Cardiogenic shock in setting of out of hospital cardiac arrest; high burden of cardiac and non-cardiac complications

Introduction: Literature data suggest that 30-40% of cardiogenic shock (CS) cases complicating myocardial infarction are admitted with cardiac arrest, with a higher economical burden of in-hospital complications, 30% of these patients being discharged with functio-nal impairment, requiring a skilled nursing facility. 3rd degree AV block is a possible complication of AMI re-quiring temporary pacing in emergency settings.. Temporary permanent (T-P) pacemakers are safe and pro-vide a stable modality of temporary pacing in multiple acute clinical settings, such as active infection or sepsis, offering ease of lead removal in case of pacemaker-lead associated endocarditis.

Case presentation: We present the case of a 53 year-old patient, with endotracheal intubation, who was admitted to our intensive care unit (ICU) after receiving CPR for a ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA). The patient was admitted with cardiogenic shock signs, and required positive inotro-pic support fluid load. The electrocardiogram (ECG) revealed third degree AV block with RBBB-morphology escape rhythm and periods of atrial fibrillation.Laboratory findings included increased highly sensiti-ve troponin I, increased NT pro-BNP, leukocytosis and increased C protein values. Transthoracic echocardiography (TTE) performed in ED showed moderately reduced left ventricular (LV) function (EF 40%), left ventricular anterior and apical walls akinesia and mo-derate mitral valve regurgitation. Coronary angiography was performed emergently and demonstrated embolic occlusion of the mid left anteri-or descending artery (LAD), with successful thrombus aspiration. Concomitant, the patient was temporary paced using a T-P pacemaker and transferred to the ICU, where target temperature management was ensured. His inflammatory status was difficult to interpret in the context of prolonged resuscitation, but his family mentioned fever and dysuria one week preceding the admission. Repeated blood cultures and bacteriologi-cal profile were negative, the inflammatory syndrome improved initially and his neurologic status progres-sively improved after the first 48 hours. The TTE and the transesophageal echography (TEE) performed after one week showed several mobile vegetations attached to the pacemaker lead. Blood cultures were obtained (negative at 24, 48 hours and 14 days) and antibiotic treatment with vancomycin and gentamicin was em-pirically started. The initial pacing system was remo-ved, and a new T-P pacemaker was implanted on the left side. However, after two weeks displacement of the ventricular pacing lead is diagnosed. Given the signifi-cant reduction in the inflammatory syndrome and the persistently negative blood cultures, a permanent pacemaker was implanted.

Particular features: The patient had a favorable reco-very of functional capacity and neurologic status, with mild signs of heart failure and an EF of 40%. This was the case of a young male patient with hypoxic-ischemic encephalopathy following VF OHCA in the setting of a myocardial infarction with embolic occlusion of LAD artery, which presented with cardiogenic shock. The patient had cardiac pump failure as result of the initial cardiac insult responsible by CS and prolonged myo-cardial stunning due to cardiac arrest and systemic va-sodilation secondary to regional and global ischemia-reperfusion injury, and severe bradycardia secondary to 3rd AV block. This is the case of a patient requiring temporary and then permanent pacing, leading to cul-ture-negative endocarditis related to the pacemaker lead. The case emphasizes the fact that the T-P pacemaker offers both a reliable short-term pacing and facilita-tes repeated pacemaker system replacement in case of potential complications such as pacemaker-lead related endocarditis or lead displacement.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)