Cardiac procedures are not always benign; percutaneous cardiac interventions (PCI) carry a risk of precipitating cardiac arrest. Unfortunately, it is often difficult to provide excellent compression during the PCI procedure. Consequently, recommendations have been developed regarding the treatment of arrest during cardiac procedures. Currently, high-quality research comparing these recommendations to the usual cardiac arrest management is lacking.

Coronary Stent Percutaneous Cardiac Intervention

Mechanical CPR during PCI

Devices that provide chest compressions exist and can be used during PCI to deliver this life-saving care. Research evaluating individuals or small case series exist showing that this is feasible and can lead to ROSC and short term survival (to hospital discharge). Additionally, these devices allow potential responders to be spared the radiology associated with the PCI. (Class IIb, Evidence level C-EO). 

Cardiopulmonary Bypass after PCI

High-risk findings, such as multiple coronary vessel disease or cardiogenic shock, can increase the chance of morbidity following PCI. Intra-aortic balloon pump (IABP), ventricular assisting device, and extracorporeal CPR (ECPR) can all be used to manage circulation or complete reperfusion during or following PCI. The necessary resources, however, may not be available at all facilities.

The use of ECPR is effective following cardiac arrest or hemodynamic catastrophe during PCI. (Class IIb, Evidence level C-LD). ECPR can be used as a temporizing measure until the patient is stable enough to undergo coronary artery bypass graft (CABG), with some research suggesting survival rates up to 64%. While IABP can improve coronary artery perfusion, improve hemodynamic instability, and decrease cardiac oxygen demand, it has not been shown to improve patient survival. ECPR used in conjunction with IABP improves outcomes compared to IABP alone in cardiac shock or arrest. 

It is vital to use clinical judgment to determine which patients benefit from these treatments as ECPR can provide hemodynamic support even in the case of a low likelihood of recovery. Hospital guidelines, as well as ethical considerations, should be taken into account when using these support devices for patients. (Class I, Evidence level C-E).

Cough CPR

In patients with new-onset ventricular arrhythmias at the time of PCI, “cough CPR” can be used as a temporizing measure. Patients must be alert and able to follow directions. Studies show that it can allow maintenance of blood pressure until other therapies can be instituted. (Class IIa, Evidence level C).

Intracoronary Verapamil

Research indicates that intracoronary verapamil can manage ventricular tachycardia (V-Tach) during mechanical revascularization. It is not effective for ventricular fibrillation (VF).