Transesophageal echocardiography diagnosis of dextrocardia during cardiac arrest guided optimal chest compression location: A case report

The incorporation of transesophageal echocardiography (TEE) into cardiac arrest management overcomes several limitations inherent to transthoracic echocardiography, while producing higher-quality images. Among other advantages, TEE can evaluate chest compression quality and location during ongoing compressions. AHA/ACLS guidelines recommend hand placement for compressions over the lower half of the sternum in order to compress the left ventricle (LV). However, literature demonstrates that chest compressions do not align with the LV over half the time, but rather lie over the left ventricular outflow tract and aortic root. Under those circumstances, the LV is compressed inadequately. The inadequate stroke volume reduces the likelihood of obtaining return of spontaneous circulation. Additionally, the aortic valve would be compressed and remain closed, which literature shows is associated with decreased survival. Furthermore, standard chest compression technique assumes typical cardiac anatomy. However, anatomical variations such as dextrocardia can render these compressions ineffective. Physicians would not be aware of conditions like these at the time of initiating cardiopulmonary resuscitation. Here, we present the first known case of cardiac arrest in which the TEE diagnosis of dextrocardia led to TEE-guided chest compressions, leading to improved markers of organ perfusion and ROSC.