CHEST Guidelines-Ultrasound-Diagnosis-of-Cardiac-Arrest-in-an-81-Ye

Ultrasound-Diagnosis-of-Cardiac-Arrest-in-an-81-Ye

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An 81-year-old man, recovering postoperatively from partial hepatectomy due to cholangiocarcinoma, experienced in-hospital cardiac arrest while in a gastroenterology ward. Immediate CPR was administered, followed by advanced cardiac life support (ACLS) upon the crash team's arrival. Initial return of spontaneous circulation (ROSC) was achieved rapidly, but pulseless electrical activity (PEA) reoccurred during transfer to the ICU, necessitating further ACLS that finally sustained ROSC. Despite treatment, the patient's condition was characterized by severe hypoxemia, hypotension, sinus tachycardia, and acidosis, prompting initiation of norepinephrine support.<br /><br />Ultrasound and electrocardiogram (ECG) evaluations revealed a significant clinical finding of ST-segment elevation in the inferior leads, typically suggesting acute coronary syndrome. However, transesophageal echocardiography (TEE) identified a systolic anterior motion (SAM) of the anterior mitral leaflet, leading to left ventricular outflow tract obstruction (LVOTO) and eccentric mitral regurgitation despite the absence of regional wall motion abnormalities. Hypovolemia, indicated by hematemesis and bleeding at the celiac trunk confirmed upon angiography, was considered the likely driver of SAM and subsequent cardiac arrest.<br /><br />These findings highlight the occurrence of SAM and LVOTO in structurally normal hearts under certain physiologic conditions like hypovolemic shock, which can be exacerbated by vasopressors such as norepinephrine. Early echocardiography is thus critical for diagnosis and management, guiding appropriate resuscitative efforts and pharmacologic interventions. Despite efforts including successful coiling, the patient's hemodynamic instability persisted, and he ultimately succumbed to multiorgan failure two days later. This case underscores the importance of recognizing SAM and LVOTO in critically ill patients, prompting examination beyond more common diagnostic considerations such as acute coronary syndromes.

Keywords

cholangiocarcinoma

cardiac arrest

advanced cardiac life support

systolic anterior motion

left ventricular outflow tract obstruction

hypovolemic shock

norepinephrine

echocardiography

multiorgan failure

acute coronary syndrome