1. How to Optimize Therapeutic Hypothermia and What to Expect
CRT 2012
How to Optimize Therapeutic Hypothermia and What to Expect
Dr. Michael Mooney
Director Interventional Cardiology Minneapolis Heart Institute
Associate Professor of Clinical Medicine
University of Minnesota

2. I have no real or apparent conflicts of interest to report.
Michael R. Mooney, MD
I have no real or apparent conflicts of interest to report.

3. Cardiac Arrest Out-of-hospital cardiac arrest (OOHCA) affects
295,000 people annually in the US
7.9% median survival rate
Anoxic encephalopathy and neurologic deficits are common and disabling - among survivors
Modest gain with CPR advances, many failed clinical trials – BRCT - barbiturates
Enormous public health issue - personal, family & societal burdens
Growing awareness of needed cardio-cerebral protection
Lloyd-Jones D, Adams R, Carnethon M et al. Heart disease and stroke statistics-2009 update. Circulation 2009;119:e21-e181.

4. Hypothermia Pivotal Studies
HACA,
2002
Bernard,
2002

5. Therapeutic Hypothermia is:
Hypothermia is the gold standard treatment for reperfusion injury
Reperfusion injury is important in both cardiac arrest/anoxic encephalopathy and acute MI
TH is pluripotent
TH is standard of care for CA
TH is an emerging treatment for Acute MII
TH is markedly underutilized

6. Hypothermia: mechanisms
ischemia
reperfusion
mitochondrial
Dysfunction /Ca influx
reactive oxygen
species (ROS)
inflammatory
cascades
hypothermia
vascular dysfunction/hypotension
apoptosis – organ dysfunction
cerebral edema
*Dr. Abella, University of Pennsylvania

7. Hypothermia Trials: Outcomes
(%)
P value
Normothermia
(%) RR
(95% CI)
Alive at hospital discharge with favourable neurological recovery
HACA
0.006
72/136
(53%)
50/137
(36%)
1.51
( )
Bernard
21/43
(49%)
9/34
(26%)
2.65
( )
0.046
Alive at 6 months with favourable neurological recovery
HACA
71/136
(55%)
50/137
(39%)
1.44
( )
0.009

8. Hypothermia guidelines New Guidelines – more aggressive, 30’ CPR
Full recoil. 30:2
Less defib use
Hypothermia Level I A recommendation
Hypothermia
guidelines

10. Theory meets Practice? – not yet
Less than 7% of OOHCA pts get TH - <15,000 of 295,000
Fewer than 300 hospitals have programs or equipment of 6,000 eligible hospitals
Awareness and funding limited – FDA approval and perceived complexity are barriers
Cardiology is not yet in the lead
Research continues – despite challenges b/o enormous persistent unmet need

12. . Helicopter Locations 2009 In Response to the STEMI Program at MHI
Red– Zone II ( mins)
Blue– Zone I (< 90 mins)
Helicopter Locations 2009
In Response to the STEMI Program at MHI
Red– Zone II ( mins)
Blue– Zone I (< 9 mins) .

13. Arctic Sun Energy Transfer Pad ™ Placement

15. Why Use the Peritoneal Cavity?
Efficient heat exchange
> 50% of total blood flow
Large surface area
Unparalleled speed ( minutes to 34°C)
Eliminates femoral access interference
Eliminates upper chest and neck area interference 15

16. Peritoneal Cooling - Velomedix™, Inc
Automated Peritoneal
Lavage System (APLS)
Efficient heat exchange
Tight control for cooling and warming
Does not restrict access
Fully automated system 16

17. Life Recovery Systems

18. Intravascular Coling Intravascular Cooling
InnerCool - Phillips

19. The Main Concepts a Cardiac Emergency Program
ACCESS TRANSPORTATION STREAMLINE CARE
DATA COLLECTION FEEDBACK RESEARCH
Prehospital
Outstate Hospital
EMS Transport
Tertiary Center

20. Abbott Northwestern Hospital 72/140 51.4%
Outcomes
Abbott Northwestern Hospital / %
Survival by diagnosis
STEMI: 49/ %
Other: 29/ %
Survival by initial rhythm
VF/VT: 68/ %
PEA/Asystole: 7/ %
Alive at hospital discharge with favourable neurological recovery

21. Transfer and Nontransfer Outcomes Transfer = Blue line, nontransfer = Red line
75% of total patients in the Cool It Program are transfers

22. Early Cooling is Critical
Source
Chi Square DF
P-value
Time ROSC to First Cooling min
5.0785 1
0.0242
Estimate
Lower CL
Upper CL
P-value
1.25
1.06
1.44
0.0081
If the time to first cooling increases by an hour the hazard of death increases 25%.

23. The best TH patient is: OOH with <15 min down time Witnessed VF
Bystander CPR
Has a STEMI
Lives in Minnesota, Seattle , Arizona, (systems of care)
Gets cooling in the first hour after rosc

24. Keys to Success Cardiology champion Form a team .. Educate
Set and follow a protocol with standardized orders
Intensivists , ICU nurses, ethics panel
Get good early results
Hold off on neuro consult for 5 days
Prognosticate only after 4-5+ days
Be patient – dark tunnel analogy

25. But, you have the equipment and will be asked to consider in hospital arrests
Difficult intubation prolonged anoxia
EMD/asystole - generally poor
Drug overdose - hypoventilation
EP incessant VT / tamponade
Sepsis /respiratory failure uniformly poor
Yes, consider but choose wisely
Be careful, your success and failure will be remembered don’t go off the reservation early
Always consider the reversibility of presenting profile

26. But, a more pressing issue
How do we advance TH in the US as the standard of care for OOHCA
Integrate into STEMI networks
Eliminate the death penalty
Foster a national comprehensive CV emergency system

27. Discharge Coordination
CV Emergency
Program
Development
Acute Coronary
Syndromes
Resuscitation
Center
Acute Aortic
Emergency
Level 1 STEMI
Level 2 NSTEMI
Urgent
Cardiac Arrest
Acute
Aortic
Dissection
Critical Limb
Ischemia
Abdominal Aortic
Aneurysm
Stroke
(Neurological
Emergencies)
Chest Pain Center
Therapeutic
Hypothermia
Non-Traumatic
Shock Treatment
Heart Failure Center
LVAD to Transplant
ED HF
Abbott Northwestern Hospital System of CV Emergency Care
Pre-Hospital
Care Coordination
Post-Hospital
Discharge Coordination
DATA COLLECTION/
ANALYSIS
Clinical Support Services
Research
Education
Publications
Advanced Imaging
Vascular Surgeons
Hemodynamic
Support
24/7
Intensivists
Hospitalists
Cardiac/Transplant
Surgeons
Rehabilitation
Administrative Support Services
CV Emergency
Program Manager
Nurse Educator
Administrative
Assistant
Clinical Assistants
Extensive Education for Patients, Community & Providers

28. To maximize benefits, cooling should be initiated as soon as possible.
Survival benefits are dramatic.
But, we under-deliver this lifesaving treatment
Systems of Care Do Make a Difference
TH capable Acute MI PCI centers should offer this lifesaving treatment, it is a public health care imperative.