Aortic dissection complicated by coronary malperfusion and cardiac tamponade

Abstract text (incl. references and figure legends)

Case history:A forty-year-old smoker male presented to the ED for pleuritic chest pain and shortness of breath of 1 hour. His medical history included obesity, obstructive sleep apnea, hypertension, and right diaphragmatic palsy secondary to viral illness.
Clinical Findings:He was alert and oriented, but in respiratory distress. He was tachycardic with blood pressure 135/87 mmHg in the right arm and 123/66 mmHg in the left arm. He was afebrile with an oxygen saturation 89% on room air improved to 94% on a non-rebreather. Physical exam was notable for diffuse expiratory wheezing. The remainder of the exam was unremarkable.
Investigation:EKG demonstrated sinus tachycardia with an incomplete right bundle branch block. Bedside TTE demonstrated a moderate pericardial effusion with more than 30% mitral inflow variability with inspiration and a plethoric IVC with minimal respiratory variation. A TTE performed 5 months prior showed an ejection fraction of 65% and a dilated ascending aorta with a diameter of 5 cm. Laboratory studies were normal including a CBC, chemistries, D-dimer and 2 sets of troponin.
Diagnosis:Computed tomography angiography showed moderate-sized pericardial effusion (hemopericardium) with acute intramural hematoma of the ascending aorta, aortic arch, descending thoracic aorta, right coronary artery, left coronary artery and left vertebral artery. No intimal flap in the aortic lumen nor any filling defect in the main and segmental pulmonary arteries.
Therapy:The patient was started on an esmolol infusion at 50 mcg/kg/min and was taken to the operating room for an ascending aortic repair, in which an aortic tear above the right coronary sinus was seen with a thrombosed false lumen, as well as hemopericardium. His postoperative course was uncomplicated, and he was discharged home five days later in stable condition.

Figure1.EKG with sinus tachycardia and incomplete RBBB with TTE four-chamber view of pericardial effusion
Figure2.Coronal view of the CTA

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