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

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

3. 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

4. Transthoracic Echocardiogram

5. On arrival to EMC:
Physical Exam: BP- 92/62 (on pressors), HR 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

6. Transesophageal Echocardiogram

7. CT chest with contrast

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

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

10. IMPLANTATION OF TANDEM HEART

11. 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

12. 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

13. Discussion (cont.)
Pericardiocentesis associated with recurrent pericardial bleeding and higher mortality
Controlled pericardial drainage ( 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): doi: /j.jchf