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A 67-year-old man is transferred to our institution from an outside facility after suffering a witnessed cardiac arrest at home.He has a medical history of hypertension, dyslipidemia, coronary atherosclerosis, prior inferior non-ST-segment elevation myocardial infarction, and sick sinus syndrome post dual-chamber pacemaker implantation.His language capacity is only “yes” and “no,” and his responses are inconsistent. Jay attempting resuscitation following a pulmonary arrest was not likely to succeed.
A recent algorithm for the management of the resuscitated comatose patient was developed and published last year.
Both type A and type B aortic dissections can present infrequently as cardiac arrest.
The initial rhythm is usually pulseless electrical activity due to blood exsanguination or cardiac tamponade.
Ventricular fibrillation is less commonly seen and is probably secondary to ischemia from coronary obstruction or intermittent obstruction of the left main coronary ostium with a dissection flap, as probably is the case in this patient.
A limited transthoracic echocardiogram showed no significant wall motion abnormalities, no significant valvular lesion, and a new small pericardial effusion.
The patient was emergently transferred to the cardiac catheterization laboratory at our hospital.
Note that the flap extends from the intramural hematoma of the posterior wall of the proximal ascending aorta just above the sinotubular junction leftwards and lower towards the left coronary cusp.
There is contrast extravasation into the left and right pleural spaces (more pronounced to the left) and pericardial effusion, probably hemopericardium.
Return of spontaneous circulation was achieved after a total of 28 minutes of appropriate cardiopulmonary resuscitation.
The patient arrived comatose at an outside facility approximately 35-40 minutes after losing consciousness.