A 23-year-old mountaineer, used to high altitude, climbed one of the highest summits in the Alps (4556 m). Back in the bivouac (approx. 3200 m) he realised the loss of his gas bottle and, therefore, further descended to a mountain hut (2795 m), where he collapsed 10 min after arrival while sitting in a chair. Two anaesthesiologists, fellow mountaineers, diagnosed pulse-less cardiac arrest and initiated cardiopulmonary resuscitation. After 30 min, a mountain rescue team arrived by helicopter and obtained a 12-lead ECG showing ventricular fibrillation, which was successfully defibrillated into sinus rhythm whereupon spontaneous circulation returned. Extensive anterior myocardial infarction was suspected due to ST-segment elevation in V1-5 (). Therefore, the patient was thrombolysed (reteplase) and flown to our hospital centre for primary angioplasty. Echocardiogram showed severely reduced left ventricular ejection fraction (EF 25–30%) with akinesia of the anterior and septal wall without significant valvulopathy. And 2.5 h after onset of cardiac arrest, coronary angiography revealed normal coronary arteries without narrowings or dissection.
ECG at presentation to the emergency room. Significant ST-segment elevation in V1-5 and ST-segment depression in II, III, aVF.
Cardiac serum markers suggested extensive myocardial necrosis with maximal creatine kinase of 15 674 U/l (myocardial fraction 737 μg/l) and maximal troponin T of 7.87 μg/l. Ten days after cardiac arrest, an ECG () showed regredient but still significant ST-segment elevation in V1-3 and negative T waves in V1-6, suggesting the sequel of extensive anterior myocardial infarction with subsequent aneurysm formation. However, left ventricular function gradually increased and was 35% and 65% after 1 and 2 weeks, respectively, without regional wall-motion abnormalities. Cardiac magnetic resonance was performed after 3 weeks to rule out cardiomyopathy. The scan was found to be normal and remarkably without scar.
ECG 10 days after cardiac arrest. Regredient ST-segment elevation remaining significant in V1-3 and discordant, negative T waves in V1-6, I, II.
Ventricular biopsy was performed to rule out inflammatory, infiltrative or degenerative causes. The former causes and in particular peri- and myo-carditis were further ruled out with a normal cardiac magnetic resonance scan.
Electrophysiological causes, for example, abnormal conduction system or repolarisation, could not be substantiated by ECG findings. In order to rule out cardiac or paradoxical embolism a trans-oesophageal echocardiogram was performed which was normal.
A cardioverter-defibrillator was implanted for secondary prevention because an arrhythmogenetic cause could not be excluded entirely. One month after the cardiac arrest, the young mountaineer was discharged in good condition. Ironically, a lost gas bottle and the subsequent descent to a mountain hut saved his life.