Emergent bedside transesophageal echocardiography in the resuscitation of sudden cardiac arrest after tricuspid inflow obstruction and pulmonary embolism
Journal
Anesthesia and Analgesia
Journal Volume
89
Journal Issue
6
Pages
1406-1408
Date Issued
1999
Author(s)
Abstract
Forty-three percent of cases of pulmonary embolism occur after abdominal surgery, of which 0.44% result in mortality (1). We report a case of sudden cardiac arrest 10 days after radical hysterectomy as a result of a total tricuspid valve obstruction and massive pulmonary embolism, which were immediately diagnosed with the use of bedside transesophageal echocardiography (TEE). The patient survived after effective resuscitation, extracorporeal membrane oxygenation (ECMO), and emergent pulmonary thromboembolectomy. The usefulness of bedside TEE is demonstrated. Case Report A 58-yr-old, 60-kg woman presented with squamous cell carcinoma of the uterine cervix. Radical hysterectomy was successfully performed with general anesthesia without immediate postoperative complications. On the tenth postoperative day, the patient developed sudden cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated with artificial ventilation via endotracheal intubation and external cardiac massage. After the IV administration of epinephrine (5 mg total), a systolic blood pressure of 80 mm Hg and a pulse rate of 140 bpm were obtained. Within 5 min, however, blood pressure decreased rapidly. Cardiac arrest ensued again and did not respond to further CPR. Emergent TEE was performed at the bedside during the resuscitation, which revealed marked dilation of the right atrium, a small right ventricle (RV), and nearly empty chambers of the left heart. Massive thromboemboli in the right atrium were found trapped at the tricuspid valve, resulting in total obstruction (Fig. 1). In an attempt to resolve the RV inflow obstruction, a right internal jugular venous catheter was inserted, and a large amount of small emboli was aspirated. However, a large mass was shown by TEE to remain trapped in the tricuspid valve. In an attempt to dislodge the embolus, we shook the patient vigorously. Figures 2 and 3 show that the embolus subsequently moved to the pulmonary artery (PA), passing through the RV. Systolic blood pressure returned to 60 mm Hg with a heart rate of 150 bpm, and the patient responded to verbal command. She was then transferred to the intensive care unit, where after IV infusion of heparin 6000 units, ECMO was immediately established via femoral arterial and venous cannulations. Once stabilized with ECMO, the patient was brought to the operating room for emergent pulmonary artery thromboembolectomy. Anesthesia was induced with IV ketamine 2 mg/kg and maintained with fentanyl/O2 and pancuronium. Thromboemboli were removed from the main, right, and left PAs. Pathological examination showed three tissue fragments of brown color, measuring 30 cm in total length and 1 cm in diameter. Repeated intraoperative and postoperative TEE revealed no residual emboli in the right heart or the PA after the embolectomy. Postoperative vital signs were stable, and the patient recovered without further incident, but hemodialysis was required because of acute renal failure. The ECMO was discontinued on the second postoperative day. Duplex Doppler examination of the lower limbs showed increased deep venous resistance, and the patient continued to receive 2000 units of IV heparin daily for 3 wk, followed by oral warfarin. Twenty days later, her renal function recovered, and hemodialysis was discontinued. Subsequently, she underwent bladder rehabilitation and psychiatric treatment for acute depression and was discharged without residual deficits after 70 days of hospitalization. Figure 1: Midesophageal transesophageal echocardiography view of a patient who developed sudden cardiac arrest after massive thromboembolism, showing a dilated RA, a small RV, and a small LA, and the thrombus occupying a large portion of the right atrium and obstructing tricuspid inflow. RA = right atrium, LA = left atrium, RV = right ventricle, AO = aorta. Arrows indicate thrombi.Figure 2: The thrombus (arrow) is shown at the bifurcation of the main PA. Ao = aorta, PA = pulmonary artery.Figure 3: Long-axis view showed the dilated LPA with the thromboembolus. DAo = descending aorta, E = embolus, LPA = left pulmonary artery.Discussion Most pulmonary emboli are microscopic, and with early diagnosis and prophylactic therapy, catastrophic pulmonary embolism is rare. Nevertheless, pulmonary embolism still accounts for 5% of all hospital mortality, or approximately 60,000 deaths each year, in the United States (2–4). TEE is a useful technique in the diagnosis of pulmonary emboli (5–9). In our case, sudden cardiac arrest developed as a result of mechanical obstruction of the tricuspid valve by massive thromboemboli, as shown by the emergent bedside TEE. Standard CPR and anticoagulant therapy could not correct such catastrophic insults. Fortunately, total tricuspid valve obstruction and pulmonary embolism can be rapidly and easily detected with the aid of bedside TEE. This early diagnosis enabled us to make appropriate decisions during CPR and helped guide subsequent treatment without delay. There is a prevailing doubt regarding impact of perioperative TEE on the clinical outcome of pulmonary embolism (10). Undoubtedly, angiography or ventilation-perfusion scintigraphy provide greater sensitivity than TEE for the detection of pulmonary embolism if the emboli occur at the proximal left PA or distal lobar PAs, where they cannot be visualized by TEE (11–13). Our case argues strongly for the use of TEE in the diagnosis and management of acute massive venous thromboembolism involving obstruction of the right heart and main PA. TEE is practical and effective under emergent conditions and requires little time. In patients with unstable hemodynamics, when any delay could cause irreversible damages, bedside TEE is superior to other diagnostic tools, such as pulmonary angiography or scintigraphy, none of which can be quickly performed at bedside. In conclusion, timely TEE diagnosis initiated at the bedside guided us to successful treatment of a case of cardiac arrest resulting from a massive venous thromboembolism with nearly complete mechanical obstruction of the right heart and PA. The authors thank C. Lee, MD, for his assistance in the revision of the manuscript.
SDGs
Other Subjects
adult; article; case report; diagnostic accuracy; diagnostic value; extracorporeal oxygenation; female; heart arrest; human; human cell; human tissue; lung embolism; priority journal; resuscitation; transesophageal echocardiography; treatment outcome; tricuspid valve disease
Publisher
Lippincott Williams and Wilkins
Type
journal article