Strana 714 VOJNOSANITETSKI PREGLED Vojnosanit Pregl 2012; 69(8): 714–716.

UDC: 616.132-007.271+616.132.2+616.126.42]: CASE REPORT :[616.12-008.315-08:616.12-089 DOI: 10.2298/VSP1208714M

Successful resuscitation from two cardiac arrests in a female patient with critical aortic stenosis, severe mitral regurgitation and Uspešna reanimacija dva srþana zastoja kod bolesnice sa kritiþnom aortnom stenozom, teškom mitralnom regurgitacijom i stenozom koronarnih arterija

Dragan Mijuškoviü*, Dušica M Stamenkoviü†, Saša Boroviü*, Menelaos Karanikolas‡

*Department of Anesthesiology and Intensive Care, Dedinje Cardiovascular Institute, Belgrade, Serbia; †Clinic of Anesthesiology and Intensive Care, Military Medical Academy, Belgrade, Serbia; ‡Department of Anaesthesiology and Critical Care Medicine, University of Patras School of Medicine, Rion, Greece

Abstract Apstrakt

Introduction. The incidence of sudden cardiac death in pa- Uvod. Incidencija iznenadne srÿane smrti kod bolesnika tients with severe symptomatic aortic stenosis is up to 34% sa simptomatskom aortnom stenozom je 34%, a reani- and resuscitation is described as highly unsuccessful. Case macija tih bolesnika ima nepredvidiv ishod. Prikaz bole- report. A 72-year-old female patient with severe aortic steno- snika. Bolesnica, stara 72 godine, sa kritiÿnom aortnom sis combined with severe mitral regurgitation and three-vessel stenozom kombinovanom sa trosudovnom koronarnom coronary artery disease was successfully resuscitated following bolešýu, ukljuÿujuýi 90% stenozu glavnog koronarnog two in-hospital cardiac arrests. The first cardiac arrest oc- stabla imala je dva srÿana zastoja, ali je uspešno reanimi- curred immediately after intraarterial injection of low osmolar rana. Prvi zastoj bio je u toku koronarografije, a drugi iodinated agent during coronary angiography. Angiography posle uvoda u anesteziju. Uspešna reanimacija na otvore- revealed 90% occlusion of the proximal left main coronary nom grudnom košu bila je praýena hirurškim zahvatom, artery and circumflex branch. The second arrest followed in- zamenom aortne valvule, mitralnom valvuloplastikom i duction of anesthesia. Following successful open-chest resus- trostrukim aortokoronarnim by-pass-om. Postoperativna citation, aortic , mitral valvuloplasty and perikardijalna tamponada rešena je hirurškom revizijom. three-vessel aortocoronary bypass were performed. Postop- Bolesnica se uspešno oporavila. Zakljuÿak. Postoji mo- erative pericardial tamponade required surgical revision. The guýnost uspešne reanimacije kod pojedinih bolesnika sa patient recovered completely. Conclusion. Decision to start aortnom stenozom, mada se, uopšteno, smatra da je to resuscitation may be justified in selected patients with critical uzaludno. aortic stenosis, even though cardiopulmonary resuscitation in such cases is generally considered futile.

Key words: Kljuÿne reÿi: arrest; resuscitation; aortic valve stenosis; mitral srce, zastoj; reanimacija; zalistak, aortni, stenoza; valve insufficiency; coronary artery disease; treatment zalistak, mitralni, insuficijencija; koronarna bolest; outcome. leÿenje, ishod.

Introduction diopulmonary resuscitation (CPR) is highly unsuccessful 1. We presented a 72 year-old-female with critical AS, severe Severe aortic stenosis (AS) is defined as aortic valve mitral regurgitation (MR) and three-vessel coronary artery area < 0.8 cm2 (normal 2.5–3.5 cm2) 1 whereas critical AS is disease with critical left main (LM) stenosis who, after suc- defined as aortic valve index < 0.5 cm2/m2 2. Sudden death cessful resuscitation from two cardiac arrests, had emergency occurs in up to 34% of symptomatic AS patients 3 and car- coronary artery bypass grafting (CABG), aortic valve re-

Correspondence to: Dušica M. Stamenkoviý, Clinic of Anesthesiology and Intensive Care, Military Medical Academy, Crnotravska 17, 11 000 Belgrade, Serbia. Phone.: +381 11 397 8659. E-mail: [email protected] Volumen 69, Broj 8 VOJNOSANITETSKI PREGLED Strana 715 placement (AVR) and replacement (MVR), sur- internal cardiac compressions and heparinization (400 vived and went home in good condition. units/kg). Heart exposure revealed 3 cm right ventricular wall laceration, likely from open heart massage. Following Case report aortic and bi-caval cannulation, (CPB) started. Myocardial protection included antegrade and A 72-year-old Caucasian female experienced dyspnea retrograde cold blood . The patient had AVR on exertion and retrosternal pain at the age of 70, and devel- (mechanical St. Jude 19, St. Jude Medical, Minnesota, USA), oped dyspnea at rest at the age of 72. The patient had no MVR (Duran Ancore ring 27, Medtronic, Minnesota, USA), other medical problems. Administered medications included three-vessel CABG (venous grafts to left anterior descend- oral aspirin, atorvastatin, enalapril, metoprolol, furosemide ing, circumflex and right coronary artery) and right ven- and nitrates. Examination revealed 4/6 holosystolic murmur tricular (RV) wall laceration repair. propagating to the axilla and neck. Electrocardiogram Cardiopulmonary bypass time was 230 min, aortic showed sinus rhythm, without Q waves or acute ST-T ab- clamp time was 160 min, and the operation lasted 290 min. normalities. revealed aortic valve calcifi- Intravenous epinephrine (0.067 ȝg/kg/min) and dobutamine cation, aortic value area 0.6 cm2, peak pressure gradient 111 (maximum 15 ȝg/kg/min) infusions were used, and the pa- mmHg by Doppler, mild aortic regurgitation, severe MR and tient was stable after cardiopulmonary bypass (sinus rhythm, preserved left ventricular function (Table 1). Clinically, the blood pressure 105/60 mmHg, central venous pressure 15 patient was at the New York Heart Association (NYHA) III mmHg, hemoglobin 11.6 g/L, normal arterial blood gases). functional status. Postoperatively, a catheter was inserted in the ICU (Table 2). Table 1 Transthoracic echocardiography findings before hospital Table 2 admission Hemodynamic variables measured with a pulmonary artery Variable Value catheter (PAC) 2 Aortic valve area (cm )0.6Variable After surgery Before PAC 2 2 Aortic valve index (cm /m ) 0.353 removal Peak aortic gradient (mmHg) 111 PCWP (mmHg) 16 8 Mean aortic gradient (mmHg) 89 Cardiac index (l/m2) 3.0 2.5 Left ventricular end diastolic diameter (mm) 42 volume (mL) 44.8 45 End systolic pressure (mmHg) 30 SVR (dyn/s/sec) 1199 Left atrial diameter (mm) 40 PVR (dyn/s/sec) 138 Left ventricular ejection fraction (%) 60 SvO2 (%) 71.8 64.7 Left ventricular septum wall thickness (mm) 13 *PCWP – pulmonary capillary wedge pressure; SVR – systemic vascular Right heart chamber Normal resistance; PVR – pulmonary vascular resistance; SvO2 – mixed venous Normal oxygen saturation

Two hours after surgery, the patient developed atrial During catheterization, immediately after contrast io- fibrillation and received three synchronized hexol 4 (Omnipaque 350, GE Healthcare, Norway) was in- and iv amiodarone loading, followed by oral amiodarone jected into the LM, the patient developed bradycardia and 1,200 mg/day. Despite postoperative troponin elevation (1.60 hypotension, rapidly deteriorating to severe dyspnea and ng/mL), there were no wall motion abnormalities on echo- asystolic cardiac arrest. Resuscitation started promptly, ac- cardiography. cording to the American Heart Association guidelines. Four hours after surgery, chest tube drainage increased Twenty minutes following resuscitation, circulation was re- (1,000 mL/2 hours), central venous pressure increased to 22, stored and spontaneous breathing returned. In the Intensive urine output decreased, and hemoglobin dropped to 8.1 g/L. Care Unit (ICU), the patient regained consciousness, re- The patient received red blood cells 645 mL, fresh frozen sponded to instruction and was able to move all extremities plasma 610 mL, platelets 6 units, epinephrine increased to 16 after thirty minutes. Catheterization showed 90% LM, 60% ȝg/kg/min, dobutamine to 20 ȝg /kg/min and norepinephrine left anterior descending and 90% circumflex stenosis. Left to 12 ȝg/min for hypotension. Emergency echocardiography ventriculogram and right coronary artery angiogram were revealed large (18 mm thick) pericardial effusion, diastolic aborted. RV collapse, but no vena cava collapse. Emergency reexplo- Then, 95 minutes after the first arrest, the patient came ration revealed bleeding from the right atrial cannulation site. to the operating room for emergency CABG-AVR-MVR. After bleeding stopped and tamponade was relieved, epi- General anesthesia was induced with diazepam 15 mg, nephrine infusion decreased to 0.05 ȝg/kg/min, norepineph- sufentanil 25 ȝg and pancuronium 10 mg, and maintained rine stopped and urine output increased. with sevoflurane 0.7–1.0 ET MAC. Ten minutes after induc- Approximately 8 h after the 2nd operation, the patient tion, the patient acutely developed hypotension and brady- woke up and responded to commands. Despite postoperative cardia unresponsive to iv epinephrine, and rapidly progressed liver dysfunction and non-oliguric renal insufficiency, the to asystole. Resuscitation included emergency sternotomy, patient gradually improved, left the ICU on the day 27 and

Mijuškoviý D, et al. Vojnosanit Pregl 2012; 69(8): 714–716 Strana 716 VOJNOSANITETSKI PREGLED Volumen 69, Broj 8 went home on the day 33. Two weeks after discharge, the shortly after general anesthesia induction, myocardial ische- patient was neurologically intact, and walked 5 km/day. mia, intraoperative and arrhythmias 3 are all plausible etiologies. This particular patient had four Discussion reasons why resuscitation was unlikely to succeed: resusci- tation from asystole has poor prognosis; external cardiac This is probably the first report on successful resuscita- compressions are ineffective in severe AS, because over- tion from two distinct cardiac arrests in a patient with a com- coming the pressure gradient across the aortic valve is diffi- bined critical AS, severe MR and severe coronary artery dis- cult 1; creating adequate cardiac output with CPR is problem- ease. A predicted perioperative mortality for patients with atic due to MR; and achieving adequate coronary perfusion NYHA III functional status, the same as the presented patient is difficult due to severe LM stenosis. However, this patient initially had, is 4.81% (logistic Euroscore). The first arrest was revived twice. Immediate sternotomy and internal car- occurred after iohexol injection for coronary angiography. diac compressions may explain CPR effectiveness after the Non-ionic contrasts are considered safer than ionic media 5, 2nd arrest 8. Prompt CPB initiation likely contributed to good and low-osmolar contrast is probably safe in patients with outcome 9, hypothermia during CBP probably provided some severe AS 6. However, serious hemodynamic and electro- brain protection 10. physiologic adverse events, including hypotension, myocar- Limitations of this report include not measuring serum dial dysfunction, arrhythmias, and cardiac arrest can occur triptase to exclude anaphylaxis to contrast, and not using a after intraarterial or intracoronary iohexol injection 7, and the pulmonary artery catheter or transesophageal echocardiogra- reported risk of death was 6.6–100/ million during angiogra- phy for perioperative hemodynamic monitoring. phy with iohexol 4. Although disastrous anaphylactic reac- 5 tions to contrast are rare (0.03%) , acute anaphylaxis cannot Conclusion be excluded in this case. A predicted perioperative mortality (Logistic Euroscore) was at that moment 20.33%. This report suggests that despite a low likelihood of Emergency surgery was indicated in this case, due to survival, full resuscitation is worth pursuing in otherwise symptomatic LM stenosis. As the second arrest occurred healthy patients with severe AS.

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Mijuškoviý D, et al. Vojnosanit Pregl 2012; 69(8): 714–716.