Comedian Joan Rivers remained in serious condition Friday after going into cardiac arrest during an outpatient procedure at a New York medical clinic a day earlier. Her daughter, Melissa, said in a statement that her 81-year-old mother is “receiving the best treatment and care possible” and that the family appreciates the public keeping Rivers in their thoughts as “we pray for her recovery.”
While devastating and frightening, cardiac arrest during surgery is rare, said Dr. Benjamin Scirica, a cardiologist at Brigham and Women’s Hospital.
“Surgeons and anesthesiologists spend a lot of time before these procedures to identify any medical history, sign, or symptom that could put a patient at risk for cardiac arrest,” he said.
Safer sedation drugs and closer cardiac monitoring have also lowered the risk of heart complications in recent years.
“Situations are far more controlled than in the past,” said anesthesiologist Dr. Emery Brown, director of the neuroscience statistic research lab at Massachusetts General Hospital.
Rivers’ age might have contributed to her risk, however, because advanced age is one of the strongest predictors of having a serious complication while under anesthesia, Scirica said.
It isn’t known whether Rivers had underlying heart disease, which would have also increased her risk of cardiac arrest -- nor have her doctors disclosed how long her brain was deprived of oxygen before she was resuscitated.
She was reportedly having an endoscopy procedure, possibly vocal surgery, at Yorkville Endoscopy, an outpatient health care facility on the Upper East Side of Manhattan, according to the New York Times. After Rivers’ heart stopped while under anesthesia, medical staff resuscitated her and sent her by ambulance to Mount Sinai Hospital, a few blocks away.
“Any surgical procedure is stressful psychologically and physiologically, which can tax the heart,” said Dr. Mark Link, a cardiologist and co-director of the New England Cardiac Arrhythmia Center at Tufts Medical Center. A drop in blood pressure caused by anesthesia drugs can reduce blood flow to the heart, which also increases the risk of cardiac arrest.
But on the rare occasion when the heart does stop, he said, doctors should have a defibrillator on hand to shock the heart into beating again. Cardiac pulmonary resuscitation -- which involves chest compressions to induce the heart to pump blood to the brain -- can also be performed to ensure the brain is not deprived of oxygen for too long.
“That’s our biggest concern,” Scirica said. “The chances of surviving -- and surviving with full brain function -- hinges on how much we can limit the time the brain spends without oxygen.”
Most patients recover from cardiac arrest quickly and with their full mental faculties intact if their heartbeat can be resumed within two to five minutes, according to Link. Those deprived of oxygen for longer than eight minutes often suffer from significant brain damage -- from the initial lack of oxygen and from the swelling that results from the healing process -- if they survive at all.
Anonymous sources who spoke to the NY Daily News on Friday claimed that Rivers was in a medically induced coma, but a Mount Sinai Hospital representative would not comment on those reports.
Patients in cardiac arrest for prolonged periods often are sedated and sometimes cooled to a low body temperature for a few days to reduce blood flow and swelling to the brain.
“Clinical trials suggest about 40 percent of these patients do reasonably well afterward,” Link said, “though that doesn’t mean they recover all their brain function.”
He questioned whether Rivers would have had a safer experience if her medical procedure had taken place at a hospital rather than at a medical clinic without a large emergency support staff.
“I would certainly want my parents in a hospital setting rather than at an outpatient clinic,” Link said, “and they’re 78.”
Whether Rivers would have benefitted from having her endoscopy in a large teaching hospital, such as where she’s now being treated, is likely impossible to determine. “The majority of people who go into cardiac arrest will die even if it occurs in the hospital,” Scirica said, “because it’s such a catastrophic event.”