Mechanical complication of  an ­infarct or of its treatment?
Outcome after a prolonged resuscitation attempt

Mechanical complication of an ­infarct or of its treatment?

Images in Cardiovascular Medicine
Issue
2016/12
DOI:
https://doi.org/10.4414/cvm.2016.00448
Cardiovascular Medicine. 2016;19(12):335

Affiliations
Department of Cardiology, University Hospital, Bern, Switzerland

Published on 21.12.2016

At 05:30 in the morning, a 51-year-old male patient in cardiogenic shock was admitted from an outside hospital. Four hours earlier, the patient had become symptomatic with epigastric pain, emesis and syncope, and suffered cardio­respiratory arrest. He had been resuscitated by his family prior to arrival of the emergency team. Professional resuscitation had been continued at the patient’s home for another 45 minutes. Coronary angio­graphy revealed three-vessel coronary artery disease with chronic total occlusions of the right coronary ­artery and the left circumflex coronary artery, as well as severe stenoses of the left anterior descending artery. Left ventricular (LV) ejection fraction was 20%. In the LV infero-basal region, a sacular structure was seen; its “neck” (→) measured >2 cm in diameter (fig. 1A, B). Initial differential diagnosis of this structure ­included, among others, LV pseudoaneurysm. Venoarterial extracorporeal membrane oxygenation (ECMO) was installed to treat the patient’s cardiogenic shock. Heparin infusion was started at 10:00. Transoesophageal echocardiography shortly after ECMO implantation revealed a permanently closed aortic valve with aortic root thrombosis (fig. 1C). At 10:00, 100 ml of ­sodium bicarbonate 8.4% was infused. At 10:57, the aortic valve was opening again, and the aortic root thrombosis had disappeared (fig. 1D). In the afternoon of the same day, the still shocked patient entered a myoclonic state. After interdisciplinary discussion, it was judged that neither surgical nor interventional therapy would alter the patient’s outcome. The patient expired late in the evening of the same day. Final diagnosis was not a mechanical complication of the probably subacute myocardial infarction (rather a congenital LV aneurysm), nor of its treatment by ECMO with aortic root thrombosis, but extensive ischaemic brain injury in the context of prolonged resuscitation.
Figure 1: Description see text.
No financial support and no other potential conflict of interest 
relevant to this article was reported.
Correspondence:
Christian Seiler, MD,
FACC, FESC
Professor of Medicine and Co-Chairman of Cardiology
University Hospital
CH-3010 Bern
christian.seiler[at]insel.ch