Int. J. Med. Sci. 2015, Vol. 12 http://www.medsci.

org 306 International Journal of

Medical Sciences 2015; 12(4): 306-311. doi: 10.7150/ijms.11343 Research Paper
Using Vascular Closure Devices Following Out-OfHospital Cardiac Arrest? Martin
Christ, Katharina Isabel von Auenmueller, Jeanette Liebeton, Martin Grett,
Wolfgang Dierschke, Jan Peter Noelke, Irini Maria Breker, Hans-Joachim Trappe
Department of Cardiology and Angiology, Marienhospital Herne, Ruhr University
Bochum, Germany Corresponding author: Dr. med. Martin Christ, Department of
Cardiology and Angiology, Marienhospital Herne, Ruhr University Bochum,
Hoelkeskampring 40, 44625 Herne, Germany. Tel: (0049)-2323-499-5620; Fax:
(0049)-2323-499-301; Email: martin.christ@marienhospital-herne.de 2015
Ivyspring International Publisher. Reproduction is permitted for personal,
noncommercial use, provided that the article is in whole, unmodified, and
properly cited. See http://ivyspring.com/terms for terms and conditions.
Received: 2014.12.14; Accepted: 2015.03.04; Published: 2015.03.28 Abstract
Objectives and Background: Despite a generally broad use of vascular closure
devices (VCDs), it remains unclear whether they can also be used in victims from
out-of-hospital cardiac arrest (OHCA) treated with mild therapeutic hypothermia
(MTH). Methods: All victims from OHCA who received immediate coronary
angiography after OHCA between January 1st 2008 and December 31st 2013
were included in this study. The operator decided to either use a VCD (AngioSeal) or manual compression for femoral artery puncture. The decision to
induce MTH was based on the clinical circumstances. Results: 76 patients were
included in this study, 46 (60.5%) men and 30 (39.5%) women with a mean age
of 64.2 12.8 years. VCDs were used in 26 patients (34.2%), and 48 patients
(63.2%) were treated with MTH. While there were significantly more overall
vascular complications in the group of patients treated with MTH (12.5% versus
0.0%; p=0.05), vascular complications were similar between patients with VCD
or manual compression, regardless of whether or not they were treated with
MTH. Conclusion: In our study, the overall rate of vascular complications related
to coronary angiography was higher in patients treated with mild therapeutic
hypothermia, but was not affected by the application of a vascular closure
device. Therefore, our data suggest that the use of VCDs in victims from OHCA
might be feasible and safe in patients treated with MTH as well, at least if the
decision to use them is individually carefully determined. Key words: out-ofhospital cardiac arrest, resuscitation, mild therapeutic hypothermia, coronary
angiography, vascular closure device Introduction The current Guidelines of the
European Resuscitation Council emphasise early coronary angiography in all
post-cardiac arrest patients who are suspected of having coronary artery disease
[1]. Several studies confirmed that the combination of mild therapeutic
hypothermia (MTH) and early coronary angiography - inclusive percutaneous
coronary intervention (PCI), if necessary - is feasible and safe in patients
following out-of-hospital cardiac arrest (OHCA) [2-6]. However, although the use
of vascular closure devices (VCDs) has increased during the past decade, no
study has focussed on the safety of VCDs prior to MTH in victims from OHCA.
Material and Methods Patients Altogether, 76 patients who received emergency
coronary angiography within the first two hours after OHCA between January 1st
2008 and December 31st 2013 were included in this study. Mean age was 64.2

12.8 years. Patients data were collected from the patients health records and
anonymously stored on a central Ivyspring International Publisher Int. J. Med. Sci.
2015, Vol. 12 http://www.medsci.org 307 database. Coronary angiography
Catheterisation was performed according to standard techniques with the six
French femoral approach. If a recent coronary-artery stenosis was found,
coronary angioplasty was attempted, unless the artery was too small or the
operator considered the procedure to be technically impossible. Standard
resuscitative and stabilisation procedures were continued during the procedure if
necessary. All patients who received percutaneous coronary intervention
received 500 mg acetylsalicylic acid and 5.000 IU unfractionated heparin
intravenously during PCI, and 600 mg clopidogrel immediately after placement of
a nasogastric tube. Vascular closure device At the end of the procedure, the
operator decided to use either a vascular closure device or manual compression
for femoral artery puncture. If a VCD was chosen, an Angio-Seal device (St.
Jude Medical, Minnetonka, MN, USA) that consists of an intra-arterially deployed
polymer anchor, a collagen sponge positioned on the outer artery wall, and a
self-tightening suture was used. The whole system is bioabsorbed within 90 days.
All patients were followed-up by an experienced emergency physician. Hbrelevant bleeding was defined as a haemoglobin drop of more than 3 g/dl within
the first 24 hours following coronary angiography and exclusion of other obvious
causes or clinical bleeding signs. Mild therapeutic hypothermia The decision to
induce MTH was based on the clinical circumstances, taking into account aspects
like initial rhythm, duration of resuscitation, and state of consciousness. If
necessary, MTH was induced immediately after the emergency coronary
procedure with the CoolGard 3000 system since several studies confirmed the
safety and effectiveness of intravascular cooling [7]. The target temperature was
33 Celsius for 24 hours, the rate of temperature change was maximised to
induce MTH and was 0.3 Celsius/hour to rewarm the patients. The Cooling
Catheter with the saline flowing within was placed via the femoral vein in the
cardiac catheterisation laboratory at the end of the coronary procedure.
Statistical analysis Statistical analysis was performed with the Statistical Package
of Social Science (SPSS 22.0, IBM, Armonk, NY, USA). Continuous variables are
expressed as the mean SD, and comparisons of categorical variables among
groups were conducted using Chi-square tests or Students t-test. Data collection
and analysis was approved by the local ethical review committee. Results All
patients Of the 76 patients were included in our study, 46 (60.5%) were men and
30 (39.5%) were women, and a mean age of 64.2 12.8 years. Altogether, 60
events (78.9%) were witnessed, lay resuscitation was attempted in 43 events
(56.6%), and 44 patients (57.9%) presented with an initial shockable rhythm. Of
the 38 (50.0%) patients that presented with myocardial infarction, 27 (35.5%)
presented with ST elevation myocardial infarction (STEMI) and 11 (14.5%)
presented with non ST elevation myocardial infarction (NSTEMI). Coronary
angiography confirmed coronary artery disease in 63 (82.9%) patients: 13
(17.1%) patients had one vessel disease, 17 (22.4%) patients had two vessel
disease, and 33 (43.4%) patients had three vessel disease. Percutaneous
coronary intervention was attempted in 53 (69.7%) patients, with the culprit
lesion in the left anterior descendens (LAD) in 21 (27.6%) patients, in the Ramus

circumflexus (RCX) in seven (9.2%) patients, in the right coronary artery (RCA) in
14 (18.4%) patients, and in a coronary artery bypass graft (CABG) in one (1.3%)
patient, while 10 (13.2%) patients received multi-vessel intervention. If
necessary, the duration of the coronary angiography and PCI was 50.0 31.0
minutes. In 17 (22.4%) patients, Eptifibatide was used during intervention.
Angio-Seal devices were used in 26 (34.2%) patients, and six (7.9%) showed
vascular complications, such as Hb-relevant bleeding (6.6%) or arterial occlusion
(1.3%). Forty-one (53.9%) patients who received immediate coronary
angiography after hospital admission survived until hospital discharge (Table 1).
Comparison of patients treated with MTH and patients not treated with MTH 48
victims from OHCA (63.2%) were treated with mild therapeutic hypothermia after
immediate coronary angiography, 28 patients (36.8%) were not. In comparison of
both groups we observed significant more lay resuscitations in the group of
patients not treated with MTH (45.8% vs 75.0%; p=0.01) and significant more
overall vascular complications in the group of patients treated with MTH (12.5%
vs 0.0%; p=0.05). No significant differences could be observed with regard on
patients` gender, age, witnessed arrests, initial shockable rhythm, myocardial
infarction, Int. J. Med. Sci. 2015, Vol. 12 http://www.medsci.org 308 prevalence of
coronary artery disease, PCI attempt, duration of coronary angiography, use of
eptifibatide during PCI, use of Angio-Seal and survival until hospital discharge
(Table 1). Table 1: Patient characteristics from all patients (first column), patients
treated with mild therapeutic hypothermia (MTH) following out-of-hospital cardiac
arrest (OHCA; second column), and OHCA victims who were not treated with MTH
(third column) All patients n = 76 Patients treated with MTH n = 48 Patients not
treated with MTH n = 28 p Male gender 46 (60.5%) 29 (60.4%) 17 (60.7%) 0.98
Age (years) [range] 64.2 12.8 [3488] 62.3 13.7 [3488] 67.5 11.3 [4788]
0.09 Witnessed cardiac arrest 60 (78.9%) 38 (79.2%) 22 (78.6%) 0.81 Lay
resuscitation 43 (56.6%) 22 (45.8%) 21 (75.0 %) 0.01 Initial shockable rhythm 44
(57.9%) 30 (62.5%) 14 (50.0 %) 0.37 Myocardial infarction 38 (50.0%) 25
(52.1%) 13 (46.4%) 0.92 ST elevation myocardial infarction (STEMI) 27 (35.5%)
19 (39.6%) 8 (28.6%) Non-ST elevation myocardial infarction (NSTEMI) 11
(14.5%) 6 (12.5%) 5 (17.9%) Coronary artery disease 63 (82.9%) 40 (83.3%) 23
(82.1%) 0.89 One vessel disease 13 (17.1%) 7 (14.6%) 6 (21.4%) Two vessel
disease 17 (22.4%) 12 (25.0%) 5 (17.9%) Three vessel disease 33 (43.4%) 21
(43.8%) 12 (42.9%) Percutaneous coronary intervention (PCI) 53 (69.7%) 35
(72.9%) 18 (64.3%) 0.43 Left anterior descendens (LAD) 21 (27.6%) 16 (33.3%) 5
(17.9%) Ramus circumflexus (RCX) 7 (9.2%) 4 (8.3%) 3 (10.7%) Right coronary
artery (RCA) 14 (18.4%) 8 (16.7%) 6 (21.4%) Multi vessel disease (MV) 10
(13.2%) 1 (1.3%) 6 (12.5%) 1 (2.1%) 4 (14.3%) 0 (0.0%) Coronary artery bypass
graft (CABG) Use of Eptifibatide (Integrilin) 17 (22.4%) 12 (25.0%) 5 (17.9%)
0.47 Duration of coronary angiography (min) [range] 50.0 31.0 [7186] 48.3
27.0 [8132] 51.0 35.7 [7186] 0.71 Vascular closure device (Angio-Seal) 26
(34.2%) 16 (33.3%) 10 (35.7%) 0.83 Vascular complication 6 (7.9%) 6 (12.5%) 0
(0.0%) 0.05 Hb relevant bleeding 5 (6.6%) 5 (10.4%) - 0.08 conservative therapy
1 (1.3%) 1 (2.1%) - transfusion 3 (3.9%) 3 (6.3%) - operation + transfusion 1
(1.3%) 1 (2.1%) - Arterial occlusion 1 (1.3%) 1 (2.1%) - 0.44 operation 1 (1.3%) 1
(2.1%) - Survival until hospital discharge 41 (53.9%) 27 (56.3%) 14 (50.0%) 0.60

Comparison of patients treated with MTH who received Angio-Seal and those
who did not Patients who were treated with MTH and received Angio-Seal
presented less often with myocardial infarction (31.3% versus 62.5%; p=0.03),
received less frequent percutaneous coronary intervention (50.0% versus 84.4%;
p=0.01), were treated with eptifibatide less frequently (6.25% versus 34.4%;
p=0.03), and coronary angiography was shorter (34.4 21.6 min versus 55.3
27.0 min; p=0.01) than in patients who did not receive an Angio-Seal device.
No significant differences were observed with regard to the patients gender,
age, witnessed arrests, lay-resuscitation, initial shockable rhythm, prevalence of
coronary artery disease, vascular complications, or survival until hospital
discharge (Table 2). Comparison of patients not treated with MTH who received
Angio-Seal and those who did not In the victims who suffered from OHCA who
were not treated with MTH, no differences could be observed between those
patients who received an Angio-Seal and those patients who did not (Table 2).
Discussion Mild therapeutic hypothermia In victims who suffered OHCA, the
combination of MTH and early coronary angiography inclusive PCI, if necessary,
has been described as feasible and safe [2-6]. Specifically, bleeding
complications have been excluded as relevant clinical problems related to MTH in
several previous studies [8-12]. However, bleeding rates varied enormously in
the different studies. While Nielsen et al. [2] described an increased risk of
bleeding in only 4% of all patients following OHCA if coronary angiography with
(6.2%) or without PCI (2.8%) was performed, other studies reported much higher
bleeding rates of more than 20% [6, 13, 14] and a tendency towards increased
bleeding complications in the MTH-treated group, which we also observed in our
data (p=0.08) (table 2) [6, 14]. The underlying mechanism for this observation is
unknown. Coronary angiography per se affects coagulation [15], and therapeutic
hypothermia may, depending on the depth and duration, induce coagulopathy
[16]. Additionally, in an animal model, thrombelastometry at 34C during
hypothermia showed significant differences for clotting time and clot formation
[17]. Nevertheless, to our knowledge, there is no study that could further
differentiate the influence of each of these individual factors. In addition,
patients routinely receive heparin before coronary angiography and platelet
inhibitors in association with PCI in a standard dose regardless of their postresuscitation status. However, although it could be shown that MTH does not
augment abciximab-induced inhibition of platelet aggregation [18], there are no
reports on the influence of hypothermia on clopidogrel, prasugrel, or ticagrelor
concentrations, and a potentially resulting risk of under- or overtreatment with
these drugs in OHCA victims treated with MTH. Int. J. Med. Sci. 2015, Vol. 12
http://www.medsci.org 309 Table 2: Comparison of out-of-hospital cardiac arrest
(OHCA) victims who received an Angio-Seal after coronary angiography and
those who did not receive an Angio-Seal with special attention to additional
treatment with mild therapeutic hypothermia Patients treated with MTH Patients
not treated with MTH Angio-Seal n = 16 No Angio-Seal n = 32 p Angio-Seal
n = 10 No Angio-Seal n = 18 p Male gender 8 (50.0%) 21 (65.6%) 0.30 5
(50.0%) 12 (66.7%) 0.39 Age (years) [range] 66.0 14.6 [3788] 60.4 13.0
[3487] 0.19 66.8 15.4 [4788] 67.9 8.7 [5385] 0.81 Witnessed cardiac
arrest 13 (81.3%) 25 (78.1%) 0.13 7 (70.0%) 15 (83.3%) 0.14 Lay resuscitation 6

(37.5%) 16 (50.0%) 0.41 8 (80.0%) 13 (72.2%) 0.73 Initial shockable rhythm 8

(50.0%) 22 (68.8%) 0.21 6 (60.0%) 8 (44.4%) 0.52 Myocardial infarction 5
(31.3%) 20 (62.5%) 0.03 5 (50.0%) 8 (44.4%) 0.79 ST elevation myocardial
infarction 5 (31.3%) 14 (43.8%) 3 (30.0%) 5 (27.8%) (STEMI) 0 (0.0%) 6 (18.8%)
2 (20.0%) 3 (16.7%) Non-ST elevation myocardial infarction (NSTEMI) Coronary
artery disease 11 (68.8%) 29 (90.6%) 0.06 8 (80.0%) 15 (83.3%) 0.83 One vessel
disease 2 (12.5%) 5 (15.6%) 0 (0.0%) 6 (33.3%) Two vessel disease 5 (31.3%) 7
(21.9%) 3 (30.0%) 2 (11.1%) Three vessel disease 4 (25.0%) 17 (53.1%) 5
(50.0%) 7 (38.9%) Percutaneous coronary intervention (PCI) 8 (50.0%) 27
(84.4%) 0.01 7 (70.0%) 11 (61.1%) 0.64 Left anterior descendens (LAD) 4
(25.0%) 12 (37.5%) 2 (20.0%) 3 (16.7%) Ramus circumflexus (RCX) 0 (0.0%) 4
(12.5%) 1 (10.0%) 2 (11.1%) Right coronary artery (RCA) 3 (18.8%) 5 (15.6%) 1
(10.0%) 5 (27.8%) Multi vessel disease (MV) 1 (6.3%) 5 (15.6%) 3 (30.0%) 1
(5.6%) Coronary artery bypass graft (CABG) 0 (0.0%) 1 (3,1%) 0 (0.0%) 0 (0.0%)
Use of Eptifibatide (Integrilin) 1 (6.3%) 11 (34.4%) 0.03 1 (10.0%) 4 (22.2%)
0.42 Duration of coronary angiography (min) [range] 34.4 21.6 [893] 55.3
27.0 [15132] 0.01 58.5 54.4 [7186] 46.8 20.2 [1676] 0.42 Vascular
complication 3 (18.8%) 3 (9.4%) 0.36 0 (0.0%) 0 (0.0%) n.a. Hb relevant bleeding
3 (18.8%) 2 (6.3%) 0.18 - - conservative therapy 1 (6.3%) 0 (0.0%) - - transfusion
1 (6.3%) 2 (6.3%) - - operation 1 (6.3%) 0 (0.0%) - - Arterial occlusion 0 (0.0%) 1
(3.1%) 0.48 - - operation - 1 (3.1%) - - Survival until hospital discharge 8 (50.0%)
19 (59.4%) 0.54 6 (60.0%) 8 (44.4%) 0.43 n.a.: not available Figure 1:
Differences within the group of patients treated with vascular closure devices
depending on whether they received mild therapeutic hypothermia (MTH) or not.
Int. J. Med. Sci. 2015, Vol. 12 http://www.medsci.org 310 We therefore
recommend that previous studies should try to verify whether some of these
factors combined may increase the risk of bleeding, requiring transfusion when
an invasive procedure is performed in resuscitated patients treated with MTH.
Vascular closure devices Several studies describe the safety of vascular closure
devices after routine coronary angiogram and routine PCI [19, 20], as well as
following coronary interventions using anticoagulation and GP IIb/IIIa inhibitor
therapy [21]. Therefore, the use of VCDs has increased during the last decade,
especially since the application of VCDs has been described as independently
associated with a reduction in the rate of vascular complications and the post-PCI
length of hospital stay [22]. Nevertheless, there are also data that reported an
increase in the serious risk for retroperitoneal bleeding in patients treated with
VCDs [23]. Additionally, in contrast to elective settings, the risk of access siterelated vascular complications was significantly increased after application of the
VCD Angio-Seal in patients undergoing emergency catheterisations for
NSTEMI/STEMI when compared with manual compression [24]. Since victims from
OHCA undergo emergency catheterisation, VCDs should be used carefully in this
group. However, no previous study focused specifically on this patient collective.
In our study, VCDs were used in about one third (34.2%) of all OHCA victims
(Table 1). Further subgroup analysis revealed that, at least in patients treated
with MTH, the application of Angio-Seal devices was influenced by coronary
findings, such as myocardial infarction, percutaneous coronary intervention, or
treatment with GP IIb/IIIa inhibitor, with less frequent use of VCDs in more

complex procedures (Table 2). However, the use of VCDs was not adapted for
further treatment with MTH in general (Table 2, Figure 1). Regardless of whether
the OHCA were treated with MTH after coronary angiography or not, we could not
observe any difference in the rate of vascular complications or survival rates
between patients treated with or without VCD (Table 2). Limitations The present
study is a single center study and, therefore, our findings should be verified by
further investigations. Conclusions In our study, the overall rate of vascular
complications related to coronary angiography was higher in patients treated
with MTH, but was not affected by the application of a VCD. Therefore, our data
suggest that the use of VCDs in OHCA victims might be also feasible and safe in
patients treated with MTH, at least if the decision to use them is carefully
considered and adapted on an individual basis. Conflict of interest All authors
declare no conflicts of interest. References 1. Nolan JP, Soar J, Zideman DA, et al.
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Int. J. Med. Sci. 2015, Vol. 12 http://www.medsci.org 306 International Journal of

Medical Sciences 2015; 12 (4): 306-311. doi: 10,7150 / ijms.11343 Kertas
Penelitian Menggunakan Vascular Penutupan Perangkat Mengikuti OutOfHospital Jantung Penangkapan? Martin Kristus, Katharina von Isabel
Auenmueller, Jeanette Liebeton, Martin Grett, Wolfgang Dierschke, Jan Peter
Noelke, Irini Maria Breker, Hans-Joachim Trappe Departemen Kardiologi dan
Angiology, Marienhospital Herne, Ruhr - Universitas Bochum, Jerman Sesuai
penulis: Dr . med. Martin Kristus, Departemen Kardiologi dan Angiology,
Marienhospital Herne, Ruhr - Universitas Bochum, Hoelkeskampring 40, 44625
Herne, Jerman. Telp: (0049) -2323-499-5620; Fax: (0049) -2323-499-301; Email:
martin.christ@marienhospital-herne.de 2015 Ivyspring Penerbit. Reproduksi
diperbolehkan untuk penggunaan pribadi, non-komersial, asalkan artikel tersebut
secara keseluruhan, dimodifikasi, dan dikutip benar. Lihat
http://ivyspring.com/terms untuk syarat dan kondisi. Diterima: 2014/12/14;
Diterima: 2015/03/04; Diterbitkan: 2015/03/28 Tujuan Abstrak dan Latar

Belakang: Meskipun penggunaan umumnya luas perangkat penutupan pembuluh

darah (VCD), masih belum jelas apakah mereka juga dapat digunakan dalam
korban dari out-of-rumah sakit serangan jantung (OHCA) diobati dengan terapi
hipotermia ringan (MTH). Metode: Semua korban dari OHCA yang menerima
langsung angiografi koroner setelah OHCA antara 1 Januari 2008 dan 31
Desember 2013 dilibatkan dalam penelitian ini. Operator memutuskan untuk
baik menggunakan VCD (Angio-Seal ) atau kompresi manual tusukan arteri
femoral. Keputusan untuk menginduksi MTH didasarkan pada keadaan klinis.
Hasil: 76 pasien dilibatkan dalam penelitian ini, 46 (60,5%) laki-laki dan 30
(39,5%) wanita dengan usia rata-rata 64,2 12,8 tahun. VCD yang digunakan
dalam 26 pasien (34,2%), dan 48 pasien (63,2%) diobati dengan MTH.
Sementara ada secara signifikan lebih komplikasi vaskular keseluruhan pada
kelompok pasien yang diobati dengan MTH (12,5% vs 0,0%; p = 0,05),
komplikasi vaskular adalah serupa antara pasien dengan VCD atau kompresi
manual, terlepas dari apakah atau tidak mereka diperlakukan dengan MTH .
Kesimpulan: Dalam penelitian kami, tingkat keseluruhan komplikasi vaskular
terkait dengan angiografi koroner lebih tinggi pada pasien yang diobati dengan
terapi hipotermia ringan, tetapi tidak terpengaruh oleh penerapan perangkat
penutupan pembuluh darah. Oleh karena itu, data kami menunjukkan bahwa
penggunaan VCD di korban dari OHCA mungkin layak dan aman pada pasien
yang diobati dengan MTH juga, setidaknya jika keputusan untuk
menggunakannya secara individual hati-hati ditentukan. Kata kunci: out-ofrumah sakit serangan jantung, resusitasi, hipotermia terapeutik ringan,
angiografi koroner, pembuluh darah Pendahuluan perangkat penutupan
Pedoman saat ini Dewan Resuscitation Eropa menekankan angiografi koroner dini
pada semua pasien serangan jantung pasca-yang diduga memiliki arteri koroner
Penyakit [1]. Beberapa penelitian menegaskan bahwa kombinasi terapi
hipotermia ringan (MTH) dan awal angiografi koroner - intervensi koroner
perkutan inklusif (PCI), jika perlu - layak dan aman pada pasien berikut
penangkapan out-of-rumah sakit jantung (OHCA) [2-6 ]. Namun, meskipun
penggunaan perangkat penutupan pembuluh darah (VCD) telah meningkat
selama dekade terakhir, tidak ada penelitian yang difokuskan pada keamanan
VCD sebelum MTH di korban dari OHCA. Bahan dan Metode Pasien keseluruhan,
76 pasien yang menerima darurat angiografi koroner dalam waktu dua jam
pertama setelah OHCA antara 1 Januari 2008 dan 31 Desember 2013 dilibatkan
dalam penelitian ini. Usia rata-rata adalah 64,2 12,8 tahun. Pasien 'Data
dikumpulkan dari pasien catatan kesehatan dan anonim disimpan pada pusat
Ivyspring Penerbit Int. J. Med. Sci. 2015, Vol. 12 http://www.medsci.org 307 basis
data. Koroner angiografi Kateterisasi dilakukan menurut teknik standar dengan
enam pendekatan femoral Perancis. Jika stenosis koroner-arteri baru-baru ini
ditemukan, angioplasti koroner dicoba, kecuali arteri itu terlalu kecil atau
operator dianggap prosedur secara teknis tidak mungkin. Resusitasi dan
stabilisasi prosedur standar dilanjutkan selama prosedur jika perlu. Semua
pasien yang menerima intervensi koroner perkutan menerima 500 mg asam
asetilsalisilat dan 5.000 IU tak terpecah heparin intravena selama PCI, dan 600
mg clopidogrel segera setelah penempatan tabung nasogastrik. Perangkat
penutupan pembuluh darah Pada akhir prosedur, operator memutuskan untuk

menggunakan perangkat penutupan pembuluh darah atau kompresi manual

tusukan arteri femoral. Jika VCD dipilih, perangkat Angio-Seal (St Jude Medical,
Minnetonka, MN, USA) yang terdiri dari dikerahkan anchor polimer-arterially
intra, spons kolagen diposisikan pada dinding arteri luar, dan self-pengetatan
jahitan digunakan. Seluruh sistem bioabsorbed dalam waktu 90 hari. Semua
pasien ditindaklanjuti oleh dokter darurat berpengalaman. Perdarahan Hbrelevan didefinisikan sebagai penurunan hemoglobin lebih dari 3 g / dl dalam 24
jam pertama setelah angiografi koroner dan eksklusi penyebab jelas lainnya atau
tanda perdarahan klinis. Hipotermia terapeutik ringan Keputusan untuk
menginduksi MTH didasarkan pada keadaan klinis, memperhitungkan aspek
seperti ritme awal, durasi resusitasi, dan negara kesadaran. Jika perlu, MTH
diinduksi segera setelah prosedur koroner darurat dengan CoolGard 3000
sistem sejak beberapa penelitian mengkonfirmasi keamanan dan efektivitas
pendinginan intravaskular [7]. Suhu target adalah 33 Celsius selama 24 jam,
laju perubahan suhu yang dimaksimalkan untuk mendorong MTH dan 0,3
Celsius / jam untuk rewarm pasien. The Cooling Kateter dengan garam yang
mengalir dalam ditempatkan melalui vena femoralis di laboratorium kateterisasi
jantung pada akhir prosedur koroner. Analisis statistik Analisis statistik dilakukan
dengan Paket statistik Ilmu Sosial (SPSS 22,0, IBM, Armonk, NY, USA). Variabel
kontinu dinyatakan sebagai mean SD, dan perbandingan variabel kategori
antara kelompok-kelompok dilakukan dengan menggunakan tes Chi-square atau
t-test Student. Pengumpulan dan analisis data telah disetujui oleh komite
peninjau etik lokal. Hasil Semua pasien Dari 76 pasien dilibatkan dalam
penelitian kami, 46 (60,5%) adalah laki-laki dan 30 (39,5%) adalah perempuan,
dan usia rata-rata 64,2 12,8 tahun. Secara keseluruhan, 60 kejadian (78,9%)
yang menyaksikan, berbaring resusitasi dicoba di 43 peristiwa (56,6%), dan 44
pasien (57,9%) disajikan dengan irama shockable awal. Dari 38 (50,0%) pasien
yang disajikan dengan infark miokard, 27 (35,5%) disajikan dengan elevasi ST
infark miokard (STEMI) dan 11 (14,5%) disajikan dengan ST elevasi infark
miokard non (NSTEMI). Angiografi koroner dikonfirmasi penyakit arteri koroner di
63 (82,9%) pasien: 13 (17,1%) pasien memiliki satu penyakit pembuluh, 17
(22,4%) pasien memiliki dua penyakit pembuluh, dan 33 (43,4%) pasien memiliki
tiga penyakit pembuluh. Intervensi koroner perkutan dicoba di 53 (69,7%)
pasien, dengan lesi pelakunya di descendens anterior kiri (LAD) di 21 (27,6%)
pasien, di Ramus circumflexus (RCX) di tujuh (9,2%) pasien, di kanan arteri
koroner (RCA) di 14 (18,4%) pasien, dan dalam koroner artery bypass graft
(CABG) dalam satu (1,3%) pasien, sedangkan 10 (13,2%) pasien menerima
intervensi multi-kapal. Jika perlu, durasi angiografi koroner dan PCI adalah 50,0
31,0 menit. Dalam 17 (22,4%) pasien, eptifibatide digunakan selama intervensi.
Perangkat Angio-Seal digunakan di 26 (34,2%) pasien, dan enam (7,9%)
menunjukkan komplikasi vaskular, seperti Hb-relevan perdarahan (6,6%) atau
oklusi arteri (1,3%). Empat puluh satu (53,9%) pasien yang menerima langsung
angiografi koroner setelah masuk rumah sakit bertahan sampai dikeluarkan dari
rumah sakit (Tabel 1). Perbandingan pasien yang diobati dengan MTH dan pasien
tidak dirawat dengan MTH 48 korban dari OHCA (63,2%) diobati dengan terapi
hipotermia ringan setelah segera angiografi koroner, 28 pasien (36,8%) tidak.
Dalam perbandingan kedua kelompok kami mengamati resusitasi lebih awam

signifikan pada kelompok pasien yang tidak diobati dengan MTH (45,8% vs
75,0%; p = 0,01) dan komplikasi vaskular keseluruhan signifikan lebih pada
kelompok pasien yang diobati dengan MTH (12,5% vs 0,0 %; p = 0,05). Tidak ada
perbedaan yang signifikan dapat diamati dengan memperhatikan jenis kelamin
patients`, usia, penangkapan menyaksikan, irama shockable awal, infark
miokard, Int. J. Med. Sci. 2015, Vol. 12 http://www.medsci.org 308 prevalensi
penyakit arteri koroner, PCI upaya, durasi angiografi koroner, penggunaan
eptifibatide selama PCI, penggunaan Angio-Seal dan kelangsungan hidup
sampai dikeluarkan dari rumah sakit (Tabel 1). Tabel 1: Karakteristik pasien dari
semua pasien (kolom pertama), pasien yang diobati dengan terapi hipotermia
ringan (MTH) berikut out-of-rumah sakit serangan jantung (OHCA; kolom kedua),
dan korban OHCA yang tidak diobati dengan MTH (kolom ketiga) Semua pasien n
= 76 Pasien yang diobati dengan MTH n = 48 Pasien tidak diobati dengan MTH n
= 28 p jender laki 46 (60,5%) 29 (60,4%) 17 (60,7%) 0,98 Usia (tahun)
[berbagai] 64,2 12,8 [ 34-88] 62,3 13,7 [34-88] 67,5 11,3 [47-88] 0.09
Disaksikan serangan jantung 60 (78,9%) 38 (79,2%) 22 (78,6%) 0,81 Lay
resusitasi 43 (56,6%) 22 (45,8 %) 21 (75,0%) 0,01 Awal ritme shockable 44
(57,9%) 30 (62,5%) 14 (50,0%) 0,37 infark miokard 38 (50,0%) 25 (52,1%) 13
(46,4%) 0,92 ST elevasi infark miokard ( STEMI) 27 (35,5%) 19 (39,6%) 8 (28,6%)
Non-ST elevasi infark miokard (NSTEMI) 11 (14,5%) 6 (12,5%) 5 (17,9%) penyakit
arteri koroner 63 (82,9%) 40 (83,3%) 23 (82,1%) 0,89 Satu penyakit pembuluh
13 (17,1%) 7 (14,6%) 6 (21,4%) Dua penyakit pembuluh 17 (22,4%) 12 (25,0%)
5 (17,9%) penyakit Tiga kapal 33 (43,4%) 21 (43,8%) 12 (42,9%) Percutaneous
coronary intervention (PCI) 53 (69,7%) 35 (72,9%) 18 (64,3%) 0,43 descendens
anterior kiri (LAD) 21 (27,6%) 16 (33,3 %) 5 (17,9%) Ramus circumflexus (RCX) 7
(9,2%) 4 (8,3%) 3 (10,7%) arteri koroner kanan (RCA) 14 (18,4%) 8 (16,7%) 6
(21,4%) kapal multi Penyakit (MV) 10 (13,2%) 1 (1,3%) 6 (12,5%) 1 (2,1%) 4
(14,3%) 0 (0,0%) bypass arteri koroner graft (CABG) Penggunaan eptifibatide
(Integrilin ) 17 ( 22,4%) 12 (25,0%) 5 (17,9%) 0,47 Lama angiografi koroner
(min) [berbagai] 50,0 31,0 [7-186] 48,3 27,0 [8-132] 51,0 35,7 [7-186]
0.71 Vascular perangkat penutupan (Angio-Seal ) 26 (34,2%) 16 (33,3%) 10
(35,7%) 0,83 Vascular komplikasi 6 (7,9%) 6 (12,5%) 0 (0,0%) 0,05 Hb relevan
pendarahan 5 (6,6%) 5 (10,4%) - 0,08 terapi konservatif 1 (1,3%) 1 (2,1%) transfusi 3 (3,9%) 3 (6,3%) - Operasi + transfusi 1 (1,3%) 1 (2,1%) - Arteri oklusi
1 ( 1,3%) 1 (2,1%) - 0,44 operasi 1 (1,3%) 1 (2,1%) - Survival sampai dikeluarkan
dari rumah sakit 41 (53,9%) 27 (56,3%) 14 (50,0%) 0,60 Perbandingan pasien
yang diobati dengan MTH yang menerima Angio-Seal dan mereka yang tidak
Pasien yang diobati dengan MTH dan menerima Angio-Seal disajikan kurang
sering dengan infark miokard (31,3% berbanding 62,5%; p = 0,03), menerima
kurang sering intervensi koroner perkutan (50,0% berbanding 84,4%; p = 0,01),
diperlakukan dengan eptifibatide lebih jarang (6,25% dibandingkan 34,4%; p =
0,03), dan angiografi koroner lebih pendek (34,4 21,6 min vs 55,3 27,0
menit; p = 0,01) dibandingkan pasien yang tidak menerima perangkat AngioSeal . Tidak ada perbedaan signifikan yang diamati berkaitan dengan pasien
jenis kelamin, usia, penangkapan menyaksikan, lay-resusitasi, irama shockable
awal, prevalensi penyakit arteri koroner, komplikasi vaskular, atau kelangsungan
hidup sampai dikeluarkan dari rumah sakit (Tabel 2). Perbandingan pasien tidak

dirawat dengan MTH yang menerima Angio-Seal dan mereka yang tidak
Dalam korban yang menderita OHCA yang tidak diobati dengan MTH, tidak ada
perbedaan yang bisa diamati antara pasien yang menerima Angio-Seal dan
pasien yang tidak (Tabel 2). Diskusi hipotermia terapeutik Mild Dalam korban
yang menderita OHCA, kombinasi MTH dan awal koroner angiografi PCI inklusif,
jika perlu, telah digambarkan sebagai layak dan aman [2-6]. Secara khusus,
komplikasi perdarahan telah dikeluarkan sebagai masalah klinis yang relevan
terkait dengan MTH dalam beberapa penelitian sebelumnya [8-12]. Namun,
tingkat pendarahan sangat bervariasi dalam studi yang berbeda. Sementara
Nielsen et al. [2] dijelaskan peningkatan risiko perdarahan hanya 4% dari semua
pasien berikut OHCA jika angiografi koroner dengan (6,2%) atau tanpa PCI (2,8%)
dilakukan, penelitian lain melaporkan tingkat perdarahan lebih tinggi lebih dari
20% [6 , 13, 14] dan kecenderungan peningkatan komplikasi perdarahan pada
kelompok MTH-diobati, yang kami juga diamati pada data kami (p = 0,08) (Tabel
2) [6, 14]. Mekanisme yang mendasari untuk pengamatan ini tidak diketahui.
Koroner angiografi per se mempengaruhi koagulasi [15], dan hipotermia
terapeutik mungkin, tergantung pada kedalaman dan durasi, menginduksi
koagulopati [16]. Selain itu, dalam model hewan, thrombelastometry pada 34 C
selama hipotermia menunjukkan perbedaan yang signifikan untuk waktu
pembekuan dan pembentukan bekuan [17]. Namun demikian, untuk
pengetahuan kita, tidak ada studi yang lebih lanjut bisa membedakan pengaruh
masing-masing faktor individu. Selain itu, pasien secara rutin menerima heparin
sebelum koroner angiografi dan platelet inhibitor dalam hubungan dengan PCI
dalam dosis standar tanpa memandang status pasca-resusitasi mereka. Namun,
meskipun dapat menunjukkan bahwa MTH tidak menambah penghambatan
abciximab-diinduksi agregasi platelet [18], tidak ada laporan tentang pengaruh
hipotermia pada konsentrasi clopidogrel, prasugrel, atau ticagrelor, dan risiko
yang berpotensi mengakibatkan kurang atau overtreatment dengan obat ini
pada korban OHCA diobati dengan MTH. Int. J. Med. Sci. 2015, Vol. 12
http://www.medsci.org 309 Tabel 2: Perbandingan serangan jantung out-of-rumah
sakit (OHCA) korban yang menerima Angio-Seal setelah angiografi koroner
dan orang-orang yang tidak menerima Angio-Seal dengan khusus
memperhatikan perawatan tambahan Pasien hipotermia terapeutik ringan
diobati dengan MTH Pasien tidak dirawat dengan MTH Angio-Seal n = 16 No
Angio-Seal n = 32 p Angio-Seal n = 10 No Angio-Seal n = 18 p Pria
jender 8 (50,0%) 21 (65,6%) 0,30 5 (50,0%) 12 (66,7%) 0,39 Usia (tahun)
[berbagai] 66,0 14,6 [37-88] 60,4 13,0 [34-87] 0.19 66,8 15,4 [47-88]
67,9 8,7 [53-85] 0.81 Disaksikan serangan jantung 13 (81,3%) 25 (78,1%) 0,13
7 (70,0%) 15 (83,3%) 0,14 Lay resusitasi 6 (37,5%) 16 (50,0% ) 0.41 8 (80,0%)
13 (72,2%) 0,73 Awal ritme shockable 8 (50,0%) 22 (68,8%) 0,21 6 (60,0%) 8
(44,4%) 0,52 infark miokard 5 (31,3%) 20 (62,5%) 0.03 5 (50,0%) 8 (44,4%) 0,79
ST elevasi infark miokard 5 (31,3%) 14 (43,8%) 3 (30,0%) 5 (27,8%) (STEMI) 0
(0,0%) 6 (18,8%) 2 (20,0%) 3 (16,7%) Non-ST elevasi infark miokard (NSTEMI)
penyakit arteri koroner 11 (68,8%) 29 (90,6%) 0,06 8 (80,0%) 15 (83,3%) 0,83
Satu penyakit pembuluh 2 (12,5% ) 5 (15,6%) 0 (0,0%) 6 (33,3%) Dua penyakit
pembuluh 5 (31,3%) 7 (21,9%) 3 (30,0%) 2 (11,1%) Tiga penyakit pembuluh 4
(25,0%) 17 (53.1 %) 5 (50,0%) 7 (38,9%) intervensi koroner perkutan (PCI) 8

(50,0%) 27 (84,4%) 0,01 7 (70,0%) 11 (61,1%) 0,64 descendens anterior kiri

(LAD) 4 (25,0% ) 12 (37,5%) 2 (20,0%) 3 (16,7%) Ramus circumflexus (RCX) 0
(0,0%) 4 (12,5%) 1 (10,0%) 2 (11,1%) arteri koroner kanan (RCA) 3 (18,8 %) 5
(15,6%) 1 (10,0%) 5 (27,8%) penyakit multi pembuluh (MV) 1 (6,3%) 5 (15,6%) 3
(30,0%) 1 (5,6%) bypass arteri koroner graft (CABG) 0 (0,0%) 1 (3,1%) 0 (0,0%) 0
(0,0%) Penggunaan eptifibatide (Integrilin ) 1 (6,3%) 11 (34,4%) 0,03 1 (10,0%)
4 (22,2%) 0.42 Durasi angiografi koroner (min) [berbagai] 34,4 21,6 [8-93]
55,3 27,0 [15-132] 0,01 58,5 54,4 [7-186] 46,8 20,2 [16-76] 0.42 Vascular
komplikasi 3 (18,8 %) 3 (9,4%) 0,36 0 (0,0%) 0 (0,0%) na Hb perdarahan yang
relevan 3 (18,8%) 2 (6,3%) 0,18 - - terapi konservatif 1 (6,3%) 0 (0,0%) - transfusi 1 (6,3%) 2 (6,3%) - - Operasi 1 (6,3%) 0 (0,0%) - - Arteri oklusi 0 (0,0%)
1 (3,1%) 0,48 - - Operasi - 1 (3,1%) - - Survival sampai dikeluarkan dari rumah
sakit 8 (50,0%) 19 (59,4%) 0,54 6 (60,0%) 8 (44,4%) 0,43 na: tidak tersedia
Gambar 1: Perbedaan dalam kelompok pasien yang diobati dengan perangkat
penutupan pembuluh darah tergantung pada apakah mereka menerima
hipotermia ringan terapi (MTH) atau tidak. Int. J. Med. Sci. 2015, Vol. 12
http://www.medsci.org 310 Oleh karena itu kami merekomendasikan bahwa studi
sebelumnya harus mencoba untuk memverifikasi apakah beberapa faktor
dikombinasikan dapat meningkatkan risiko perdarahan, membutuhkan transfusi
saat prosedur invasif dilakukan pada pasien diresusitasi diobati dengan MTH.
Perangkat penutupan pembuluh darah Beberapa penelitian menggambarkan
keamanan perangkat penutupan pembuluh darah setelah angiogram koroner
rutin dan PCI rutin [19, 20], serta intervensi koroner berikut menggunakan
antikoagulan dan GP IIb / IIIa inhibitor terapi [21]. Oleh karena itu, penggunaan
VCD telah meningkat selama dekade terakhir, terutama karena penerapan VCD
telah digambarkan sebagai independen terkait dengan penurunan tingkat
komplikasi pembuluh darah dan panjang pasca-PCI tinggal di rumah sakit [22].
Namun demikian, ada juga data yang dilaporkan peningkatan risiko serius bagi
perdarahan retroperitoneal pada pasien yang diobati dengan VCD [23]. Selain
itu, berbeda dengan pengaturan elektif, risiko akses situs yang berhubungan
dengan komplikasi vaskular meningkat secara signifikan setelah penerapan VCD
Angio-Seal pada pasien yang menjalani catheterisations darurat untuk NSTEMI
/ STEMI bila dibandingkan dengan kompresi pengguna [24]. Sejak korban dari
OHCA menjalani kateterisasi darurat, VCD harus digunakan dengan hati-hati
dalam kelompok ini. Namun, tidak ada penelitian sebelumnya difokuskan secara
khusus pada kolektif pasien ini. Dalam penelitian kami, VCD yang digunakan
dalam sekitar sepertiga (34,2%) dari semua korban OHCA (Tabel 1). Analisis
subkelompok lebih lanjut mengungkapkan bahwa, setidaknya pada pasien yang
diobati dengan MTH, penerapan Angio-Seal perangkat dipengaruhi oleh
temuan koroner, seperti infark miokard, intervensi koroner perkutan, atau
pengobatan dengan GP IIb / IIIa inhibitor, dengan kurang sering digunakan VCD
dalam prosedur yang lebih kompleks (Tabel 2). Namun, penggunaan VCD tidak
disesuaikan untuk perawatan lebih lanjut dengan MTH secara umum (Tabel 2,
Gambar 1). Terlepas dari apakah OHCA diobati dengan MTH setelah angiografi
koroner atau tidak, kita tidak bisa mengamati perbedaan dalam tingkat
komplikasi vaskular atau tingkat kelangsungan hidup antara pasien yang diobati
dengan atau tanpa VCD (Tabel 2). Keterbatasan Penelitian ini adalah studi pusat

tunggal dan, karena itu, temuan kami harus diverifikasi oleh penyelidikan lebih
lanjut. Kesimpulan Dalam penelitian kami, tingkat keseluruhan komplikasi
vaskular terkait dengan angiografi koroner lebih tinggi pada pasien yang diobati
dengan MTH, tapi tidak terpengaruh oleh penerapan VCD. Oleh karena itu, data
kami menunjukkan bahwa penggunaan VCD di korban OHCA mungkin juga layak
dan aman pada pasien yang diobati dengan MTH, setidaknya jika keputusan
untuk menggunakannya dengan hati-hati dipertimbangkan dan disesuaikan
secara individual. Konflik kepentingan Semua penulis menyatakan tidak ada
konflik kepentingan. Referensi 1. Nolan JP, Melambung J, Zideman DA, et al.
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