Presenter: Harish Raj Seetha Rammohan

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Presentation transcript:

Presenter: Harish Raj Seetha Rammohan DOWN AT DUNKIN’ Presenter: Harish Raj Seetha Rammohan

Case 49 year old male found unresponsive outside Dunkin’ Donuts Initial presentation to ER: hypotensive, tachycardic, tachypneic Required intubation and started on pressors

Case (contd.) Past Medical History HTN End- stage renal disease on dialysis Renal cell cancer 2003 s/p R nephrectomy Found to have an abnormal echo and transferred to EMC for further management

Transthoracic Echocardiogram

On arrival to EMC: Physical Exam: BP- 92/62 (on pressors), HR-95-110 bpm Clear lungs Heart: s1, s2 regular no murmurs/rubs/gallops Ext: cold, no edema, low volume pulses EKG: anterolateral ST depressions and inferior T inversions

Transesophageal Echocardiogram

CT chest with contrast

Diagnosis Type A Aortic dissection (AoD) with intrapericardial rupture and compression of right atrium and right ventricle

Clinical course Right sided tandem heart placed for hemodynamic support Shock liver, thrombocytopenia, hemolytic anemia Questionable neurologic recovery

IMPLANTATION OF TANDEM HEART

Follow-up: After stabilization, hematoma evacuated with pericardial window & tube pericardiostomy Explant of Tandem Heart Ventricular Assist Device Currently in rehab & scheduled for aortic dissection repair

Discussion Cardiac tamponade diagnosed in 8% - 10% patients with acute Type A AoD Clinical predictor of poor outcomes and mortality Localized compression of left atrium described post cardiac surgery Rare cases of aorto-atrial fistulas Circulation 2010; 121: e266-e369

Discussion (cont.) Pericardiocentesis associated with recurrent pericardial bleeding and higher mortality Controlled pericardial drainage (10-100 ml) shown to improve blood pressure in series of 18 patients Right sided Tandem Heart: a novel approach for initial management for hemodynamic stabilization Circulation.2012; 126: S97-S101 Image: JCHF. April 2013,1(2):127-134 doi:10.1016/j.jchf.2013.01.007