Cardiac arrest after uncomplicated right upper lobectomy

DIAGNOSTIC DILEMMA Steven Konstadt, M D Section Editor

Cardiac Arrest After Uncomplicated Right Upper Lobectomy Emilio B. Lobato, MD, Christoph N. Seubert, MD, Jeffrey Bott, MD, and Daniel G. Knauf, MD A

65-year-old man who smoked, with a right Pancoast tumor, was scheduled for lung resection after undergoing radiation and chemotherapy for staging of his disease. Under combined general and epidural anesthesia, he underwent a right upper and middle lobectomy. The patient was awakened and extubated on his side and rolled supine for transport. At this

Fig 1.

Four-chamber view.

point, he became cyanotic, unresponsive, and hypotensive. Shortly thereafter, he had electromechanical dissociation on the electrocardiogram. Immediate reexploration, followed by resuscitation, failed to show a tension pneumothorax, evisceration of the heart, or a hemothorax. Transesophageal echocardiography was performed (Figs 1 and 2). What is the diagnosis?

Fig 2.

Parasternalshort-axis view,

From the Departments of Anesthesiology and Cardiothoracic Surgery, University of Florida College of Medicine, Gainesville, FL. Reprints not available. Address correspondence to Emilio B. Lobato, MD, Attn: Editorial Offtce, Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL 32610-0254. Copyright © 1999 by W.B. Saunders Company 1053-0770/99/1301-0022510. 00/0 Key words: transesophageal echocardiography, cardiac arrest, pulmonary embolus

Journal of Cardiothoracic and Vascular Anesthesia,

Vo113,No 1 (February),1999:pp 105-106

105

106

LOBATO, SEUBERT, BOTT, AND KNAUF DIAGNOSIS:

PULMONARY EMBOLI

Massive pulmonary embolism with a clot in the right pulmonary artery and loss of the left pulmonary artery (Fig 3), as well as severe right atrial and ventricular dilatation with corresponding septal shift are seen.

Fig 3. Echogenic density compatible with a blood clot in the right pulmonary artery (arrow).

Intraoperative pulmonary embolus is an infrequent cause of cardiac arrest. It has been described in association with pelvic and orthopedic surgery, but is more often caused by preexisting venous thrombosis, either from the pelvic veins or veins of the lower extremities. Transesophageal echocardiography is very helpful in providing a differential diagnosis of acute cardiovascular collapse. The sensitivity for pulmonary emboli is mostly limited to major central clots, 1,2 because only the main pulmonary trunk, part of the left pulmonary artery, and the right pulmonary artery can be visualized. However, this is extremely useful because these emboli are the types associated with cardiovascular collapse. 3,4 This patient received maximal pharmacologic support with epinephrine. After spontaneous circulation was reestablished, nitroglycerin, amrinone, and nitric oxide were used, along with anticoagulation with heparin. Surgical embolectomy and/or thrombolysis were not contemplated because of his advanced cancer, which showed chest wall invasion intraoperatively. He died 12 hours postoperatively. Postmortem examination confirmed massive pulmonary embolism and extensive bilateral extremity deep venous thrombosis. Notice the close correspondence of the appearance of the clot on the pathologic specimen with the echocardiographic findings (Fig 4).

Fig 4. Pathologic specimen showing clot (arrow). Note the correlation with the TEE (Fig 3).

REFERENCES

1. Li YH, Shyu GK, Kuan P: Expanded indications: Diagnosis of pulmonary embolism by transesophageal echocardiography. Int J Cardio139:91-92, 1993 2. Wilson WC, Frankville DD, Maxwell W, et al: Massive intraoperafive pulmonary embolus diagnosed by transesophageal echocardiography. Anesthesiology 81:504-508, 1994

3. Rittoo D, Sutherland GR, Samuel L, et al: Role of transesophageal echocardiography in diagnosis and management of central pulmonary artery thromboembolism. Am J Cardio171:1115-1118, 1993 4. Sisto D, Hoffman D, Camacho M, et aI: Massive intraoperative pulmonary embolism. Chest 102:307-308, 1992