Horses and Zebras: complex cardiac anatomy in a patient with out-of-hospital cardiac arrest
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CASE REPORT
Horses and Zebras: complex cardiac anatomy in a patient with out-of-hospital cardiac arrest Samuel M. Brown • Dylan V. Miller • Daniel Vezina • Nathan C. Dean • Colin K. Grissom
Received: 19 October 2010 / Accepted: 3 February 2011 / Published online: 24 February 2011 Ó Springer-Verlag 2011
Abstract This case report describes a woman presenting after out-of-hospital cardiac arrest with several cardiac anomalies, including a form fruste of Ebstein’s anomaly complicated by a large tricuspid valve vegetation. On autopsy, she proved to have unstable plaques in epicardial vessels that likely caused arrhythmic sudden cardiac death, a reminder that even in the presence of rare anomalies, common things are common. Keywords anomaly
Echocardiography Cardiac arrest Ebstein’s
Electronic supplementary material The online version of this article (doi:10.1007/s13089-011-0059-2) contains supplementary material, which is available to authorized users. S. M. Brown (&) N. C. Dean C. K. Grissom Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT, USA e-mail: [email protected] S. M. Brown C. K. Grissom Critical Care Echocardiography Service, Intermountain Medical Center, Salt Lake City, UT, USA S. M. Brown N. C. Dean C. K. Grissom Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA D. V. Miller Department of Pathology, Intermountain Medical Center, Salt Lake City, UT, USA D. Vezina Department of Anesthesiology and Division of Cardiology, University of Utah, Salt Lake City, UT, USA
A 62-year-old woman with moderate chronic obstructive pulmonary disease and a recent history of treated leg cellulitis presented with sudden onset of dyspnea followed by out-of-hospital cardiac arrest. Spontaneous circulation returned after approximately 30 min of cardiopulmonary resuscitation. On hospital admission, the patient was deeply comatose and in profound shock with respiratory failure requiring mechanical ventilation. Electrocardiogram demonstrated delayed R wave progression and first-degree atrioventricular block, but no features of Wolff–Parkinson– White or Brugada syndromes. An echocardiogram revealed left ventricular hypertrophy and normal left ventricular function with mild right ventricular dilation and hypertrophy. The tricuspid valve (TV) appeared abnormal, with a large, complicated, mobile mass and associated severe tricuspid regurgitation, abnormal chordal movement, and chaotic motion near the valvular apparatus (Figs. 1, 2 and Video 1 of supplementary material). The mobile mass extended well into the inferior vena cava during cardiac systole (Fig. 3 and Video 2 of supplementary material). CT pulmonary angiogram was not undertaken; compression ultrasound of the legs excluded thrombosis. Intravenous antibiotic therapy was initiated, given the possibility of infective endocarditis. Therapeutic hypothermia was undertaken for 24 h but on return to normothermia, the patient demonstrated postanoxic myoclonic status epilepti
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