Incidence and Clinical Relevance of Echocardiographic Visualization of Occult Ventricular Fibrillation: A Multicenter Prospective Study of Patients Presenting to the Emergency Department After Out-of-Hospital Cardiac Arrest - 18/09/25
, Robert Lindsay, MD a, Trent She, MD b, Josie Acuna, MD c, Andrew Balk, MD d, Jakub Bartnik, MD e, Jacob Baxter, MD f, Drew Clare, MD g, Richard J. Caplan, PhD h, John DeAngelis, MD i, Levi Filler, DO j, Powell Graham, MD a, Mike Hill, MD a, John Hipskind, MD k, Ryan Joseph, DO l, Monica Kapoor, MD a, Tobi Kummer, MD m, Margaret Lewis, MD n, Stephanie Midgley, MD o, Ari Nalbandian, MD a, Offdan Narveas-Guerra, MD f, Jason Nomura, MD p, Irina Sanjeevan, MD q, Mark Scheatzle, MD r, Nikolai Schnittke, MD s, Michael Secko, MD t, Zachary Soucy, DO u, Jeffrey R. Stowell, MD j, Rebecca G. Theophanous, MD, MHSc v, Jordan Tozer, MD w, Tyler Yates, MD x, Timothy Gleeson, MD aAbstract |
Study objectives |
Ventricular fibrillation (VF) is traditionally identified on ECG but echocardiography can visualize myocardial fibrillation. The prevalence and importance of occult VF defined as a nonshockable ECG rhythm but VF by echocardiography is unknown.
Methods |
In this multicenter, prospective study, emergency department patients presenting following out-of-hospital cardiac arrest were eligible for inclusion if echocardiography and ECG were performed simultaneously. Recorded echocardiography and ECG were interpreted separately by physicians blinded to all patient and resuscitation information. The primary outcome was percentage of occult VF. The secondary outcomes included survival to hospital discharge, termination of defibrillated VF, and return of spontaneous circulation (ROSC). Termination of VF is described as a postdefibrillation change in ECG rhythm to a nonshockable rhythm. Multivariate modeling accounted for confounding variables.
Results |
Of 811 patients enrolled, 5.3% (95% confidence interval [CI] 3.9 to 7.1) demonstrated occult VF. An additional 24.9% (95% CI 22.1 to 28.0) demonstrated ECG VF. Of the patients with occult VF, 81.4% demonstrated ECG pulseless electrical activity (PEA) and 18.6% demonstrated ECG asystole. Occult VF was less likely to be defibrillated compared with ECG VF. Defibrillation was not significantly more likely to terminate occult VF (75.0% vs 55.6%; odds ratio [OR], 2.3; 95% CI 0.42 to 15.24). ROSC was not statistically different for occult VF compared with ECG VF (39.5% vs 24.8%; OR, 2.26; 95% CI 0.87 to 5.9). Survival to hospital discharge was no different for patients with occult VF compared with ECG VF (7.0% vs 5.4%; OR, 3.6; 95% CI 0.63 to 19.2) despite fewer defibrillation attempts for patients with occult VF.
Conclusion |
Occult VF was seen in 5.3% of patients following out-of-hospital cardiac arrest. Recognizing and treating occult VF who otherwise would have been treated as PEA or asystole led to survival outcomes indistinguishable to traditionally recognized VF.
Le texte complet de cet article est disponible en PDF.Keywords : Cardiac arrest, Ventricular fibrillation, Echocardiography, Electrocardiography, ECG
Plan
| Please see page 329 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Michael Gottlieb, MD. Specific detailed information about possible conflicts of interest for individual editors is available at editors. |
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| Author contributions: RG conceived the study and designed the trial. RG, TG, PG, and RL supervised the conduct of the trial and data collection. All authors undertook recruitment of participating centers and patients and managed the data, including quality control. RG and RJC provided statistical advice on study design and analyzed the data; PG chaired the data oversight committee. RG drafted the manuscript, and all authors contributed substantially to its revision. RG takes responsibility for the paper as a whole. |
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| Data sharing statement: Partial datasets and data dictionary are available from January 1, 2026, upon request to Dr. Gaspari at email Romolo.Gaspari@umassmemorial.org. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The study was conducted without funding, but statistical support during the final revisions of the manuscript was provided by an Institutional Development Award (IDeA) from the National Institute of General Medical Sciences of the National Institutes of Health under grant number U54-GM104941 (PI: Hicks) and the state of Delaware. Tobias Kumar reports consulting fees from GE HealthCare and research funding from Philips. Jason Nomura reports consulting fees from Philips and Caption AI and research funding from Bayer. Nikolai Schnittke reports research funding from Phillips. Zachary Soucy reports consulting fees from Creare Inc and is on the Advisory Board for Sonosite/Fujifilm. All other authors report no conflicts of interests. |
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| Trial registration number: 04906252 |
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| Presentation information: Data of this article were presented at the following meetings: Society for Academic Emergency Medicine National Conference, Phoenix, Arizona, May 2024; American College of Emergency Physicians Research Forum (ACEP24), Las Vegas, Nevada, October 2024; and American Heart Association Resuscitation Science Symposium Conference, Chicago, Illinois, November 2024. |
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Vol 86 - N° 4
P. 328-336 - octobre 2025 Retour au numéro
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