Abstract Sun1402: Fatal Pulmonary Embolism Following Intravascular Cooling for TTM in a Young Cardiac Arrest Survivor

Abstract

Case Presentation: A 38-year-old male with a history of GERD and nicotine vaping suffered a witnessed out-of-hospital cardiac arrest. CPR was initiated immediately, and EMS arrived within five minutes to find the patient in ventricular fibrillation. ROSC was achieved after a single defibrillation. On arrival, the patient was comatose. EKG demonstrated a Brugada Type 1 pattern. Initial workup suggested cardiogenic shock and possible anoxic injury. Targeted temperature management (TTM) was initiated using a 9.3F femoral intravascular cooling (IC) catheter, achieving 36°C within two hours. Heparin was started on Day 1 and transitioned to enoxaparin. Differential Diagnosis: Initial considerations included myocardial infarction, pulmonary embolism, primary arrhythmia, and toxic/metabolic causes. Normal coronary angiography combined with the EKG findings supported Brugada syndrome as the etiology of the initial arrest. A second arrest on Day 9 presented as pulseless electrical activity, inconsistent with recurrent ventricular arrhythmia. Treatment and Management Details: The patient showed neurologic recovery by Day 6 with improved LVEF and successful self-extubation. On Day 7, he developed bilateral leg swelling; Doppler confirmed femoral DVTs, and a heparin infusion was initiated. On Day 9, he experienced a second cardiac arrest. eCPR was initiated with mechanical CPR and VA-ECMO, achieving ROSC after 26 minutes. TTM restarted through ECMO therapy. Imaging revealed massive bilateral PE. Emergent thrombectomy was performed, but RV dysfunction persisted. HIT IgG returned positive; anticoagulation was switched to argatroban. SRA was later negative. Outcome: Despite early neurologic improvement, the patient developed cerebral edema and herniation by Day 11 and was declared brain-dead on Day 16. Teaching Points: This case highlights a fatal thromboembolic complication of femoral IC in a recovering cardiac arrest patient and underscores the importance of individualized TTM planning. SC with temperature feedback should be first-line for most patients. If IC is required, jugular or subclavian access is preferred, and femoral access should be avoided unless emergent or anatomically necessary. Early DVT surveillance, pharmacologic thromboprophylaxis, and daily reassessment of catheter need are critical. When thrombotic risk is elevated, such as in cardiogenic shock or low-flow states, choosing the least harmful modality is essential.