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  1. SUMMARY OF RELAVENT ARTICLES REGARDING THE RIGHT HEART AND ARREST Reference Study Design Results/conclusions Aagaard R, Caap P, Hansson NC, Bøtker MT, Granfeldt A, Løfgren B. Detection of Pulmonary Embolism During Cardiac Arrest-Ultrasonographic Findings Should Be Interpreted With Caution. Critical care medicine. 2017; 45(7):e695-e702. [PMID: 28403120] • • • N =24 pigs given cardiac arrest (via pulmonary embolism, hypoxia, or primary arrhythmia; 8 in each group), then were resuscitated after 7 minutes of untreated cardiac arrest. Ultrasonographic images were obtained and the right ventricular diameter was measured. Results from the article: The right ventricle was more dilated during resuscitation when cardiac arrest was caused by pulmonary embolism compared with hypoxia and primary arrhythmia. However, the right ventricle was dilated, irrespective of the cause of arrest, and diagnostic accuracy by physicians with basic training in focused cardiac ultrasonography was modest. These findings challenge the paradigm that right ventricular dilatation on ultrasound during cardiopulmonary resuscitation is particularly associated with pulmonary embolism. Shows that pigs with hypoxia and to a certain extent, arrhythmia, can also have RV dilation, especially if they’re untreated or under-treated. Not every RV dilation seen on arrest is from PE. Especially if its mild-moderate dilation. Also did another mini-study where they had physicians look at the images and rate them as “severely” or “moderately” dilated: N = 18 EP’s (anesthesiologist) The physicians tested could identify the severely dilated RV with a sensitivity of 79% (95% CI, 64–94) and a specificity of 68% (95% CI, 56–80). Keep in mind, thought, that the ultrasound images were presented on a laptop in an office setting and the ability to detect a difference would most likely be lower in a clinical setting. The right ventricle was dilated during resuscitation from cardiac arrest caused by hypovolemia, hyperkalemia, and primary arrhythmia. These findings indicate that right ventricle dilation may be inherent to cardiac arrest, rather than being associated with certain causes of arrest. • • • Aagaard R, Granfeldt A, Bøtker MT, Mygind-Klausen T, Kirkegaard H, Løfgren B. The Right Ventricle Is Dilated During Resuscitation From Cardiac Arrest Caused by Hypovolemia: A Porcine Ultrasound Study. Critical care medicine. 2017; 45(9):e963-e970. [PMID: 28430698] N = 30 pigs got cardiac arrest via three different methods, hypovolemia, hyperkalemia, primary arrhythmia. Had 7 mins of untreated arrest was followed by resuscitation. Echo done at various times. Primary endpoint was the right ventricular diameter at the third rhythm analysis. Prospective observational study of consecutive patients (n=36) who were admitted with (n=20) or unexpectedly developed (n=16) sudden cardiac arrest of unknown cause were studied with transesophageal echocardiography during CPR N = 19 pigs (13 intervention, 6 control) were given hypoxia by disconnecting the ETT. They took the equivalent of parasternal short axis clips every 30 seconds. They looked for RH enlargement via evaluating the left ventricular (LV) eccentricity index (which is an index of LV D-shaping). Higher number is more D-shaping of the LV. Ventricular dimensions were determined by MRI for 30 minutes of untreated VF in a closed- chest, closed-pericardium model in 6 swine. • • Comess KA, DeRook FA, Russell ML, et al: The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity. Am J Med 2000; 109:351–356 In one sample of 25 patients with PEA, 14 had a significantly enlarged RV, but PE could only be confirmed in nine cases by either direct visualization with TEE or autopsy (22). • • Sørensen AH, Wemmelund KB, Møller-Helgestad OK, Sloth E, Juhl-Olsen P. Asphyxia causes ultrasonographic D-shaping of the left ventricle--an experimental porcine study. Acta anaesthesiologica Scandinavica. 2016; 60(2):203-12. [PMID: 26346667] Their conclusion: The early and transient acute dilatation of the RV, coinciding with D-shaping of the LV and decrease in LV end-diastolic area was seen in asphyxia. These findings, while traditionally attributed to PE, can also be seen in asphyxia. • • • Berg RA, Sorrell VL, Kern KB. Magnetic resonance imaging during untreated ventricular fibrillation reveals prompt right ventricular overdistention without left ventricular volume loss. Circulation. 2005; 111(9):1136-40. [PMID: 15723975] Within 1 minute of untreated VF, mean right ventricular volume increased by 29% but did not increase thereafter. Recent visual epicardial observations in an open-chest, open-pericardium model of swine VF indicate that blood flows from the high-pressure arterial system to the lower-pressure venous system during untreated VF, thereby overdistending the right ventricle and apparently decreasing left ventricular size