(P75) Small Tear, Big Root: Aortic Root Aneurysm Complicated by Pericardial Effusion and Cardiac Tamponade

Saturday, September 9, 2023

12:30 PM - 1:30 PM EEST

Poster Presenter / Primary Author(s)

Maia Winkel, MD

Resident Physician
Jacobi Medical Center and Montefiore Medical Center
New York, New York, United States

Co-Author(s)

TB

Taylor Burden, MD

Resident Physician
Jacobie Medical Center and Montefiore Medical Center
New York, New York, United States
GS

Gagandeep Singh, MD

Ultrasound Fellow
Jacobi Medical Center
New York, New York, United States
Benjamin Araki, DO

Emergency medicine resident physician
Albert Eistein School of Medicine, Jacobi/Montefiore Emergency Medicine Program
Bronx, New York, United States
LC

Laila Cochon, MD

Resident Physician
Jacobi Medical Center and Montefiore Medical Center
New York, New York, United States
AL

Alexandra Lew, MD

Resident Physician
Jacobi Medical Center and Montefiore Medical Center
New York, New York, United States
EP

Eldin Pupovic, MD

Resident Physician
Jacobi Medical Center and Montefiore Medical Center
New York, New York, United States
PG

Peter Gruber, MD

Attending Physician
Jacobi Medical Center
New York, New York, United States

Chief Complaint : chest pain

History of Present Illness : 59-year-old male, daily smoker with no other past medical history comes in by ambulance for sudden-onset, non-radiating, substernal chest pain associated with lightheadedness and shortness of breath that began while standing in the bathroom just prior to arrival. On arrival, the patient was hypotensive, tachycardic, and diaphoretic all while clutching his chest and complaining of severe chest pain and shortness of breath. He denied drug and alcohol use, and did not have a significant family history of cardiac disease.

Pertinent Physical Exam: ED vital signs: BP 97/62, HR 106, T 97.3 F, RR 17, O2 99% on RA

On exam, the patient appeared uncomfortable and lethargic but was oriented to person, place and time. He had distant heart sounds on cardiac auscultation and his skin was pale and diaphoretic.

Bedside point-of-care-ultrasound (POCUS) showed a large pericardial effusion with a clot, dilatation of aortic root, diastolic right ventricular collapse, possible systolic right atrial collapse, and a plethoric inferior vena cava (IVC). There was no obvious dissection flap seen on the cardiac or abdominal ultrasound.

Pertinent Laboratory Data: EKG: NSR and no acute signs of ischemia
Labs: none resulted prior to transfer

Case Discussion: Chest pain is one of the most common chief complaints in the emergency department – key features can help distinguish the benign from the life-threatening. In a hypotensive patient with sudden-onset chest pain, it is imperative to evaluate for the fatal causes: acute coronary syndrome, aortic dissection, cardiac tamponade, esophageal rupture, pulmonary embolism, and pneumothorax.[1] Ultrasound is an efficient, non-invasive, bedside imaging modality that can guide both emergency evaluation and treatment. In order to better elucidate pathology, the Rapid Ultrasound for Shock and Hypotension (RUSH) exam can be used to obtain the following views: parasternal long, apical four-chamber, IVC, right upper quadrant (most sensitive), left upper quadrant (most dependent), bladder, aorta, bilateral pulmonary views, including the base of the thoraces. The combination of a focused history, physical, and ultrasound led to a quick diagnosis of aortic root dilatation and accompanying tamponade physiology with a pericardial clot.[2,3] Notably, the listed criteria for cardiac tamponade were all visualized: pericardial effusion, diastolic right ventricular collapse (high specificity), systolic right atrial collapse (earliest sign), plethoric IVC without respiratory variation (high sensitivity).[3] Intravenous fluids and blood products were immediately administered.[4] Based on the aforementioned ultrasound findings, the decision was made to forego cardiac catheterization and, instead, obtain an emergent CTA dissection study and arrange transfer to a nearby hospital with a cardiothoracic surgery service. The CTA showed a dense, large pericardial effusion concerning for hemopericardium, an intramural hematoma, possible ulceration of the ventral ascending aorta, and aortic root ectasia (4.9 cm).[5] The patient was emergently transferred and, intraoperatively, a large hematoma involving the aortic root with a tear above the right coronary ostium was found just superior to the aortic valve. A valve-sparing aortic root replacement was performed and the patient was discharged home six days later.[6]

References and Acknowledgements (Optional): Johnson, K., & Ghassemzadeh, S. (2023). Chest Pain. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470557/

Thomas, K., & Amr, O. (2022). Use of Point-of-Care Ultrasound for Early Identification of Acute Aortic Root Dissection. Case Rep Crit Care, 2022, 7166230. doi: 10.1155/2022/7166230. PMID: 36299499; PMCID: PMC9592206.

Alerhand, S., & Carter, J. M. (2019). What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med, 37(2), 321-326. doi: 10.1016/j.ajem.2018.11.004. PMID: 30471929.

Sagristà-Sauleda, J., Angel, J., Sambola, A., & Permanyer-Miralda, G. (2008). Hemodynamic effects of volume expansion in patients with cardiac tamponade. Circulation, 117(12), 1545-9. doi: 10.1161/CIRCULATIONAHA.107.737841. PMID: 18332261.

Mussa, F. F., Horton, J. D., Moridzadeh, R., Nicholson, J., Trimarchi, S., & Eagle, K. A. (2016). Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. JAMA, 316(7), 754-63. doi: 10.1001/jama.2016.10026. PMID: 27533160.

Brown, J. A., Arnaoutakis, G. J., Kilic, A., Gleason, T. G., Aranda-Michel, E., & Sultan, I. (2020). Current trends in the management of acute type A aortic intramural hematoma. J Card Surg, 35(9), 2331-2337. doi: 10.1111/jocs.14819. PMID: 32652687.