Extensive intracardiac thrombosis detected during perioperative cardiac arrest following toe amputation: a case report

Background The use of a tourniquet in patients with severe preoperative hypercoagulability may precipitate life-threatening intravascular thrombosis, yet evidence for risk stratification and prophylactic anticoagulation in emergency surgery is limited. Few prior reports have described extensive intracardiac and suspected great-vessel thrombus-like material detected by transoesophageal echocardiography (TEE) after tourniquet deflation with markedly elevated D-dimer and reduced antithrombin activity. Case presentation An 87-year-old man with diabetes, heart failure and chronic kidney disease underwent emergency tourniquet-assisted toe amputation for septic right-foot gangrene. Preoperative testing showed severe hypercoagulability: D-dimer 18.58 µg/mL (> 37-fold upper limit of normal) and antithrombin activity 57.5%. Prophylactic anticoagulation was withheld because of concerns about surgical bleeding and the priority for rapid source control. Forty-four minutes after tourniquet release, pulseless cardiac arrest occurred. As a single continuous examination, multiplane TEE was obtained within 6 min of the onset of pulseless cardiac arrest, during ongoing chest compressions and shortly after a transient return of spontaneous circulation. Representative static TEE images are shown in Fig. 1A-E, and corresponding real-time clips are provided as supplementary videos (A-E). Extensive, heterogeneous echogenic material was visualised within multiple cardiac chambers on two-dimensional TEE during active chest compressions, occupying a large portion of the visible cross-sectional cavity. Thrombus-like material appeared to extend toward major great vessels on the available imaging views. Intracardiac thrombus can develop or propagate under marked circulatory stasis during resuscitation. Therefore, these echocardiographic findings acquired during resuscitation cannot differentiate pre-existing thrombus from thrombus that formed or enlarged after the onset of cardiac arrest. Despite resuscitation efforts, the patient died. Conclusion This report describes peri-arrest transoesophageal echocardiographic findings consistent with extensive intracardiac thrombus-like material during pulseless cardiac arrest following emergency toe amputation. The relative contributions of pre-existing intracardiac thrombus, circulatory stasis after cardiac arrest, sepsis-associated coagulation activation and tourniquet-related pathophysiological changes to the final echocardiographic appearance remain unclear. This case supports careful individualised risk–benefit assessment in similar patients. However, no anticoagulation prophylaxis thresholds or novel resuscitation protocols can be established from this single observation. Several relevant laboratory and imaging datasets could not be acquired in the emergent clinical setting, limiting interpretation of the present findings.