The Heart Team approach to cardiac arrest

Abstract

Cardiac arrest is a critical emergency in cardiovascular medicine, requiring rapid, multidisciplinary interventions to enhance patient survival and neurological outcomes. This review explores the unique challenges of managing out-of-hospital (OHCA) and in-hospital cardiac arrest (IHCA), with a focus on mechanical circulatory support (MCS) and extracorporeal cardiopulmonary resuscitation for selected patients. While OHCA management should prioritize rapid transport to specialized centres, IHCA may allow for immediate, patient-tailored interventions. Post-cardiac arrest syndrome adds complexity, often requiring nuanced MCS escalation and weaning. Standardized protocols, ethical considerations, and further research are essential to refine patient selection and improve outcomes, ultimately advancing cardiac arrest care.

Keywords: Cardiac arrest; Heart Team; In-hospital cardiac arrest; Mechanical circulatory support; Out-of-hospital cardiac arrest; Post-cardiac arrest syndrome.

Figure 1

Patients with refractory cardiac arrest and extracorporeal cardiopulmonary resuscitation management. Patients with refractory cardiac arrest, who meet eligibility criteria for extracorporeal cardiopulmonary resuscitation (ECPR), may be considered for ECPR to achieve immediate cardiopulmonary stabilization. In contrast, patients who do not fulfil ECPR criteria may be considered for donation after circulatory death with the patient’s advanced directives and the preferences of their relatives. Neurological prognostication should be initiated following ECPR as part of the post-cardiac arrest therapeutic protocol. At 24 h, central nervous system function should be assessed, and in cases where brain death is diagnosed, donation after brain death may be considered in alignment with the patient’s advanced directives and the preferences of their relatives. If central nervous system function is poor or uncertain, a follow-up assessment is conducted after 48 hours (h). However, if cooling is in place at 24 h, completing brain death diagnostics is not feasible at this time point and might be delayed. During the post-cardiac arrest treatment phase, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) should be gradually weaned in stable patients. If adverse effects associated with VA-ECMO, such left ventricular overload or pulmonary congestion, or insufficient level of haemodynamic support with VA-ECMO alone become apparent, the additional insertion of a percutaneous or surgically implanted micro-axial flow pump (mAFP) may be considered, a strategy commonly referred to as "ECMELLA". The optimal timing for initiating left ventricular unloading or escalating support with mAFP remains uncertain. The use of a surgically implanted mAFP may theoretically offer further benefits by facilitating the weaning process from VA-ECMO and supporting patient recovery (extubation and mobilization).