RESUMO
BACKGROUND: Massive anterior mediastinal hematoma due to chest compression during cardiopulmonary resuscitation is often caused by internal mammary artery injury. However, critical massive anterior mediastinal hematoma without damage to major blood vessels is extremely rare. We report a case of life-threatening anterior mediastinal hematoma without internal mammary artery injury during extracorporeal cardiopulmonary resuscitation. CASE PRESENTATION: A 70-year-old man was transferred to our emergency department because of ventricular fibrillation arrest. Manual chest compressions and venoarterial extracorporeal membrane oxygenation were applied in the angiography room. Acute myocardial infarction was diagnosed, and percutaneous coronary intervention with stent placement was performed. Despite the establishment of venoarterial extracorporeal membrane oxygenation flow, the hemodynamics were unstable. Computed tomography revealed a massive anterior mediastinal hematoma compressing the right heart system and causing obstructive shock. Although local incision and anterior mediastinal hematoma drainage were tried for resolving obstructive shock, the patient's anemia did not improve, and there was still continuous hemorrhaging from the drainage tube. A median thoracotomy was then performed. There was no injury of the main trunk of the internal mammary artery but only hemorrhaging from the sternal fracture site. The patient's hemodynamics and anemia improved after hemostasis and gauze packing. Re-thoracotomy for gauze removal and sternal closure was performed three days post-hospitalization. CONCLUSIONS: It is important to consider hemorrhaging and unstable hemodynamics in patients who receive extracorporeal cardiopulmonary resuscitation. Therefore, a thoracotomy may take precedence over intravascular treatment for restoring hemostasis when there is no information regarding the bleeding site, such as the presence of extravasation.
RESUMO
Mechanical complications (MCs) following acute myocardial infarction (AMI), such as ventricular septal rupture (VSR), free-wall rupture (FWR), and papillary muscle rupture (PMR), are fatal. However, the risk factors of in-hospital mortality among patients with MCs have not been previously reported in Japan. The purpose of this study was to evaluate the prognostic factors of in-hospital mortality in these patients. The study cohort consisted of 233 consecutive patients with MCs from the registry of 10 facilities in the Cardiovascular Research Consortium-8 Universities (CIRC-8U) in East Japan between 1997 and 2014 (2.3% of 10,278 AMI patients). The authors conducted a retrospective observational study to analyse the correlation between the subtypes of MCs with in-hospital mortality, clinical data, and medical treatment. We observed a decreasing incidence of MC (1997-2004: 3.7%, 2005-2010: 2.1%, 2011-2014: 1.9%, p < 0.001). In-hospital mortality among patients with MCs was 46%. Thirty-three percent of patients with MCs were not able to undergo surgical repair due to advanced age or severe cardiogenic shock. In-hospital mortality among patients who had undergone surgical repair was 29% (VSR: 21%, FWR: 33%, PMR: 60%). In patients with MCs, hazard ratio for in-hospital mortality according to multivariate analysis of without surgical repair was 5.63 (95% CI 3.54-8.95). In patients with surgical repair, the hazard ratios of blow-out-type FWR (5.53, 95% confidence interval (CI) 2.22-13.76), those with renal dysfunction (3.11, 95% CI 1.37-7.05), and those receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) (3.79, 95% CI 1.81-7.96) were significantly high. Although primary percutaneous coronary intervention (PCI) is associated with decreased incidence of MCs, high in-hospital mortality persisted in patients with MCs that also presented with renal dysfunction and in those requiring VA-ECMO. Early detection and surgical repair of MCs are essential.
