The Future of Cardiac Arrest Management: Integrating Innovative Techniques like REBOA

Cardiac arrest remains one of the most critical challenges in emergency medicine. Patient outcomes often hinge on how quickly and effectively treatment is provided. Despite significant advances in cardiopulmonary resuscitation (CPR) techniques and technologies, survival rates for out-of-hospital cardiac arrest remain discouragingly low.

To put this in perspective, a comprehensive meta-analysis by Yan et al. (2020) provides a detailed look at out-of-hospital cardiac arrest (OHCA) outcomes globally. The study analyzed data from 141 studies and found that while 29.7% of patients achieved a return of spontaneous circulation (ROSC) pre-hospital, only 22% survived to hospital admission. More critically, just 8.8% of patients survived to hospital discharge. These sobering statistics have spurred researchers to explore innovative approaches to improve these outcomes. 

One such innovation gaining attention is Resuscitative Endovascular Balloon Occlusion of the Aorta or REBOA. This technique is emerging as a potential game-changer in cardiac arrest management. But what exactly is REBOA, and how might it help? Let’s dive in.

The Current Landscape of Cardiac Arrest Management

Before we explore REBOA, it’s important to understand the current approach to managing cardiac arrest. The foundation of cardiac arrest treatment is built on what’s known as the “chain of survival.” This concept emphasizes five key steps:

1. Early recognition of cardiac arrest and calling for help
2. Immediate high-quality CPR
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care

While this approach has saved countless lives, it has limitations. This is particularly true in cases of refractory cardiac arrest, where standard interventions fail to restart the heart.

In recent years, medical professionals have introduced several advanced techniques to address these challenging cases:

1. Extracorporeal CPR (ECPR): This technique involves using a machine to circulate blood outside the body, essentially taking over the function of the heart and lungs. A review by Holmberg et al. (2018) found that ECPR could more than double the chances of survival and good neurological outcomes in selected patients. However, it is extremely resource intensive, requiring specialized equipment and trained personnel, limiting its use to advanced medical centers.
2. Mechanical CPR Devices: These are machines designed to perform chest compressions automatically. The idea is to provide consistent, high-quality CPR without the fatigue that human rescuers experience. However, a comprehensive review by Wang et al. (2016) found no clear evidence that these devices improve survival rates compared to manual CPR performed by trained professionals.
3. Targeted Temperature Management (TTM): This involves cooling the patient’s body after cardiac arrest to help protect the brain from damage. However, recent research has challenged its effectiveness. A large trial by Dankiewicz et al. (2021) found that actively cooling patients to 33°C (91.4°F) didn’t provide additional benefits compared to simply preventing fever.

Despite these advancements, there’s still a pressing need for new strategies to improve outcomes, especially for patients who don’t respond to standard treatments. REBOA may ultimately be able to fill this very important gap.

Understanding REBOA: A New Approach to Cardiac Arrest

REBOA, or Resuscitative Endovascular Balloon Occlusion of the Aorta, is a technique originally developed to manage severe bleeding in trauma patients. Now, researchers are exploring its potential in cardiac arrest management.

Here’s how it works: A specially designed catheter with a balloon at its tip is inserted into the femoral artery (a large artery in the groin) and guided into the aorta (the main artery carrying blood from the heart to the rest of the body). Once in position, the balloon is inflated, blocking blood flow to the lower body. This redirects blood to the heart and brain – the two organs most critical for survival in cardiac arrest.

The potential benefits of REBOA in cardiac arrest include:

1. Improved Blood Flow to Vital Organs: By blocking blood flow to less critical areas, REBOA may increase blood supply to the heart and brain during CPR.
2. Enhanced CPR Effectiveness: REBOA could amplify the effects of chest compressions by directing the limited blood flow to where it’s needed most.
3. Bridge to Advanced Treatments: For patients needing complex interventions like ECPR, REBOA might provide a strong “perfusion bridge” to allow for ECPR preparation and implementation.

What Does the Research Say?

While the use of REBOA in cardiac arrest is still experimental, early studies in humans have shown promise:

• A small study by Levis et al. (2017) reported success in using REBOA as a bridge to ECPR in three cases of refractory cardiac arrest. All three patients survived and left the hospital with good neurological outcomes – an impressive result given the typically poor prognosis for such cases.
• A pilot study by Brede et al. (2019), published in the Journal of the American Heart Association, explored REBOA in out-of-hospital cardiac arrest. In this small study of 10 patients, REBOA was successfully used in every case, with the procedure taking an average of just under 12 minutes. Six of the ten patients (60%) regained a pulse, indicating that REBOA could play a role in restoring circulation. Additionally, the study found that end-tidal CO2 levels, a marker for blood flow, increased significantly after REBOA placement, indicating better organ perfusion during CPR. These promising findings have since led to the following study mentioned below. 
• Brede JR et al. (2021) described an ongoing clinical trial in Norway that aims to provide more definitive evidence. This study, known as the REBOARREST trial, plans to include 200 patients and compare survival rates between those receiving REBOA and those receiving standard advanced cardiac life support.

However, it’s crucial to note that large-scale clinical evidence is still lacking. Researchers are still working to establish the best ways to use REBOA in cardiac arrest situations.

How Does REBOA Compare to Other New Technologies?

To understand REBOA’s potential impact, it’s helpful to compare it to other emerging technologies in cardiac arrest management:

Both REBOA and ECPR aim to improve blood flow but in different ways. REBOA might be faster to initiate and could potentially stabilize patients until ECPR can be started, and it may be used in more resource-restrictive environments. However, ECPR provides more comprehensive support by fully taking over heart and lung functions. When compared to mechanical CPR devices, which aim to provide consistent chest compressions, REBOA takes a different approach by redirecting blood flow. It could potentially enhance the effectiveness of both manual and mechanical CPR and is seen as complementary rather than competitive. However, it’s important to note that REBOA is more invasive and requires specialized training to use than CPR.

Potential Impact on Organ Donation

Advanced resuscitation techniques like REBOA have the potential to increase rates of return of spontaneous circulation (ROSC) in cardiac arrest patients. However, achieving ROSC does not always correlate with good neurological outcomes. This scenario raises an important consideration: the potential impact on organ donation rates. In the context of ECPR, studies have suggested that its use in refractory cardiac arrest might increase the pool of potential organ donors.

While specific data on REBOA’s impact on organ donation is not yet available, the parallels with ECPR suggest this could be an important area for future research. As studies on REBOA in cardiac arrest continue, it will be crucial to monitor not only survival rates and neurological outcomes but also any potential effects on organ donation rates.

Challenges and Ethical Considerations

While REBOA shows promise, its potential integration into cardiac arrest treatment isn’t without challenges. The technical complexity of REBOA, which requires specialized training and equipment, could limit its widespread adoption, especially in smaller hospitals or rural areas. As an invasive procedure, REBOA carries risks, including potential injury to blood vessels and ischemia-reperfusion injury – a type of damage that can occur when blood flow is restored to tissues after a period without oxygen, potentially causing inflammation and tissue damage. Determining who might benefit from REBOA in the fast-paced, high-stress environment of cardiac arrest treatment is challenging, and implementing REBOA would require investment in equipment and training. These factors collectively pose hurdles to the widespread integration of REBOA in cardiac arrest management protocols.

Important ethical considerations must also be addressed. These include ensuring fair access to this advanced treatment, addressing informed consent in emergency situations, and balancing innovation with patient safety.

Looking to the Future

As REBOA research in cardiac arrest progresses, several key challenges are emerging that will shape future investigations. A major hurdle is the risk of rearrest after achieving return of spontaneous circulation (ROSC) with REBOA, as it improves blood flow but doesn’t address the underlying cause of arrest. To combat this, researchers may explore integrating REBOA with extracorporeal cardiopulmonary resuscitation (ECPR) for longer-term support and develop techniques to reduce heart workload post-ROSC. The role of targeted temperature management and other post-resuscitation strategies in REBOA-assisted resuscitations needs further study, as does refining patient selection to identify which cardiac arrest cases benefit most from this intervention. Future research will likely focus on these challenges, aiming to develop comprehensive protocols that integrate REBOA into a multi-faceted approach to cardiac arrest management, with collaboration across specialties being key to addressing these complex issues and improving patient outcomes.

Conclusion

As explored throughout this article, REBOA represents an intriguing new approach to cardiac arrest management. While it’s too early to call it a breakthrough, the potential benefits are certainly worth our attention.

The early results from REBOA studies give us reason for cautious optimism. We’ve seen cases where patients with otherwise grim prognoses have survived, offering a glimmer of hope in situations that often feel hopeless. 

That said, we can’t ignore the challenges. REBOA is complex, requires specialized training, and comes with its own set of risks. It would be no small feat to implement it widely, especially in resource-limited settings. And as with any new medical intervention, we must carefully weigh the potential benefits against the risks and costs.

Despite these hurdles, there’s something exciting about REBOA. It represents the kind of innovative thinking we need in emergency medicine. In the end, whether it’s REBOA or another innovation yet to come, our goal remains the same: to give cardiac arrest patients a better chance at survival and recovery. It’s a tough challenge, but every small step forward matters. REBOA might be one of those steps.

References:

1. Brede JR, Lafrenz T, Klepstad P, et al. Feasibility of Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta in Non-Traumatic Out-of-Hospital Cardiac Arrest. J Am Heart Assoc. 2019;8(22):e014394. doi:10.1161/JAHA.119.014394 https://pubmed.ncbi.nlm.nih.gov/31707942/
2. Brede JR, Skulberg AK, Rehn M, et al. REBOARREST, resuscitative endovascular balloon occlusion of the aorta in non-traumatic out-of-hospital cardiac arrest: a study protocol for a randomised, parallel group, clinical multicentre trial. Trials. 2021;22(1):511. Published 2021 Jul 31. doi:10.1186/s13063-021-05477-1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8325811/
3. Dankiewicz J, Cronberg T, Lilja G, et al. Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2021;384(24):2283-2294. doi:10.1056/NEJMoa2100591 https://pubmed.ncbi.nlm.nih.gov/34133859/
4. Holmberg MJ, Granfeldt A, Guerguerian AM, et al. Extracorporeal cardiopulmonary resuscitation for cardiac arrest: An updated systematic review. Resuscitation. 2023;182:109665. doi:10.1016/j.resuscitation.2022.12.003 https://pubmed.ncbi.nlm.nih.gov/36521684/
5. Levis A, Greif R, Hautz WE, et al. Resuscitative endovascular balloon occlusion of the aorta (REBOA) during cardiopulmonary resuscitation: A pilot study. Resuscitation. 2020;156:27-34. doi:10.1016/j.resuscitation.2020.08.118 https://pubmed.ncbi.nlm.nih.gov/32866549/
6. Brooks SC, Hassan N, Bigham BL, Morrison LJ. Mechanical versus manual chest compressions for cardiac arrest. Cochrane Database Syst Rev. 2014;(2):CD007260. Published 2014 Feb 27. doi:10.1002/14651858.CD007260.pub3 https://pubmed.ncbi.nlm.nih.gov/24574099/
7. Yan S, Gan Y, Jiang N, et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Crit Care. 2020;24(1):61. Published 2020 Feb 22. doi:10.1186/s13054-020-2773-2 https://pubmed.ncbi.nlm.nih.gov/32087741/