mhif research highlights: january 2019€¦ · dr. daniel melby and team – congratulations on...

MHIF Research Highlights: JANUARY 2019

FEATURED MHIF STUDIES Open for Enrollment and Referrals!

ACCUCINCH early feasibility in significant symptomatic MVR and LV remodelingCONTACT: Sara Olson, 612-863-7601

XIENCE 90 for patients at high risk of bleeding who need coronary stentsCONTACT: Amy McMeans, 612-863-3895

VISITAG SURPOINT tag index-guided ablation for atrial fibrillationCONTACT: Jacob Cohen, 612-863-6051

MARK YOUR CALENDARSCongratulations on First Enrollments!

• Dr. Daniel Melby and team –Congratulations on first enrollment inthe VISITAG SURPOINT study!

• Dr. David Lin and Christine Majeski– Way to go on your FIRST IN THEWORLD enrollment for the Rhapsodystudy!

Time to Run… or volunteer!MHIF is proud to sponsor the Valentine’s 5K with Twin Cities in Motion. Mark your calendar!

Sat., Feb. 9, Lake Nokomis!

Raising Awareness of Valvular Disease!MHIF is hosting a second annual Mechanics of a Healthy Heart event for patients.

Thurs, Feb. 21, Golden Valley Country Club!

SHARING GREAT RESEARCH…

Dr. Jay Traverse published NHLBI-Sponsored postconditioning study in Circulation Research showing delayed benefit for STEMI patients!

THANKS Dr. Retu Sexana for sharingimportant updates on women’s heart health for the Twin Cities in Motion Podcast!

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Minneapolis Heart Institute Foundation® Cardiovascular Grand Rounds Title: A promising therapy in resuscitation: head up cardiopulmonary resuscitation

Speaker: Johanna C. Moore, MD, MS Faculty Physician, Director of Laboratory Research Department of Emergency Medicine Hennepin Healthcare

Assistant Professor of Emergency Medicine University of Minnesota Medical School

Date: February 4, 2019 Time: 7:00 – 8:00 AM

Location: ANW Education Building, Watson Room

OBJECTIVES At the completion of this activity, the participants should be able to: 1. Describe physiology of cardiac arrest and use of circulatory adjuncts during CPR to improve perfusion.2. Understand the proposed physiology and mechanisms of actions of Head Up CPR.3. Explain potential clinical benefits of Head Up CPR.

ACCREDITATION Physician - Allina Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Nurse - This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.0 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education.

DISCLOSURE POLICY & STATEMENTS Allina Health, Learning & Development intends to provide balance, independence, objectivity and scientific rigor in all of its sponsored educational activities. All speakers and planning committee members participating in sponsored activities and their spouse/partner are required to disclose to the activity audience any real or apparent conflict(s) of interest related to the content of this conference.

The ACCME defines a commercial interest as “any entity” producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to be commercial interests - unless the provider of clinical service is owned, or controlled by, an ACCME-defined commercial interest.

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Moderator(s)/Speaker(s) Dr. Johanna Moore has disclosed that she DOES NOT have any real or apparent conflicts with any commercial interest as it relates to presenting the content in this activity/course.

Planning Committee Dr. Alex Campbell, Jake Cohen, Jane Fox, Dr. Mario Gössl, Dr. Kevin Harris, Dr. Kasia Hryniewicz, Rebecca Lindberg, Amy McMeans, Dr. Michael Miedema, Dr. JoEllyn Moore, Pamela Morley, Dr. Scott Sharkey, and Jolene Bell Makowesky have disclosed that they DO NOT have any real or apparent conflicts with any commercial interest as it relates to the planning of this activity/course. Dr. David Hurrell has disclosed the following relationship -Boston Scientific: Chair, Clinical Events Committee.

NON-ENDORSEMENT OF COMMERCIAL PRODUCTS AND/OR SERVICES We would like to thank the following company for exhibiting at our activity.

Amgen Zoll LifeVest

Accreditation of this educational activity by Allina Health does not imply endorsement by Allina Learning & Development of any commercial products displayed in conjunction with an activity.

A reminder for Allina employees and staff, the Allina Policy on Ethical Relationship with Industry prohibits taking back to your place of work, any items received at this activity with branded and or product information from our exhibitors.

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If audited by a licensing board or submitting for license renewal or certification renewal, boards will ask you not the entity providing the education for specific information on each activity you are using for credit. You will need to demonstrate that you attended the activity with a copy of your certificate/evidence of attendance, a brochure/flier and/or the conference handout.

Each attendee at an activity is responsible for determining whether an activity meets their requirements for acceptable continuing education and should only claim those credits that he/she actually spent in the activity.

Maintaining these details are the responsibility of the individual.

PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE.

Signature: __________________________________________________________________________ My signature verifies that I have attended the above stated number of hours of the CME activity.

Allina Health - Learning & Development - 2925 Chicago Ave - MR 10701 - Minneapolis MN 55407

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MHIF CV Grand Rounds – Feb 4, 2019

Head Up CPRFebruary 4, 2019

Johanna Moore MD, MScDepartment of Emergency MedicineHennepin Healthcare

Assistant ProfessorUniversity of Minnesota Medical School

Financial Disclosures

• No COI to disclose

• Co‐PI on NIH NHLBI SBIR grant

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This is your brain…on CPR. What do you want?

Cerebral Perfusion Pressure = Mean Arterial Pressure‐ Intracranial PressureACD: Active Compression DecompressionITD: Impedance Threshold Device

Ryu HH, Moore JC, Yannopoulos D, Lick M, McKnite S, Shin SD, Kim TY, Metzger A, Rees J, Tsangaris A, Debaty G, Lurie KG. The effect of head up cardiopulmonary resuscitation on cerebral and systemic hemodynamics. Resuscitation. 2016;102:29‐34

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Head Up CPR: Take Home Points

• Animal studies have shown that Head Up CPR as compared to flat CPR:

Increases cerebral perfusion pressure

Increases cerebral blood flow

Increases coronary perfusion pressure

Decreases Intracranial Pressure

• Human cadaver studies have shown that Head Up CPR as compared to flat CPR:

Increases cerebral perfusion pressure and decreases intracranial pressure

• Head Up CPR used as a part of new bundles of care has resulted in increased hospital to admission rates

Why do we need to improve CPR?

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Girotra S et al. Regional Variation in Out‐of‐Hospital Cardiac Arrest Survival in the United States. Circulation. 2016 May 31;133(22):2159‐68.

2017 CARES Data: HEMS

Hennepin EMS(n = 357)

Minnesota(n = 2,216)

National(n = 76,215)

Overall Survival(all rhythms)

14.0% (50) 12.0% (267) 10.4% (7949)

Overall Survival with good brain function

9.8% (35) 9.7% (216) 8.4% (6392)

Utstein Bystander(shockable rhythm, witnessed,bystander CPR)

46.9% (32) 40.8% (184) 36.5% (4935)

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Time Up After 23‐25ish Minutes?

0

.05

.1

.15

.2

.25

.3

Cu

mula

tive

Inci

denc

e

0 20 40 60 80analysis time

PEA / asystole VF / VT

Competing-risks regression

DebatyG, Moore JC, Labarere J, Burkhart N, Segal N, Lurie KG. Defining the End of the Circulatory Phase in Humans Undergoing Cardiopulmonary Resuscitation. Circulation. 2017; 136:A20385.

There Is No Silver Bullet

• There is not a single fix to improve outcomes

• We must build upon the chain of survival

‐Try to ensure patients get as many elements as possible

‐Build new promising therapies into the chain of survival

• Enhancing perfusion during CPR is optimal for all brains and hearts,regardless of etiology of arrest

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Inspiration

What Position is best?

93

Head Down

Head Up

Flat

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Head Up CPR: How Does It Work?•Similar to the concept of elevating the head of a patient with a neurosurgical emergency

• Increases venous drainage from head, venous sinuses, and cervical paravertebral plexus

•Decreases “concussion with every compression” by mitigating pressure transduced up the vasculature to the head

•Ultimately improves cerebral blood flow, perfusion pressures

• Improves cardiac flow? Reduces pulmonary vascular resistance? Improves neuro outcomes?

• 14 pigs were placed on a tilt table, underwent LUCAS+ITD CPR

• 5 min supine, 5 min Head Up, 5 min Head Down after 6 min of ventricular fibrillation

• An additional 8 pigs were measured at different angles of CPR

• Brain blood flow was measured in 8 pigs

Head Up CPR‐First Study 2014

Debaty G, Shin SD, Metzger A, Kim T, Ryu HH, Rees J, McKnite S, Matsuura T, Lick M, Yannopoulos D, Lurie K. Tilting for perfusion: Head‐up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87:38‐43

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Debaty et al, Resuscitation, 2015

Supine 0° CPR 30° Head down CPR

Change of position (CPR + ITD ‐ rate 100/min)

Ao

ICP

CerPP

Debaty et al, Resuscitation, 2015.

Change of Position: Head Down

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Supine 0° CPR 30° Head up CPR

Change of position (CPR + ITD - rate 100/min)

Ao

ICP

CerPP

Debaty et al, Resuscitation, 2015.

Change of Position: Head Up

Head Up CPR: First Study

• Cerebral brain blood flow was 50% higher (0.19 ± 0.04 ml/min/g/tissue at 0◦ vs 0.27 ± 0.04 at 30◦ Head Up )

• Cerebral perfusion pressure was higher (19 ± 3 mmHg at 0◦ vs 35 ± 3 at 30◦ Head Up (p < 0.001)

• Coronary perfusion pressure was higher (19 ± 2 mmHg at 0◦ vs 30 ± 3 at 30◦ Head Up (p < 0.001)

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Ryu HH, Moore JC, Yannopoulos D, Lick M, McKnite S, Shin SD, Kim TY, Metzger A, Rees J, Tsangaris A, Debaty G, Lurie KG. The effect of head up cardiopulmonary resuscitation on cerebral and systemic hemodynamics. Resuscitation. 2016;102:29‐34

Head Up CPR: Second Study

• Different body position

• Different CPR methods: ACD+ITD and standard

• Longer ventricular fibrillation time (8 min)

• 2 minutes flat, or “priming”

• Longer CPR time (22 min total)

Moore JC, Segal N et al. Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged cardiac arrest. Resuscitation 2017; 121:195‐200.

• Sought to replicate study 2, with brain blood flow Brain blood flow doubled at 15 min:

ACD+ITD Flat at 0.21 ± 0.04 mg/mL/g tissueACD+ITD Head Up 0.42 ± 0.05 mg/mL/g tissue (p = 0.01)

**0.19 ± 0.04 flat vs. 0.27 ± 0.04 mg/mL/g tissue HUP with LUCAS+ITD at 5 minutes

Head Up CPR: Third Study

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Is There an Optimal Angle?

• VF left untreated for 8 minutes

• Animals were randomized to one of 6 combinations for 5 minute CPR intervals:

20°, 30°, 40° 20°, 40°, 30°

30°, 20°, 40° 30°, 40°, 20°

40°, 20°, 30° 40°, 30°, 20°

• No difference in Cerebral Perfusion Pressure (p = 0.52) in 13 pigs:

20°, 36 ± 19

30°, 42 ± 21

40°, 44 ± 27

Is There an Optimal Angle?• Must balance ICP and Aortic Pressure 30 degrees of elevation maximizes coronary and cerebral perfusion with LUCAS+ITD

• Probably between 30° and 40° but the absolute height of the heart and brain and rate of rise is more important

Debaty G, Shin SD, Metzger A, Kim T, Ryu HH, Rees J, McKnite S, Matsuura T, Lick M, YannopoulosD, Lurie K. Tilting for perfusion: Head‐up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87:38‐43

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CerPP was higher if 40o HUP was performed during the last 5 minutes of the resuscitation (81 mmHg ± 16), versus 20o HUP and 30o HUP combined (41 mmHg ± 19, p = 0.007)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

5 minutes 10 minutes 15 minutes

mmHg

Cerebral Perfusion Pressure

20 degrees 30 degrees 40 degrees

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0


mmHg

Coronary Perfusion Pressure

20 degrees 30 degrees 40 degrees

Moore et al, AHA‐ReSS, 2018

Sequence Study

• 13 animals studied: 7 with 20°, 30°, 40° sequence and 6 with 40°, 30°, 20°

• After 15 minutes of CPR, CerPP were higher with the 20°, 30°, 40° sequence: 54 ±21 mmHg versus 26 ± 18 mmHg (p = 0.03)

Cerebral Perfusion Pressure, mmHg ± SD

Coronary Perfusion Pressure, mmHg ± SD

20°, 30°, 40° 54 ± 21 45 ± 20

40°, 30°, 20° 26 ± 18 * 25 ± 16

* p = 0.03


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Sequence Study

0

10

20

30

40

50

60

5 minutes 10 minutes 15 minutes*

mmHg

Cerebral Perfusion Pressure

40,30,20 20,30,40

* p = 0.03

0

10

20

30

40

50


mmHg

Coronary Perfusion Pressure

40,30,20 20,30,40


Sequence Study

0

10

20

30

40

50

60

70


mmHg

Mean Aortic Pressure

40,30,20 20,30,40

0

5

10

15

20


mmHg

Mean Intracranial Pressure

40,30,20 20,30,40


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How Fast to Raise The Head?

0

10

20

30

40

50

60

70

BL 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Cer

ebra

l Per

fusi

on P

ress

ure

(mm

Hg)

CPR Duration

10 min 4 min 24 sec 2 min

Rojas‐Salvador C, et al. NAEMSP 2019

You’re Doing It Wrong…

•All animal studies have shown that Head Up CPR is reliant on technology that augments perfusion during CPR such as LUCAS+ITD or ACD+ITD

•Standard CPR does not provide good enough baseline perfusion to harness the effect of HUP CPR

•It is hard to pump blood uphillDebaty G, Pepe P, Yannopoulos D, Segal N, Lurie KG, Moore JC. Impact of the Impedance Threshold Device During Cardiopulmonary Resuscitation in Head up Position. Circulation. 2017;136:A20275

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20.00

30.00

40.00

50.00

60.00

70.00

Cereb

ral P

erfusion Pressure (mmHg)

CPR time (minutes)Fast Slow

Standard

ACD+ITD

Putzer G et al.

Rojas‐Salvador C et al.

Ryu HH et al.

Human Cadaver Head Up Studies

• Sought to replicate Head Up physiology in humans

• Studied 9 recently deceased human cadavers who had donated their bodies to science

• Bodies were never frozen. Airway, Vascular, Intracranial Access

• 2 minute epochs of standard, ACD+ITD CPR, ACD+ITD Head Up CPR

S‐CPR ACD+ITD

CPR

ACD+ITD

HUP CPR

ITP ‐0.1±1 ‐5.0±2 ** ‐5.7±2

MAP 7.8±4 5.2±3* 5±5

RA 9.0±2 8.7±3 9.9±5

ICP 0.8±2 0.7±3 ‐8.1±6**

CerPP 3.5±4 1.3±4.3* 11.3±5**

*** p≤0.001 ; ** p<0.01 ; * p<0.05 vs the previous intervention

Moore JC, Holley JE, Frascone R, Segal N, Lick C, Klein L, et al. Abstract 18260: Head up Position Lowers Intracranial Pressure in a Human Cadaver Model of Cardiopulmonary Resuscitation. Circulation. 2016;134(Suppl 1):A18260‐A

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Moore JC, Holley JE, Frascone R, Segal N, Lick C, Klein L, et al. Abstract 18260: Head up Position Lowers Intracranial Pressure in a Human Cadaver Model of Cardiopulmonary Resuscitation. Circulation. 2016;134(Suppl 1):A18260‐A

Head Up Intervention

Human Cadaver Tracing

ITP

Aortic BP

Right Atrial Pressure

ICP

CorPP

CerPP

Erich J. Heads‐Up CPR: Can Elevating the Patient’s Head Improve Outcomes? 2015. Available from: http://www.emsworld.com/article/12088616/heads‐up‐cpr

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Palm Beach County FloridaHead Up CPR Experience (2014‐2016)

Paul E. Pepe, MD, MPH, Kenneth A. Scheppke, MD, Peter M. Antevy, MD

Protocol Changes in 2015

1) Ensure proper use of mechanical CPR

2) Apply O2 but defer ventilation 6 mins;

3) Apply impedance threshold device;

4) Automated CPR

5) Raise the backboard 30o (head/torso up position).

34

In PressCritical Care Medical 2018

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Overall Outcomes – Survival to Hospital Admission

Resuscitation Rates Before After p value

All patients 17.9% 34.2% <0.001

VF/VT 23.0% 44.4% =0.001Non-VF/VT 13.6% 30.9% <0.001

Pepe et al. Crit Care Med. In Press.

2100 Cases from 2014‐2016Palm Beach County Outcomes: Survival to Hospital Admission

Outcome improved across all subgroups while response intervals, indications for initiating CPR, and bystander CPR rates were unchanged

Pepe et al. Crit Care Med. In Press.

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Wedge and towel

37

Mechanical lift with sniffing position

38

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Body and LUCAS Slip Off

39

EleGARD with Automated CPR

40

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The ”Do’s and Don’ts” of Head Up CPR

•Do’s

1. Use circulatory adjuncts during CPR (ITD alone + standard CPR, automated CPR+ ITD, ACD+ITD)

2. ”Prime” the circuit before elevation (90‐120 sec)

3. Consider elevating the head and chest/shoulders only during CPR

•Don’ts

1. Perform Head Up CPR with standard CPR alone

2. Raise the head of the patient immediately while in arrest

3. Avoid elevating the whole body over prolonged CPR effort

4. Elevate at a high angle, then come down, there is a sequence effect

Moore et al. Resuscitation 2018.

The Bundle of Care‐Head Up CPR

Electrical Circulatory Metabolic Refractory Arrest Post ROSC

0 to 4 minutes 4 to 10 (20?) minutes

10 (20?) to 60 minutes?

>60 min, await ROSC post cath

Immediate High Quality CPR

Defibrillation

Head Up CPR

Epinephrine

High Quality CPR

Defibrillation

Head Up CPR

Epinephrine?

Anti‐arrhythmics

High Quality CPR

eCPR <60 min

Defibrillation

Head Up CPR

Additional pharmacologic agents

Continue eCPR

Cardiac Catheterization

Head Up CPR

Therapeutic Hypothermia

Maintain MAP (65? 80?) via pressors, fluids, active IPR therapy

Head Up Position?

Avoid hypoxia

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Summary1. Head Up CPR improves cerebral perfusion, and to a lesser degree, cardiac

perfusion.

2. Findings of animal studies have been replicated in cadaver studies

3. Head Up CPR is used as parts of new bundles of care in a few sites throughout the country, with improved outcomes

4. Head Up CPR must be performed with circulatory adjuncts

5. Head Up CPR is a promising therapy to improve neurologic outcome after cardiac arrest

6. There is no silver bullet for cardiac arrest‐many things must be performed correctly in the chain of survival for a good neurologic outcome!

References 1• DebatyG, Shin SD, Metzger A, Kim T, Ryu HH, Rees J, McKnite S, Matsuura T, Lick M, Yannopoulos D, Lurie K. Tilting for perfusion: Head‐up position during cardiopulmonary resuscitation improves brain flow in a porcine model of cardiac arrest. Resuscitation. 2015;87:38‐43

• Debaty G, Pepe P, Yannopoulos D, Segal N, Lurie KG, Moore JC. Impact of the Impedance Threshold Device During Cardiopulmonary Resuscitation in Head up Position. Circulation. 2017;136:A20275

• Erich J. Heads‐Up CPR: Can It Improve Outcomes? A new twist on an old method has some top docs excited. EMS World. 2015 44:22‐4.

• Moore JC, Segal N, Lick MC, Dodd KW, Salverda BJ, Hinke MB, Robinson AE, DebatyG, Lurie KG. Head and thorax elevation during active compression decompression cardiopulmonary resuscitation with an impedance threshold device improves cerebral perfusion in a swine model of prolonged of cardiac arrest. Resuscitation. Resuscitation. 2017; 121: 195‐200. PMID: 28827197

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References 2• Moore JC, Holley J, Segal N, Lick M, Labarère J, Frascone RJ, Dodd K, Robinson A, Lick C, Klein LR, Ashton A, McArthur A, Tsangaris A, Makaretz A, Makaretz M, DebatyG, Pepe P, Lurie KL. Consistent Head Up Cardiopulmonary Resuscitation HaemodynamicsAre Observed Across Porcine and Human Cadaver Translational Models. Resuscitation. 2018. pii: S0300‐9572(18)30170‐9. doi: 10.1016/j.resuscitation.2018.04.009. [Epub ahead of print] PMID: 29702188

• Moore JC, Segal N, DebatyG, Lurie KG. The “Do’s and Don’ts” of Head Up CPR: Lessons Learned from the Animal Laboratory.” Resuscitation. August 2018; 129: e6‐e7

• Moore JC, Salverda B, Lick M, Rojas‐Salvador C, DebatyG, Segal N, Lurie KG. Controlled progressive elevation maximizes cerebral perfusion pressure during head up CPR in a swine model of cardiac arrest. Accepted for oral presentation at the AHA Resuscitation Science Symposium, November 2018, Chicago, IL.

References 3

• Pepe PE, Scheppke KA, Antevy PM, Coyle C, Millstone D, PrusanskyC, Moore JC. Confirming the clinical safety and feasibility of a bundled methodology to improve cardiopulmonary resuscitation involving a head‐up/torso‐up chest compression technique. Critical Care Medicine. In Press.

• Putzer G, Braun P, Martini J, Niederstätter I, Abram J, Lindner AK, et al. Effects of head‐up vs. supine CPR on cerebral oxygenation and cerebral metabolism – a prospective, randomized porcine study. Resuscitation 2018;128:51‐5.

• Rojas‐Salvador C, Moore JC, Salverda B, DebatyG, Lick M, Lurie KG. Controlled fast head and thorax elevation improves cerebral perfusion pressure during active compression and decompression cardiopulmonary resuscitation with an impedance threshold device in a porcine model of cardiac arrest. Accepted for poster presentation at the NAEMSP Annual Meeting, 2019, Austin TX.

• Ryu HH, Moore JC, Yannopoulos D, Lick M, McKnite S, Shin SD, Kim TY, Metzger A, Rees J, Tsangaris A, Debaty G, Lurie KG. The effect of head up cardiopulmonary resuscitation on cerebral and systemic hemodynamics. Resuscitation. 2016;102:29‐34.

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mhif research highlights: january 2019€¦ · dr. daniel melby and team – congratulations on...

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