E–cpr in Prolonged Refractory Cardiac Arrest Post Cardiac Tamponade and Severe Biventricular Disfunction in a Young Woman

A 19y woman admitted to ED for generalized seizures, preceded by 1week of fever and a recent trip to Lapland: she was comatose GCS 3, stable haemodynamic, EKG SR and non–specific abnormalities, severe hypoglycaemia 5 mg/dL. Neurological status improved after i.v. glucose.Brain CT unremarkable.Lab tests: leukocytosis (lymphocytic), high CRP 6, thrombocytopenia, mild troponin elevation, creatinine 2.8, INR 2.7,mildly increased AST/ ALT, high LDH, CK and myoglobin.Roughly 2 h after admission,sudden cardiac arrest (CA) occurred due to PEA.ACLS and endotracheal intubation started.Echo:massive pericardial effusion causing cardiac tamponade. Emergency pericardiocentesis drained exudative fluid; however, refractory CA persisted, with only a brief return of ROSC after 60 min, followed by prolonged PEA.After 107 min of manual chest compression, VA–ECMO was initiated.Early echo showed severe biventricular dysfunction with minimal aortic valve opening, so IABP was implanted for left ventricular venting.Suspecting acute myopericarditis, high–dose corticosteroids and i.v. immunoglobulins were given, EMB was not feasible due to severe instability.Cardiac function progressively improved in normalization of biventricular systolic function within 48–72 hours, allowing ECMO weaning,which was complicated by Harlequin syndr, requiring urgent ECMO removal while maintaining IABP support, which was subsequently removed together with the pericardial drain.ICU course was complicated by left lower limb compartment syndr.requiring fasciotomy, acute limb ischemia due to embolization from femoral pseudoaneurysm, mild intracranial hemorrhagic suffusion during UF heparin, and pneumonia with pleural effusion requiring drainage. Extensive microbiological test on blood, BAL, cerebrospinal fluid and nasal swab was negative.Patient slowly recovered and was extubated without neurological sequelae.Seen persistent mild pericardial effusion and pericardial thickening, colchicine and low–dose corticosteroids were continued.Cardiac MR 15 days later:pericardial edema, circumferential effusion max 9 mm, diffuse LGE of pericardial layers, no myocardial edema or enhancement, consistent with acute pericarditis.Ibuprofen was therefore added.Overall, the most likely diagnosis was acute viral myopericarditis complicated by cardiac tamponade, multiorgan dysfunction and severe transient biventricular stunning after prolonged CA, with a possible overlapping contribution of systemic inflammatory response syndr.