Prolonged cardiac arrest during primary PCI in acute anterior wall myocardial infarction

Sushma1*, Shalini H S2, Vijayakumari D3

1Cath lab Incharge, Kauvery Hospital, Electronic City, Bangalore

2CNO, Kauvery Hospital, Electronic City, Bangalore

3Nurse Educator, Kauvery Hospital, Electronic City, Bangalore

*Correspondence

Abstract

Acute ST Elevation Myocardial Infraction, especially Acute anterior wall myocardial infarction (AWMI) due to left anterior descending artery occlusion may be complicated by malignant arrythmias (recurrent ventricular tachycardia (VT), ventricular fibrillation (VF) and cardiac arrest. Primary Percutaneous coronary intervention (PCI) is the preferred reperfusion therapy. However cardiac arrest during PCI presents significant clinical challenges. We report a case of prolonged cardiac arrest during primary PCI for AWMI that was successfully managed with prolonged cardiopulmonary resuscitation & timely coronary revascularization.

Keywords: Acute anterior wall myocardial infarction; Primary PCI; Prolonged cardiac arrest; Ventricular fibrillation; Resuscitation

Introduction

Acute Anterior Wall Myocardial Infarction (AWMI) due to proximal Left Anterior Descending (LAD) artery occlusion accounts for a substantial proportion of ST‑Elevation Myocardial Infarctions (STEMIs) and is associated with large myocardial territory involvement. Ventricular arrhythmias, particularly Ventricular Fibrillation (VF), are frequent complications and contribute to high early mortality. Primary Percutaneous Coronary Intervention (PCI) within guideline‑recommended timelines is the gold‑standard reperfusion strategy owing to its mortality benefit over fibrinolytic therapy. However, the occurrence of cardiac arrest during PCI poses critical management challenges, especially when prolonged resuscitation is required. Acute Anterior Wall Myocardial Infarction (AWMI) is associated with significant complications including malignant ventricular arrhythmias and cardiogenic shock. Survival following prolonged cardiac arrest during primary PCI is uncommon, and neurologically intact recovery is even rarer.

This case demonstrates the importance of:

  • Immediate recognition and intervention.
  • High-quality CPR.
  • Aggressive arrhythmia management.
  • Coordinated ER, Cath lab, and ICU nursing teamwork.
  • Timely reperfusion therapy.

Case Presentation

A 27-year-old male presented to the emergency department with acute chest pain and was diagnosed with AWMI. Shortly after arrival, he developed recurrent VT and VF requiring defibrillation, antiarrhythmic loading doses, and endotracheal intubation. He was shifted emergently to the cardiac catheterization laboratory for primary percutaneous coronary intervention (PCI). During the procedure, he developed recurrent VT followed by asystole requiring prolonged CPR, multiple defibrillations, and advanced cardiac life support (ACLS) medications. Due to persistent instability, family members were counselled regarding poor prognosis. The patient was transferred to the ICU under ongoing resuscitative support. Remarkably, spontaneous circulation stabilized within two hours. The following day, the patient was awake, extubated, and demonstrated intact neurological function.

Initial Assessment

  • ECG: ST-segment elevation in anterior leads consistent with AWMI.
  • Hemodynamically unstable.
  • Developed recurrent episodes of VT and VF in ER. 

Emergency Management

  • Immediate defibrillation.
  • Loading doses of antiarrhythmic (e.g., amiodarone).
  • Endotracheal intubation for airway protection.
  • Transfer to Cath lab for primary PCI.

Procedure Finding

Coronary angiography demonstrated a 100% occlusion of the proximal LAD. During guidewire manipulation of the LAD lesion, the patient developed sudden VF-induced cardiac arrest. Immediate high‑quality CPR was initiated.

During coronary intervention:

  • Recurrent VT.
  • Progression to asystole.
  • Prolonged CPR performed.
  • Multiple defibrillations.
  • ACLS medications administered (adrenaline, amiodarone, etc.).
  • Given the prolonged arrest and instability, family counselling was done regarding guarded prognosis.

Post Procedure Care

The patient was shifted to ICU with ongoing resuscitative support. Approximately 2 hours later:

  • Hemodynamic stability gradually improved.
  • Sinus rhythm restored.
  • Vasopressor support reduced. 

Neurological Outcome

On the following day:

  • Patient regained consciousness.
  • Followed commands.
  • No focal neurological deficit.
  • Extubated successfully.
  • Brain function intact.

This represented a complete neurological recovery despite prolonged cardiac arrest.

Discussion

AWMI involving the LAD predisposes to extensive myocardial ischemia and electrical instability, increasing susceptibility to malignant ventricular arrhythmias such as VF & VT. During PCI, ischemia‑reperfusion phenomena and mechanical stimulation of atherosclerotic plaques can precipitate arrhythmias, especially in high‑risk lesions.

Current guidelines emphasize early defibrillation and uninterrupted, high‑quality CPR in managing cardiac arrest. In the setting of VF due to acute coronary occlusion, restoring coronary perfusion is essential for ROSC and myocardial salvage. Successful outcomes have been reported when prolonged resuscitation is undertaken concurrently with definitive revascularization efforts.

In cases of refractory cardiac arrest or cardiogenic shock, mechanical circulatory support devices such as intra‑aortic balloon pump (IABP), Impella, or extracorporeal membrane oxygenation (ECMO) may be considered to maintain perfusion and facilitate PCI, although availability and institutional protocols vary. 

Prognostic Determinants

Young age may have contributed to favourable recovery despite severe ischemic insult

  • Early recognition of STEMI.
  • Immediate initiation of ACLS.
  • Rapid transfer for primary PCI.
  • High-quality CPR.
  • Persistent resuscitation efforts.
  • Exceptional ER and Cath lab nursing coordination.

The role of nursing staff was pivotal in:

  • Rapid drug preparation and administration.
  • Continuous monitoring.
  • Defibrillation readiness.
  • Airway management assistance.
  • Documentation and communication.
  • Emotional support for family.

Conclusion

Prolonged cardiac arrest during primary PCI for AWMI is a critical event requiring immediate, coordinated action. High‑quality resuscitation efforts, collaboration between interventional and critical care teams, and early coronary reperfusion can result in favourable outcomes. This case illustrates that even in seemingly futile situations, continued evidence-based resuscitation can result in extraordinary recovery. The dedication and coordinated doctors and nurse’s efforts of ER and Cath lab played a crucial role in achieving a neurologically intact survival. Such cases remind clinicians to maintain persistence, teamwork, and hope in critical care scenarios.

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