Sudden cardiac death: directing the scope of resuscitation towards the heart and brain.
BACKGROUND: The fundamental goal of cardiopulmonary resuscitation (CPR) is recovery of the heart and the brain. This is best achieved by (1) immediate CPR for coronary and cerebral perfusion, (2) correction of the cause of cardiac arrest, and (3) controlled cardioplegic cardiac reperfusion. Failure of such an integrated therapy may cause permanent brain damage despite cardiac resuscitation. METHODS: This strategy was applied at four centers to 34 sudden cardiac death patients (a) after acute myocardial infarction (n = 20), (b) "intraoperatively" following successful discontinuation of cardiopulmonary bypass (n = 4), and (c) "postoperatively" in the surgical ICU (n = 10). In each witnessed arrest the patient failed to respond to conventional CPR with ACLS interventions, including defibrillation. The cardiac arrest interval was 72 +/- 43 min (20-150 min). Compression and drugs maintained a BP > 60 mmHg to avoid cerebral hypoperfusion. Operating room (OR) transfer was delayed until the blood pressure was monitored. In four patients femoral bypass maintained perfusion while an angiographic diagnosis was made. RESULTS: Management principles included no repeat defibrillation attempts after 10 min of unsuccessful CPR, catheter-monitored peak BP > 60 mmHg during diagnosis and transit to the operating room, left ventricular venting during cardiopulmonary bypass and 20 min global and graft substrate enriched blood cardioplegic reperfusion. Survival was 79.4% with two neurological complications (5.8%). CONCLUSIONS: Recovery without adverse neurological outcomes is possible in a large number of cardiac arrest victims following prolonged manual CPR. Therapy is directed toward maintaining a monitored peak BP above 60 mmHg, determining the nature of the cardiac cause, and correcting it with controlled reperfusion to preserve function.