By Demetris Yannopoulos, MD
Although ventricular tachycardia/ven- tricular fibrillation (v tach/v fib) consti- tutes only 25–35% of all cardiac arrests,
more than 80% of all cardiac arrest survivors with
favorable neurological function present with
v tach/v fib.
1, 2 (See Figure 1, p. 12.) Despite that,
only one third (approximately 30%) of patients
presenting initially with v tach/v fib survive to hospital discharge with good neurological function.
Compared to the other presenting rhythms (
asystole and pulseless electrical activity) v tach/v fib
is associated with the highest survival and stands
out as the most important positive predictive factor for neurological intact survival with odd ratios
ranging from 15 to > 40.3 As such, v fib remains a
very important target to improve overall survival
since it represents patients that are viable.
Over the last 20 years, a significant body of evi-
dence has emerged highlighting the importance of
significant coronary artery disease in patients pre-
senting with v tach/v fib and out-of-hospital car-
diac arrest (OHCA).
4–8 The accumulated evidence
in regard to the presence of coronary artery dis-
ease has introduced significant scientific questions
about the role of diagnostic and interventional pro-
cedures aiming to identify and reverse the potential
cause of the arrest. Currently the American Heart
Association recommends all patients resuscitated
from first presenting shockable rhythms that have
ST elevation on the post-resuscitation ECG gain
access to the cardiac catheterization lab (CCL)
per standard ST-elevation myocardial infarction
guidelines—even if they’re comatose.
For patients that have no ST elevation, there’s
varied treatment practices, with early CCL access
and ICU initial access followed by cardiology consultation as needed. The PEARL and the ACCESS
trials are currently evaluating these two major
approaches currently in the United States and
results will be available the next few years.
The Emergence of ECMO
Recent developments in the use of extracorporeal membrane oxygenation (ECMO) and clinical advancements have introduced a significant
The dawn of a new era
A cardiac catheterization
protocol at the University of
Minnesota utilized a high
volume/expertise group of
cardiologists to start and
management ECMO upon
arrival of the patient.