Prolonged Use of Intra-Aortic Phase Shift Balloon Pumping in Cardiogenic Shock

The present case is one of the few examples in which a right heart mural thromboembolus and pulmonary em­ bolus play an important role in the genesis of the ter­ minal syndrome in patients with chronic pulmonary obstructive disease. The size, location and the formation of the thromboembolus in this instance is quite unusual. We suspect that a mural thrombus developed in the right atrial appendage long ago, as often happens in these eases, but that the formation and extension of this atrioventricular thromboembolus was a direct result of the external cardiac massage. It is well known that this procedure, used for resuscitation, has a high rate of complication, some of which are perilous for the patient Of 46 patients on whom this procedure was applied Baringer et al3 found 36 complications such as: frac­ tured ribs, hemothorax, hemopericardium, liver injuries and bone marrow emboli in the pulmonary arteries. One patient was found with bone marrow embolus which was adherent to a mural thrombus in the right atrium. A simi­ lar process took place in our case. Here, the bone mar­ row emboli were trapped in the heart by their adherence to the old atrial thrombus due to retardation, or stasis of blood flow consequent to pulmonary hypertension and cor pulmonale. These conditions permitted the bone marrow emboli and spicules to remain in the heart cavi­ ties as a nidus for further thrombus formation. Another important factor was the partial obstruction of the tricus­ pid valve with encroachment of the lumina of the right heart cavities by the thrombus and its extension toward the pulmonary artery from which an embolus containing bone marrow structure had broken off and went to a branch of the pulmonary artery. In certain areas of these thromboembolic formations, very recent deposits of blood elements could be identified. We feel that these fresh areas were part of a continuing process which began long before the episode of cardiac arrest which ultimately terminated life. Baum and Fisher4 call atten­ tion to the fact that few reports have emphasized the role of the right heart mural thrombi and pulmonary emboli in the genesis of the terminal syndrome in those patients. The French specialists5-6 have a large number of studies of the so-called preagonique clots, and even in these cases they attributed a high degree of significance, considering them a grave complication. Gibbon et al7 discussed the changes in the circulation produced by the occlusion of the pulmonary artery and compared the event with a state of shock or hemorrhage in which death occurs not primarily from cardiac failure, but from the effect of reduced blood volume with accumulation of blood in the venous side of the circulatory system. The effect was much more serious in this patient where, in addition to the pulmonary embolus, there was longstand­ ing impairment of filling the right heart cavities. In effect, the thrombus was a space occupying mass pro­ ducing a reduction in the normal amount of blood present in these chambers and the hemodynamic effect of the pulmonary artery embolism was aggravated thereby. We believe that all these events should be considered as a cause of death following the complica­ tion from external cardiac massage.