Free
Education  |   April 2014
Systemic Thrombus Formation in Cardiac Arrest: Manifestation of Cardiac Arrest-related Hypercoagulability Visualized by Transesophageal Echocardiography
Author Affiliations & Notes
  • Joseph L. Weidman, M.D.
    From the Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts.
  • Jan N. Hilberath, M.D.
    From the Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Address correspondence to Dr. Hilberath: jhilberath@partners.org
Article Information
Education / Images in Anesthesiology / Cardiovascular Anesthesia / Critical Care / Hematologic System / Radiological and Other Imaging
Education   |   April 2014
Systemic Thrombus Formation in Cardiac Arrest: Manifestation of Cardiac Arrest-related Hypercoagulability Visualized by Transesophageal Echocardiography
Anesthesiology 04 2014, Vol.120, 997. doi:10.1097/ALN.0000435861.14403.59
Anesthesiology 04 2014, Vol.120, 997. doi:10.1097/ALN.0000435861.14403.59

Supplemental Digital Content is available in the text.

A 63-YR-OLD man with ischemic cardiomyopathy presented for pacemaker laser lead extraction with general anesthesia. After successful lead removal, he became acutely hypotensive. Immediate transe sophageal echocardiography (TEE) revealed a large pericardial effusion, and despite pericardiocentesis and pharmacologic intervention, the patient suffered cardiac arrest. After a brief period of cardiopulmonary resuscitation, spontaneous circulation was restored. At that time, TEE showed multiple new thrombi in the heart and descending thoracic aorta that were not visualized earlier (fig., and see video clip, Supplemental Digital Content 1, http://links.lww.com/ALN/A993). Heparin was administered before emergent institution of cardiopulmonary bypass, and aminocaproic acid was deliberately withheld in light of widespread arterial thrombosis. After surgical repair of a superior vena cava tear caused by the lead extractions, TEE did not demonstrate remaining thrombus and heparin was subsequently reversed with protamine. The patient recovered without manifestations of embolic disease such as stroke, renal dysfunction, intestinal ischemia, or acronecrosis. He was discharged 9 days later.
A significant increase in procoagulant activity after cardiac arrest and resuscitation has been described even in patients without preexisting coagulation abnormalities.1  Endogenous anticoagulation and fibrinolysis typically fail to adequately oppose this induction of systemic hypercoagulability.1  Although earlier retrospective analyses favored the use of anticoagulant and fibrinolytic medications in the treatment of cardiac arrest, a more recent, prospective trial could not confirm these findings in general.2  In this patient, we chose to withhold our standard antifibrinolytic therapy during cardiopulmonary bypass and fully reversed the systemic heparinization based on TEE imaging. This case highlights the potential value of TEE in guiding therapy during cardiac arrest and cardiopulmonary resuscitation.3 
Competing Interests
The authors declare no competing interests.
References
Neumar, RW, Nolan, JP, Adrie, C, Aibiki, M, Berg, RA, Böttiger, BW, Callaway, C, Clark, RS, Geocadin, RG, Jauch, EC, Kern, KB, Laurent, I, Longstreth, WTJr, Merchant, RM, Morley, P, Morrison, LJ, Nadkarni, V, Peberdy, MA, Rivers, EP, Rodriguez-Nunez, A, Sellke, FW, Spaulding, C, Sunde, K, Vanden Hoek, T Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, Australian and New Zealand Council on Resuscitation, European Resuscitation Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); the American Heart Association Emergency Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the Stroke Council.. Circulation. (2008). 118 2452–83 [Article] [PubMed]
Bottiger, BW, Arntz, HR, Chamberlain, DA, Bluhmki, E, Belmans, A, Danays, T, Carli, PA, Adgey, JA, Bode, C, Wenzel, V Thrombolysis during resuscitation for out-of-hospital cardiac arrest.. N Engl J Med. (2008). 359 2651–62 [Article] [PubMed]
Memtsoudis, SG, Rosenberger, P, Loffler, M, Eltzschig, HK, Mizuguchi, A, Shernan, SK, Fox, JA The usefulness of transesophageal echocardiography during intraoperative cardiac arrest in noncardiac surgery.. Anesth Analg. (2006). 102 1653–7 [Article] [PubMed]