A COMPLEX POST CARDIAC–ARREST SYNDROME: FROM UNCERTAIN NEUROLOGICAL OUTCOME TO HEMORRHAGIC COMPLICATION

Abstract

Abstract A 49–years–old woman with type II diabetes mellitus, hypothyroidism and Churg–Strauss syndrome experienced chest pain with loss of consciousness. Emergency service was called and CPR promptly started. Cardiac arrest with shockable rhythm was documented, DC–shock performed with sign of anterior STEMI after ROSC, then refractory cardiac arrest appeared. The patient was centralized in our hospital and VA–ECMO was positioned through a percutaneous femoral access in cath–lab. Coronary angiography showed acute occlusion of the mid–proximal LAD and subocclusive stenosis of the dominant Cx for which PCI with DES was performed, then intra–aortic balloon pump (IABP) was implanted. At ICCU admission the patient was supported by ECMO and IABP with MAP 65 mmHg and lactates 3.5 mmol/L. Echocardiography and chest X–ray showed severe biventricular dysfunction and pulmonary overload (Fig 1). She was ventilated via ECMO circuit and mechanical ventilation setting protective TV values of 6 ml/kg. Diuresis was good with low dose of furosemide, lactates progressively decreased. Temperature control was set within 36°C with the cooling system of the ECMO circuit. Cardioaspirin, ticagrelor and bivalirudin were administered. At early neurological stratification EEG documented absence of epileptiform anomalies, responsiveness to painful stimuli, SSPE showed normal and symmetrical morphology, NSE at 48 h was 59 ng/mL, she opened eyes and performed simple orders. Levosimendan was administered with partial recovery of the right ventricular dysfunction leading to ECMO removal on 5th day. Due to poor consciousness recovery despite sedation reduction, percutaneous tracheostomy was performed on 8th day, IABP removed and the following day all vasopressors suspended. Neurological improvement allowed transition to spontaneous breathing and weaning from mechanical ventilation; on 19th day tracheostomy was removed. Massive enterorrhagia appeared after ECMO removal (figure 2). The colonoscopy showed ischemic pancolitis, therefore ticagrelor was suspended. On 18th day clopidogrel was reintroduced based on hemoglobin stability and endoscopic improvement. She was discharged from the cardiology department after a total length of stay of thirty days, with normal neurological status, no motor deficits, recovery of left and right ventricular function, stable hemoglobin levels.