You are called to the emergency department to see a 74-year-old man. He has a history of heavy smoking and hypertension. The patient cannot remember his medications, but he reports not taking them on a routine basis. In the past few hours before presentation, he experienced a sudden onset of severe leftsided chest pain with radiation to the left scapula. Approximately half an hour later, he noted some difficulty breathing. In the emergency department, he is noted to be diaphoretic and in significant respiratory distress. His physical examination reveals a BP of 160/90 mmHg, elevated jugular venous pressures, and a quiet precordium. His ECG is reported as sinus tachycardia with no acute ST-T changes. After initial pain and BP management, a transesophageal echocardiography (TEE) is performed to rule out aortic dissection. The findings of the TTE are shown in Figure below.
What is your recommendation?
The patient should have immediate surgical intervention. This patient has evidence of acute type A aortic dissection with extension to the pericardium, as evidenced by the pericardial effusion on the TEE. He should be immediately referred for surgical repair. If the diagnosis were not certain based on the TEE, then CT, MRI, or aortic angiography would be needed to better define the anatomy. The safest and most efficient management of patients with aortic dissection is to carry out all diagnostic procedures in the operating room. Pericardial drainage often gives only temporary relief or no relief of the tamponade, and the subsequent increase in BP disrupts sealing clots, accelerating intrapericardial leakage.
A 42-year-old man was referred for evaluation of symptomatic mitral regurgitation. He was diagnosed with mitral valve prolapse that was not suitable for repair. Given his family history of CAD and tobacco use, he underwent a coronary angiogram, which revealed no evidence of obstructive coronary disease. He underwent an uneventful mitral valve replacement. He was extubated and transferred from the intensive care unit 48 hours after the operation. On postoperation day 3, you note the patient to be pale and lethargic and in mild respiratory distress. His BP is 100/60 mmHg. His cardiac and lung examination is compromised by the presence of rapid breathing and chest tubes. His ECG reveals normal sinus rhythm (NSR) at 97 bpm with no acute ST-T changes. A TTE is performed. Selected views are shown in Figure below.
As the patient continues to deteriorate and becomes hypotensive, a TEE is performed next, as shown in Figure below.
What should you recommend?
Immediate surgical exploration of the pericardium. The TTE and TEE demonstrate a pericardial hematoma compromising RA and RV filling. This is an indication for surgical exploration and evacuation of the hematoma.
A 49-year-old black man with hypertension and chronic renal insufficiency presents with dyspnea and fluid overload with decreased urine output. He is treated in the hospital with diuretics, and his symptoms improve. However, his renal function continues to deteriorate with an increasing blood urea nitrogen of 90 and a creatinine of 5.4. In addition, the patient is noted to have several bruises on his arms from needlestick blood draws and IV lines. On hospital day 4, the patient is noted to be hypotensive and tachycardic: BP, 80/40 mm Hg; HR, 110 bpm. No jugular venous distention is noted, but heart sounds are diminished, and a loud pericardial rub is heard. His TTE is shown in Figure below.
What is the next step in management?
IV hydration. This patient has evidence of pericarditis likely related to uremia, as he is close to requiring dialysis. Although his TTE shows signs of tamponade (RA collapse, moderate-sized effusion, and respiratory variation across the mitral inflow), there is no jugular venous distention, and the inferior vena cava is small sized, indicating that this patient has been overdiuresed. His hypotension and tachycardia are related to dehydration. He should, therefore, be treated with IV hydration.
A 42-year-old white male chef is brought into the emergency department after a motor vehicle accident in which he fell asleep at the wheel and ran into a tree. He is reporting anterior chest discomfort and shortness of breath. He relates no prior medical conditions and takes no medications. Vitals are stable with a BP of 120/60 mmHg and an HR of 90 bpm. His ECG is shown in Figure below.
A TTE is performed. Diastolic images are shown in Figure below.
Laboratory tests show modest elevation of creatinine phosphokinase at 240. Which of the following is the most reasonable next step in managing this patient?
Admit the patient for observation on telemetry with a follow-up TTE. The ECG shows findings consistent with an anterior wall injury, and the TTE shows a small pericardial effusion. Given this patient’s history, he most likely has a cardiac contusion. Although the prognosis for recovery is generally excellent, these patients require careful monitoring and follow-up for late complications, which range from ventricular arrhythmias to cardiac rupture. Hence, the most logical answer to this question is to admit the patient to a telemetry bed with follow-up TTE.
A 22-year-old white man is newly diagnosed with non-Hodgkin lymphoma. He undergoes a metastatic workup that includes an MRI of the chest and abdomen, which is shown in Figure below.
The plan is for chemotherapy, but you are consulted for cardiac assessment before beginning chemotherapy. Radionuclide ventriculography shows a normal LV EF of 65%. What should you recommend?
Proceeding with chemotherapy without further cardiac evaluation. This patient’s MRI shows congenital absence of the pericardium. This is a benign condition usually found incidentally. No specific cardiac treatment is needed unless there is entrapment of one of the cardiac chambers.
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