Survival of Cardiac Arrest with Withdrawal of Mechanical Ventilator: A Case Report

Asploro Cardiovascular Case Reports and Research

Article Type: Case Report
DOI: 10.36502/2025/ACCRR.6104
Asp Cardio Case Rep and Res. 2025 Feb 04;2(1):6-10

Goutom Chandra Bhowmik^1iD*, Sanjib Chowdhury², Kamrul Hasan³, Muhammad Abdullah³, Jahidul Islam⁴, Likhon Howlader⁵, Oishorjo Bala⁶
¹Assistant Registrar, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
²Associate Professor, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
³Medical Officer, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
⁴Assistant Professor, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
⁵Emergency Medical Officer, Anabil Hospital & Diagnostic Center, Dhaka, Bangladesh
⁶Medical Officer, Khulna City Medical College & Hospital, Khulna, Bangladesh

Corresponding Author: Goutom Chandra Bhowmik ^{ORCID iD}
Address: Assistant Registrar, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh.
Received date: 05 December 2024; Accepted date: 27 January 2025; Published date: 04 February 2025

Citation: Bhowmik GC, Chowdhury S, Hasan K, Abdullah M, Islam J, Howlader L, Bala O. Survival of Cardiac Arrest with Withdrawal of Mechanical Ventilator: A Case Report. Asp Cardio Case Rep and Res. 2025 Feb 04;2(1):6-10.

Copyright © 2025 Bhowmik GC, Chowdhury S, Hasan K, Abdullah M, Islam J, Howlader L, Bala O. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Cardiac Arrest, Cardiopulmonary Resuscitation (CPR), Percutaneous Intervention (PCI), Return of Spontaneous Circulation (ROSC), Case Report

Abbreviations: CPR: Cardiopulmonary Resuscitation; PCI: Percutaneous Intervention; ROSC: Return of Spontaneous Circulation

Abstract

Background: In-hospital cardiac arrest (IHCA) is a common clinical event with extremely poor outcomes associated with cardiovascular disease. Although IHCA, associated with a high mortality rate, has received little attention compared to other cardiovascular conditions such as myocardial infarction and stroke [1]. The survival rate of IHCA to discharge is approximately 25% [2]. We report a case of cardiac arrest survival in a patient with a history of old MI (anterior), SVD, and uncontrolled DM and HTN. The patient was initially treated with resuscitation according to guidelines due to the unavailability of consent for PCI.
Case Presentation: A 55-year-old South Asian woman presented with massive acute anterior MI with uncontrolled DM and HTN. After proper management of acute MI in the hospital, she was discharged with advice and a suggestion for coronary angiography. Before angiography, an ECHO was done, revealing an LVEF of only 46%, regional wall motion abnormality, and grade II diastolic dysfunction. She was strongly advised to undergo coronary angiography as early as possible. Angiography revealed a massive occlusion of 99% in the mid-LAD. When the cardiac team decided to perform PCI, the patient’s guardian did not give immediate consent. During this time, the patient suffered a cardiac arrest, and an emergency event occurred. ROSC was established through CPR for 30 minutes, followed by intubation and mechanical ventilation. The patient was transferred to the CCU [3]. In the CCU, the patient remained on mechanical ventilation for about 48 hours. After correcting biochemical imbalances, the patient regained hemodynamic stability. She is now undergoing cardiac rehabilitation and has provided consent for PCI.
Conclusion: Cardiac arrest is a sudden event that occurs mostly due to cardiac causes. It is difficult to manage and has a high mortality rate. The key elements of treatment during cardiac arrest include chest compressions, ventilation, early defibrillation when applicable, and immediate attention to potentially reversible causes such as hyperkalemia or hypoxia. There is limited evidence to support more advanced treatments. PCI remains the mainstay of treatment for cardiac arrest caused by thrombus-mediated flow limitation.

Introduction

Sudden cardiac arrest (SCA) is one of the most challenging events in hospital conditions. SCA seems to account for ≈50% of all cardiovascular deaths [1]. Myocardial infarction, especially ST-segment elevated myocardial infarction (STEMI), is the most efficient cause of SCA. Other causes, such as cardiovascular disease, cardiomyopathy, and valvular heart disease, can also cause SCA, while some modifiable or nonmodifiable risk factors further enhance the incidence of cardiac arrest. These include a positive family history, uncontrolled HTN, DM, smoking, obesity, age, and ethnicity, which make individuals more prone to coronary artery disease, resulting in MI.

There are many diagnostic tools, such as 12-lead ECG, color Doppler ECHO, ETT, and cardiac markers (troponin-I, CK-MB), that are used for the diagnosis of MI. The gold standard investigation for the diagnosis and prognosis of MI is coronary angiogram. In-hospital cardiac arrest followed by MI management requires a team approach conducted according to ACLS guidelines.

PCI remains the mainstay of treatment, even under mechanical ventilation. Other reversible causes, like hypoxia, hypovolemia, metabolic changes, hyperkalemia, or hypokalemia, should be treated. A MAP of ≥70 mmHg should be maintained to optimize cerebral perfusion. Physiological targets following a return of spontaneous circulation (ROSC) should be maintained until the removal of mechanical ventilation. After ROSC, post-cardiac arrest care should be taken to prevent post-cardiac arrest syndrome.

The purpose of this report is to present a case of cardiac arrest survival followed by an old MI right after a coronary angiogram in the Cath lab. Due to the lack of consent, PCI was not performed. Despite fatal metabolic changes, proper and immediate correction enabled the patient to regain consciousness, serving as a good example of effective management.

Case Presentation

A 55-year-old South-Asian woman with a history of uncontrolled Diabetes Mellitus and Hypertension was relatively stable in February 2024. Six months later, in September, she developed chest pain and slight chest discomfort. She visited a doctor and was advised to undergo investigations, including ECG, Trop-I, RBS, and Serum Lipase. The ECG report revealed changes in V1-V6 leads, and Trop-I was elevated to 10.4, indicating STEMI (Ant.) (Fig-1). She was admitted to NICVD, where she received appropriate management for AMI and was subsequently discharged with in-house treatment and advice for a coronary angiogram.

Fig-1: Acute STEMI

Before undergoing the angiogram, an ECHO was performed, showing marginal wall motion abnormality at rest, LVEF of 45%, Grade II diastolic dysfunction, and mild pulmonary hypertension (Fig-2). A few days later, the patient was readmitted to NICVD for the angiogram. The coronary angiogram revealed 99% occlusion in the mid LAD (Fig-3). PCI was deemed mandatory to save her life, and consent was sought. Unfortunately, before the consent could be obtained, the patient suffered a sudden cardiac arrest.

Fig-2: ECHO of the Patient Before Angiogram

Fig-3: Sketch of Occlusion in Angiogram

The resuscitation team immediately took over, performing approximately 30 minutes of CPR, APAP, intubation, and administration of adrenaline at 3-5 minute intervals. They successfully resuscitated the patient. However, her guardians, unable to comprehend the urgency of the situation, did not provide consent for PCI. Consequently, the patient was transferred to the CCU and placed on mechanical ventilation in VCV mode.

While on mechanical ventilation, the oxygen flow was set to 100%, and the controlled respiratory rate was initially 18 breaths/min. Norcurium Bromide, Propofol, Noradrenaline, and Dopamine were administered via syringe pumps. The patient’s heart rate ranged between 130-132 bpm, blood pressure was 100/60 to 100/70 mmHg, and SpO₂ was 99%. During this time, the patient developed severe respiratory acidosis (Fig-4). A senior anesthesiologist administered 12 vials of Sodi-bi-carb diluted with 750 ml of N/S over an hour. Repeat ABG analysis revealed respiratory alkalosis with hypernatremia (Fig-4).

Fig-4: ABG Analysis Report

The patient was on NG tube feeding, and her urine output remained normal. Other treatments included antibiotics, antiulcerants, antidiabetic medications, and parenteral anticoagulants.

The following day, as sedatives were gradually tapered and other biochemical changes in her blood were corrected, she began to regain consciousness. Serum creatinine and electrolyte reports confirmed normal kidney function (Fig-5), though she had both hypokalemia and hypernatremia.

Fig-5: Biochemical Report

The head of the cardiac team adjusted the treatment, adding medications and planning to taper the doses of Dopamine and Noradrenaline if her blood pressure and oxygen saturation remained stable. Sedatives were stopped, and the anesthesiologist advised gradually decreasing the ventilator’s respiratory rate and oxygen flow while monitoring oxygen saturation.

By evening, the patient underwent a T-piece trial for one hour with 2L oxygen/min, maintaining saturation above 95%. She met the extubation criteria and was successfully extubated. Post-extubation, she received chest physiotherapy and was encouraged to practice breathing exercises while her vital parameters were monitored in the CCU for 24 hours.

After approximately 72 hours, the patient was moved to the HDU. Two days later, she was discharged with medications (Fig-6). She is currently in cardiac rehabilitation and has been advised to undergo PCI after 4-6 weeks. The guardians have now agreed to provide consent for the procedure.

Fig-6: Present Condition of the Patient

Discussion

Sudden cardiac arrest (SCA) is a significant international public health problem, accounting for an estimated 15–20% of all deaths. Although resuscitation rates are improving globally, the majority of individuals who experience sudden cardiac arrest do not survive. SCD most commonly develops in older adults with acquired structural heart disease, but it can also rarely occur in younger individuals, where inherited disorders are more often the cause.

Coronary heart disease (CHD) is the most common pathology underlying SCD, followed by cardiomyopathies, inherited arrhythmia syndromes, and valvular heart disease [3]. If cardiac arrest occurs in a hospital, approximately one in five individuals will survive. “Of those who survive, around half will have cognitive limitations, and just 25% will be able to continue living at home independently without assistance,” says Hunziker [4]. Our case exemplifies this condition.

Conclusion

Acute coronary occlusion is the leading cause of cardiac arrest. The primary goal of treatment for cardiac arrest is to rapidly achieve the return of spontaneous circulation through various interventions, including CPR, defibrillation, and/or cardiac pacing. Two protocols have been established for CPR: basic life support (BLS) and advanced cardiac life support (ACLS) [5]. Nevertheless, the mainstay treatment for cardiac arrest caused by infarction remains PCI.

Acknowledgements

We acknowledge the following institutions for their contributions:

Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh.
Anabil Hospital & Diagnostic Center, Dhaka, Bangladesh.
Khulna City Medical College & Hospital, Khulna, Bangladesh.

Author Contributions

All authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation, or all these areas. All authors took part in drafting, revising, or critically reviewing the article, gave final approval of the version to be published, agreed on the journal to which the article has been submitted, and agree to be accountable for all aspects of the work.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of Data and Materials

Not applicable.

Ethics Approval and Consent to Participate

We received approval from the ethics committee of the Faculty of Interventional Cardiology. All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional research committee.

Consent for Publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal upon request.