazuhiro Yoshida, M.D.
  • * Senior Resident, § Professor, † Associate Professor, § Lecturer, Department of Anesthesiology and Intensive Care Medicine, ∥ Department of Gastroenterological Surgery, Kawasaki Medical School.
  • From the Departments of Anesthesiology and Intensive Care Medicine and Gastroenterological Surgery, Kawasaki Medical School, Okayama, Japan.
Article Information
Case Reports
Case Reports   |   November 2003
Successful Resuscitation from Prolonged Ventricular Fibrillation Using a Portable Percutaneous Cardiopulmonary Support System
Anesthesiology 11 2003, Vol.99, 1227-1229. doi:
Anesthesiology 11 2003, Vol.99, 1227-1229. doi:
TWO cases of ventricular fibrillation (VF) under general anesthesia during noncardiac surgery are presented. Although both patients were refractory to conventional cardiopulmonary resuscitation (CPR), they were rescued using a percutaneous cardiopulmonary support (PCPS) system without any complications. We emphasize the importance of emergency extracorporeal circulation with PCPS as a life-saving measure in prolonged CPR during intraoperative cardiac arrest.
Case Reports
Case 1
A 75-yr-old man was scheduled for gastrectomy under general anesthesia with a diagnosis of early gastric cancer. He had had dilated cardiomyopathy for 5 yr. His medications included an angiotensin-converting enzyme inhibitor, digitalis, and a β-blocker. His physical status was New York Heart Association class II. Preoperative echocardiography revealed mild mitral regurgitation and diffuse left ventricular hypokinesis with an ejection fraction of 34%. Coronary angiography performed 1 month earlier showed mild luminal irregularities in the right and left coronary arteries but no significant stenotic changes.
Anesthesia was induced with midazolam, fentanyl, and vecuronium, and the trachea was intubated. Anesthesia was maintained with sevoflurane–oxygen and nitrous oxide. Radial artery and pulmonary artery catheters were inserted, and their pressures were 120/80 mmHg and 25/12 mmHg, respectively. Ten milliliters 1% lidocaine was administered through an epidural catheter inserted from Th8 to Th9, followed by continuous infusion at a rate of 4 ml/h of a mixture of 40 ml 1% lidocaine and 500 μg fentanyl.
The surgery proceeded uneventfully with stable hemodynamics and arterial oxygen saturation. When the epigastric artery was ligated 1 h after the surgery was begun, however, VF occurred after ventricular extrasystoles. Closed-chest compression was immediately started by the surgeons, sevoflurane was switched off, and the lungs were manually ventilated with oxygen. For resuscitation, 1.0 mg ephedrine, 3.0 mg epinephrine in total, 80 mg lidocaine, and 20 ml sodium bicarbonate were administered. The findings of arterial blood gas/pH and electrolyte analysis during CPR revealed pH 7.41, 29 mmEq/l pco2, 477 mmHg po2, 131 mEq/l Na, and 4.3 mEq/l K, with a hematocrit of 38%. A peak arterial pressure of 80 mmHg was maintained by closed-chest compression during CPR. The patient could not be defibrillated with direct current shocks despite six attempts (200 J × 3, 300 J, 400 J × 2). The decision to use PCPS was made 25 min after the onset of VF. A 16.5-French, 15-cm perfusion cannula (CX-EB16ASH; TERUMO, Tokyo, Japan) was inserted through the left femoral artery, and a 21-French, 50-cm draining cannula (CX-EB21VSH, TERUMO) was inserted in the right atrium through the right internal jugular vein. Placement of perfusion and draining cannulae was performed using a modified Seldinger technique as follows. After skin preparation and draping, we advanced an 18-gauge needle into the vessels, replaced it with a guidewire, and incised the skin. The percutaneous tract was then serially dilated with 8-French and 12-French dilators. The perfusion and draining cannulae incorporated with a dilator were advanced over the guidewire. The right jugular vein was chosen for venous access, because an attempt to puncture both femoral veins was not successful, whereas arterial access could be easily obtained by locating pulsation of the femoral artery.
Extracorporeal circulation was started at a flow rate of 2 to 3 l/min with our portable PCPS system (Capiox SP-101, TERUMO), and closed-chest compression was discontinued (fig. 1). The mean aortic pressure was 130 mmHg. It took about 10 min from the decision to initiate extracorporeal circulation. The patient resumed spontaneous rhythm (120 beats/min) and an arterial pressure of 140/100 mmHg with the first direct current shock 3 min after the start of extracorporeal circulation. PCPS was continued at a flow rate of 2 l/min with an arterial pressure of 100/60 mmHg. Anticoagulation with heparin was started 1 h later to keep the automated clotting time around 200 s. After hemostasis and closure of the abdomen, the patient was transferred to the intensive care unit with the PCPS system. Although he had to undergo relaparotomy for hemostasis the same night, he could be separated from the PCPS system the next day. He remained in the intensive care unit for 2 days under hemodynamic monitoring. Playback of the monitor recording during operation revealed ST segment elevation in electrocardiogram lead II before VF developed. The patient underwent gastrectomy 4 weeks later uneventfully with PCPS standby.
Fig. 1. Schematic diagram of the portable cardiopulmonary support system. It consists of a controller with a battery, a flow meter probe, a cone-type centrifugal pump, a heating pad, and heparin-bonded preconnected circuitry with a hollow fiber membrane oxygenator. The system has an autopriming function to facilitate air bubble elimination from the circuitry. Priming with 470 ml normal saline solution and clearance of air from the whole circuitry can be completed in less than 5 min. The hatched area  is kept sterile until connection to perfusion and draining cannulae. Thick arrows  indicate blood flow direction, and thin arrows  indicate oxygen flow direction.
Fig. 1. Schematic diagram of the portable cardiopulmonary support system. It consists of a controller with a battery, a flow meter probe, a cone-type centrifugal pump, a heating pad, and heparin-bonded preconnected circuitry with a hollow fiber membrane oxygenator. The system has an autopriming function to facilitate air bubble elimination from the circuitry. Priming with 470 ml normal saline solution and clearance of air from the whole circuitry can be completed in less than 5 min. The hatched area 
	is kept sterile until connection to perfusion and draining cannulae. Thick arrows 
	indicate blood flow direction, and thin arrows 
	indicate oxygen flow direction.
Fig. 1. Schematic diagram of the portable cardiopulmonary support system. It consists of a controller with a battery, a flow meter probe, a cone-type centrifugal pump, a heating pad, and heparin-bonded preconnected circuitry with a hollow fiber membrane oxygenator. The system has an autopriming function to facilitate air bubble elimination from the circuitry. Priming with 470 ml normal saline solution and clearance of air from the whole circuitry can be completed in less than 5 min. The hatched area  is kept sterile until connection to perfusion and draining cannulae. Thick arrows  indicate blood flow direction, and thin arrows  indicate oxygen flow direction.
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Case 2
A 68-yr-old man was scheduled for internal drainage of a pancreatic pseudocyst by Roux-en-Y cystojejunostomies. He had a 4-yr history of diabetes mellitus, which was treated with insulin. Although he had had chest pain 8 yr earlier, his coronary artery was angiographically normal. He had had no limitation in his physical activity. Preoperative echocardiography revealed good wall motion of the left ventricle with an ejection fraction of 76% and moderate mitral regurgitation. His preoperative blood tests were normal except for a high blood sugar level.
Anesthesia was induced and maintained in the same way as in case 1. Epidural analgesia was performed. Routine monitoring included electrocardiography, pulse oxymetry, capnometry, and direct arterial pressure via  the left radial artery (fig. 2A). The patient was hemodynamically stable except for short runs of ventricular extrasystole observed when the surgery was started. This was treated with intravenous 125 mg mexiletine hydrochloride.
Fig. 2. (A  ) Playback of the electrocardiogram II lead and arterial pressure tracing at a paper speed of 25 mm/s from case 2 after induction of anesthesia (arterial pressure = 125/51 mmHg). (B  ) Arterial pressure decreased suddenly to 50/25 mmHg. ST segment elevation and short run are noted. (C  ) Thirty seconds later, ventricular fibrillation developed.
Fig. 2. (A 
	) Playback of the electrocardiogram II lead and arterial pressure tracing at a paper speed of 25 mm/s from case 2 after induction of anesthesia (arterial pressure = 125/51 mmHg). (B 
	) Arterial pressure decreased suddenly to 50/25 mmHg. ST segment elevation and short run are noted. (C 
	) Thirty seconds later, ventricular fibrillation developed.
Fig. 2. (A  ) Playback of the electrocardiogram II lead and arterial pressure tracing at a paper speed of 25 mm/s from case 2 after induction of anesthesia (arterial pressure = 125/51 mmHg). (B  ) Arterial pressure decreased suddenly to 50/25 mmHg. ST segment elevation and short run are noted. (C  ) Thirty seconds later, ventricular fibrillation developed.
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When the pancreatectomy was almost completed with 200 ml blood loss 3 h after the start of the surgery, VF developed shortly after hypotension (fig. 2B and C). Resuscitative measures were promptly started, and the lungs were ventilated with pure oxygen. Direct current shocks (200 J, 300 J, 360 J × 3) along with administration of drugs, including 50 mg lidocaine, 5.5 mg epinephrine in total, and 40 U vasopressin, were ineffective for restoring spontaneous heart rhythm. VF persisted despite CPR. We decided to use PCPS 20 min after the onset of VF. Emergency extracorporeal circulation was established percutaneously through cannulae inserted into the femoral vein and artery 10 min after that. We stopped chest compression and administration of drugs for resuscitation on initiation of extracorporeal circulation. Although a high mean arterial pressure was achieved initially because of the residual vasoconstrictive effect, it could be maintained at a flow rate of 3 l/min with a mean arterial pressure of 80 mmHg 20 min later. Direct current shock immediately after extracorporeal circulation failed, but the patient was defibrillated on PCPS 20 min later and spontaneous circulation was restored. The flow rate was reduced to 2.0 l/min, and sevoflurane inhalation was restarted. Twenty milligrams heparin was administered for anticoagulation at 1 h after extracorporeal circulation. The automated clotting time was maintained around 200 s after that. The surgery was completed 4 h later. Coronary angiography performed on the same day as PCPS revealed mild stenosis in the left anterior descending coronary artery. This was interpreted as insignificant by cardiologists. The patient was successfully decannulated the next day in the intensive care unit and transferred to the ward the following day. He was able to return home 2 weeks later without any neurologic complications.
Discussion
We experienced two successful CPRs using PCPS in patients with refractory VF during noncardiac surgery. In our patients, conventional CPR was continued for about 35 min and 30 min in cases 1 and 2, respectively. The time required to initiate cardiopulmonary support after a decision to do so was made was 10 min. We believe that the two patients would not have fully recovered without the use of PCPS.
In 1989, Long et al.  1 reported a case of successful resuscitation of bupivacaine-induced cardiac arrest using a conventional cardiopulmonary bypass machine. They needed a midsternotomy for total extracorporeal circulation, blood transfusion to increase hematocrit, and volume infusion to increase mean arterial pressure. The complexity and technical difficulty of the procedure prevented its widespread use as a resuscitative measure. With the advent of the PCPS system composed of a centrifugal pump and heparin-bonded preconnected circuitry with a hollow fiber membrane, extracorporeal circulation became more practical.
Extracorporeal circulation with PCPS is a well-established clinical technique in high-risk cardiac catheterization and postcardiotomy cardiogenic shock. 2 Recently, anecdotal case reports have suggested increased recognition of emergency PCPS as a life-saving measure for pulmonary thrombosis, 3 cardiac failure with pulmonary hypertension, 4 in-hospital CPR, 5 and drug intoxication. 6 Nevertheless, statistics regarding the use of emergency PCPS have revealed that the results are not necessary favorable, especially when the neurologic outcome is considered as the end point. 7 Implementation of PCPS more than 30 min after unwitnessed cardiac arrest or CPR yields a patient survival rate of less than 10%. 7–9 The decision to use PCPS should be made as soon as possible in prolonged CPR for complete recovery.
To the best of our knowledge, no cases of emergent PCPS resuscitation in patients with noncardiac surgery have been previously reported. Because cardiac arrests during general anesthesia are all witnessed, victims in the operating room seem to benefit most from PCPS. A reported good survival rate for cardiac arrest victims in a catheterization laboratory, where situations are similar to those observed in the operating room with the use of PCPS, confirms this speculation. 10 
Technical advances such as preassembled circuity, a small prime volume of 470 ml, a centrifugal pump, ease of air clearance from circuitry because of the absence of the heat exchanger and autopriming functions of the system, and a percutaneous technique with thin-walled cannulae made the rapid initiation of extracorporeal circulation feasible (fig. 1). Because the heating pad incorporated into the PCPS is not so effective as a heat exchanger for the control of body temperature, patients become slightly hypothermic at 33–35°C during the course of extracorporeal circulation with our PCPS. Because hypothermia has neuroprotective effects, however, the unavoidable hypothermia might have contributed to the complete recovery of our patients to some extent.
Although PCPS seems to be life saving in many cases of prolonged CPR in the operating room, it is not indicated for patients with active bleeding or severe aortic regurgitation. The potential complications of PCPS include perforation or injury of vessels during placement of the large cannulae and ischemia in the lower extremities because of compromised blood flow in the femoral artery by the perfusion cannulae. 11 
It should be emphasized that for immediate and safe institution of extracorporeal circulation, teamwork on the part of the specialists in the operating room (e.g.  , anesthesiologists, cardiologists, perfusionists, surgeons) is imperative along with a rapidly available PCPS system.
The increase in coronary perfusion pressure with PCPS may play a pivotal role in the return of spontaneous circulation, because adequate coronary perfusion pressure is well known to be the best predictor of successful defibrillation. 12 In our cases, mean aortic pressures to 130 mmHg (case 1) or 80 mmHg (case 2) were achieved with the institution of PCPS. Right atrial pressure presumably decreased because of venous drainage to PCPS, leading to a substantial increase in the coronary perfusion pressure. The successful defibrillation in our cases may thus be explained by the increased coronary perfusion pressure induced by PCPS.
In summary, we have described two patients with intraoperative cardiac arrest who were successfully resuscitated using a PCPS system. The patients could not have survived without it. Because intraoperative cardiac arrest victims are considered good candidates for full recovery, PCPS should be considered in any difficult cases of CPR in the operating room.
The authors thank Kazuo Tanemoto, M.D. and Sohei Hamanaka, M.D., Department of Cardiothoracic and Vascular Surgery, Ken'ichi Kasai, Perfusionist, and our colleagues in the Departments of Anesthesiology and Intensive Care Medicine and Cardiology, Kawasaki Medical School, Kurashiki, Japan, for their cooperation during resuscitation.
References
Long WB, Rosenblum S, Grady IP: Successful resuscitation of bupivacaine-induced cardiac arrest using cardiopulmonary bypass. Anesth Analg 1989; 69: 403–6Long, WB Rosenblum, S Grady, IP
Booth KL, Roth SJ, Perry SB, del Nido PJ, Wessel DL, Laussen PC: Cardiac catheterization of patients supported by extracorporeal membrane oxygenation. J Am Coll Cardiol 2002; 40: 1681–6Booth, KL Roth, SJ Perry, SB del Nido, PJ Wessel, DL Laussen, PC
Szocik J, Rudich S, Csete M: ECMO resuscitation after massive pulmonary embolism during liver transplantation. A nesthesiology 2002; 97: 763–4Szocik, J Rudich, S Csete, M
Satoh H, Masuda Y, Izuta S, Yaku H, Obara H: Pregnant patient with primary pulmonary hypertension: General anesthesia and extracorporeal membrane oxygenation support for termination of pregnancy. A nesthesiology 2002; 97: 1638–40Satoh, H Masuda, Y Izuta, S Yaku, H Obara, H
Chen YS, Chao A, Yu HY, Ko WJ, Wu IH, Chen RJ, Huang SC, Lin FY, Wang SS: Analysis and results of prolonged resuscitation in cardiac arrest patients rescued by extracorporeal membrane oxygenation. J Am Coll Cardiol 2003; 41: 197–203Chen, YS Chao, A Yu, HY Ko, WJ Wu, IH Chen, RJ Huang, SC Lin, FY Wang, SS
Holzer M, Sterz F, Schoerkhuber W, Behringer W, Domanovits H, Weinmar D, Weinstabl C, Stimpfl T: Successful resuscitation of a verapamil-intoxicated patient with percutaneous cardiopulmonary bypass. Crit Care Med 1999; 27: 2818–23Holzer, M Sterz, F Schoerkhuber, W Behringer, W Domanovits, H Weinmar, D Weinstabl, C Stimpfl, T
Hill JG, Bruhn PS, Cohen SE, Gallagher MW, Manart F, Moore CA, Seifert PE, Askari P, Banchieri C: Emergent applications of cardiopulmonary support: A multiinstitutional experience. Ann Thorac Surg 1992; 54: 699–704Hill, JG Bruhn, PS Cohen, SE Gallagher, MW Manart, F Moore, CA Seifert, PE Askari, P Banchieri, C
Kurusz M, Zwischenberger JB: Percutaneous cardiopulmonary bypass for cardiac emergencies. Perfusion 2002; 17: 269–77Kurusz, M Zwischenberger, JB
Wittenmyer BL, Pomerants BJ, Duff SB, Watson WD, Blackford JM: Single hospital experience with emergency cardiopulmonary bypass using the portable CPS (Bard) system. J Extracorp Technol 1997; 29: 73–7Wittenmyer, BL Pomerants, BJ Duff, SB Watson, WD Blackford, JM
Mooney MR, Arom KV, Joyce LD, Mooney JF, Goldenberg IF, Von Rueden TJ, Emery RW: Emergency cardiopulmonary bypass support in patients with cardiac arrest. J Thorac Cardiovasc Surg 1991; 101: 450–4Mooney, MR Arom, KV Joyce, LD Mooney, JF Goldenberg, IF Von Rueden, TJ Emery, RW
Ullrich R, Kneifel W, Fuchs M, Hodl W, Zimpfer M, Germann P: Portable cardiopulmonary support (ECPS) in the emergency room. Anaesthesia 1998; 53( suppl 2): 6–8Ullrich, R Kneifel, W Fuchs, M Hodl, W Zimpfer, M Germann, P
Paradis NA, Martin GB, Rivers EP, Goetting MG, Appleton TJ, Feingold M, Nowak RM: Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. JAMA 1990; 263: 1106–13Paradis, NA Martin, GB Rivers, EP Goetting, MG Appleton, TJ Feingold, M Nowak, RM
Fig. 1. Schematic diagram of the portable cardiopulmonary support system. It consists of a controller with a battery, a flow meter probe, a cone-type centrifugal pump, a heating pad, and heparin-bonded preconnected circuitry with a hollow fiber membrane oxygenator. The system has an autopriming function to facilitate air bubble elimination from the circuitry. Priming with 470 ml normal saline solution and clearance of air from the whole circuitry can be completed in less than 5 min. The hatched area  is kept sterile until connection to perfusion and draining cannulae. Thick arrows  indicate blood flow direction, and thin arrows  indicate oxygen flow direction.
Fig. 1. Schematic diagram of the portable cardiopulmonary support system. It consists of a controller with a battery, a flow meter probe, a cone-type centrifugal pump, a heating pad, and heparin-bonded preconnected circuitry with a hollow fiber membrane oxygenator. The system has an autopriming function to facilitate air bubble elimination from the circuitry. Priming with 470 ml normal saline solution and clearance of air from the whole circuitry can be completed in less than 5 min. The hatched area 
	is kept sterile until connection to perfusion and draining cannulae. Thick arrows 
	indicate blood flow direction, and thin arrows 
	indicate oxygen flow direction.
Fig. 1. Schematic diagram of the portable cardiopulmonary support system. It consists of a controller with a battery, a flow meter probe, a cone-type centrifugal pump, a heating pad, and heparin-bonded preconnected circuitry with a hollow fiber membrane oxygenator. The system has an autopriming function to facilitate air bubble elimination from the circuitry. Priming with 470 ml normal saline solution and clearance of air from the whole circuitry can be completed in less than 5 min. The hatched area  is kept sterile until connection to perfusion and draining cannulae. Thick arrows  indicate blood flow direction, and thin arrows  indicate oxygen flow direction.
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Fig. 2. (A  ) Playback of the electrocardiogram II lead and arterial pressure tracing at a paper speed of 25 mm/s from case 2 after induction of anesthesia (arterial pressure = 125/51 mmHg). (B  ) Arterial pressure decreased suddenly to 50/25 mmHg. ST segment elevation and short run are noted. (C  ) Thirty seconds later, ventricular fibrillation developed.
Fig. 2. (A 
	) Playback of the electrocardiogram II lead and arterial pressure tracing at a paper speed of 25 mm/s from case 2 after induction of anesthesia (arterial pressure = 125/51 mmHg). (B 
	) Arterial pressure decreased suddenly to 50/25 mmHg. ST segment elevation and short run are noted. (C 
	) Thirty seconds later, ventricular fibrillation developed.
Fig. 2. (A  ) Playback of the electrocardiogram II lead and arterial pressure tracing at a paper speed of 25 mm/s from case 2 after induction of anesthesia (arterial pressure = 125/51 mmHg). (B  ) Arterial pressure decreased suddenly to 50/25 mmHg. ST segment elevation and short run are noted. (C  ) Thirty seconds later, ventricular fibrillation developed.
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