Hospital: Hospital Universitario de Salamanca.
Ciudad:
Nº:
Aut@r o Autores: D. González Calle, A. Elvira Laffond. Servicio de Cardiología del,
Presentación:
A 50-year-old patient presented to the Emergency Department at 06:48 AM with right upper quadrant pain that radiated to the back and had begun 12 hours earlier. The patient described the pain as constant and diffuse, and had prevented him from sleeping. He had ceased to smoke eight years ago and referred no other cardiovascular risk factors. He had been intervened of descending aortic aneurysm with an endoprosthesis in 2011. The patient was currently under treatment with aspirin 300 mg every 24 hours and omeprazole 40 mg every 24 hours. On physical examination, the patient was conscious and oriented. Blood pressure was of 158/90 mmHg, heart rate of 78 bpm and oxygen saturation of 98%. The abdomen was soft and non-tender. No murmurs were found in auscultation. Cardiac and respiratory examinations were normal. Pulses were present and symmetrical in both superior and inferior extremities. An electrocardiogram (EKG) and an abdominal CT were performed. The EKG showed sinus rhythm at 75 bpm with no further alterations. Abdominal CT, performed at 08:16 AM, demonstrated no changes compared to previous CT (18/11/2018). The endoprosthesis was well placed at the aortic arch and descending aorta. A noncomplicated aneurysm of 75 mm of maximum diameter was observed distally (picture 1 A-B). After CT was performed, the patient remained in observation in the Emergency Department. At 08:40 AM the patient suffered a cardiac arrest. Advanced life support was initiated and the Vascular Surgery Department was informed. An acute aortic syndrome was deemed unlikely, and the Cardiology Department was contacted. Upon the cardiologist arrival, the patient was in cardiac arrest with electrical activity without pulse. It was decided to implant a venous-arterial extracorporeal membrane oxygenation (ECMO) device at the Emergency Department. There were no complications during the procedure, which lasted for 22 minutes (38 minutes of assisted cardiac arrest). Notwithstanding, no effective blood flow was obtained with the device. On transesophageal echocardiogram (picture 1.C-D) a shunt between the descending aorta and the pleural cavity was observed. No effective mechanical support was possible, and the patient was exitus after 60 minutes of advanced life support.
Discusión:
When an acute aortic syndrome is suspected and the patient is stable, CT remains the imaging technique of choice. Unfortunately, in this case the sequence of diagnostic tests and its results might have implied uncertainty concerning the initial clinical diagnosis.In such circumstances, transesophageal echocardiography proves its value as an emergency diagnostic technique.
Conclusión:
When an acute aortic syndrome is suspected and the patient is stable, CT remains the imaging technique of choice. Unfortunately, in this case the sequence of diagnostic tests and its results might have implied uncertainty concerning the initial clinical diagnosis.In such circumstances, transesophageal echocardiography proves its value as an emergency diagnostic technique.
Bibliografía:
– Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Th