P333 A RARE CAUSE OF SHOCK: AORTO–PULMONARY FISTULA AS AORTIC ANEURYSM COMPLICATION

Abstract

Abstract Clinical case A 69–year–old man with right shoulder discomfort, malaise for one hour and hemodynamic instability was admitted to our Emergency Department (ED). The patient had a history of arterial hypertension, diabetes, renal failure on peritoneal dialysis and ischemic cardiomyopathy with preserved ejection fraction treated by angioplasty and stent implantation on right coronary. At first medical contact out of hospital the patient appeared confused with severe hypotension (BP 70/40 mmHg). ECG transmitted to our Cardiology Unit showed sinus tachycardia with repolarization abnormalities consistent with diffuse ischemia. The patient was centralized with clinical suspicion of acute coronary syndrome complicated by cardiogenic shock. In ED, BP was 65/35 mmHg. On physical examination extremities were cold and mottled, crackles in the lower lung zones and turgid jugulars were present. Pulses were weak but present. ECG was repeated and no evolutive signs were detected. Echocardiography finding were: not dilated left ventricle with global systolic function at the lower limits, moderate aortic insufficiency, right ventricle with dimensions at the upper limits and hypocontractile, moderate tricuspid regurgitation, inferior vena cava dilated with preserved inspiratory collapse. Aortic root was non dilatated but aortic arch was 55 mm with no images of dissection flap. At blood test lactates were 4,2 with metabolic acidosis, troponin was just above the upper limit, inflammation indices were negative and electrolytes were in range. Vasopressor support with norepinephrine was started. With the high suspicion of acute aortic disease, CT angiography was performed showing a voluminous aneurysm of the aortic arch of 70x56 mm rupturing into the left pulmonary artery (Figure 1,2). Concomitant bilateral iliac artery dissection was detected. Cardiac and Vascular Surgeons were promptly alerted to plan tan emergent surgical intervention whose complexity was increased by the difficult vascular cannulation for iliac dissection. However, the patient‘s hemodynamic rapidly deteriorated requiring intubation and, after subsequent episodes of cardiac arrest in pulseless electrical activity (PEA), his death was assessed.