Atrial Collapse Research Articles

12393 Myxedema Presenting With Impending Cardiac Tamponade : A Case Report

Abstract Disclosure: A. Hoskote: None. V. Gupta: None. J. Seidenberg: None. The widespread availability of thyroid stimulating hormone (TSH) assays, routine screening and affordable replacement therapy has resulted in decreased prevalence of complications of untreated hypothyroidism. “Myxedema heart” is a rare syndrome that results in bradycardia, cardiomyopathy and pericardial effusion. We present a rare case of cardiac tamponade due to myxedema in a patient with unidentified hypothyroidism. A 49-year-old male was brought to the ER by his family for several weeks of cognitive slowing, weakness and inappropriate behavior involving defecating on himself eating old food and barricading in his room. The patient denied past medical or psychiatric history, medication use or recent physician evaluation. On exam he had macroglossia, was disheveled, forgetful but alert with slow speech, ataxia and muscle wasting. He was afebrile and hemodynamically stable. EKG showed sinus bradycardia. Labs were notable for sodium 133, hemoglobin 8.8g/dL and TSH was incidentally >100U. Levothyroxine was begun. The next day, he was noted to have increased lethargy, bradycardia and hypoglycemia and was transferred to the intensive care unit with concern for myxedema coma. Free T4 was <0.3 ng/dL (0.6-1.6) and free T3 was 1.6pg/mL (2.5-3.9). An echocardiogram revealed a large circumferential pericardial effusion with right atrial and ventricular collapse with tamponade. Treatment with 5 mcg liothyronine, intravenous levothyroxine and stress dose hydrocortisone was begun. A pericardial drain was placed, draining 980mL of sanguineous fluid. After clamping trials, the drain was removed 48 hours later. Labs revealed thyroglobulin <0.1ng/mL (1.6-50), thyroid peroxidase (TPO) antibody 574 IU/mL (<9), thyroglobulin antibody >2500 (<4) and thyroid ultrasound showed a normal sized thyroid gland with heterogenous echogenicity confirming a diagnosis of Hashimoto’s thyroiditis. Serial echocardiograms during the admission and a follow-up two months later showed a stable posterior effusion with no recurrence of the anterior pericardial effusion. Gradually mentation, hemodynamics and electrolyte derangements improved, and he was discharged on oral levothyroxine. TSH values showed sequential improvement to 48U in 15 days and to 11U in 2 months. Myxedema is a manifestation of severe hypothyroidism. The pericardium, a collagen-rich structure, is susceptible to myxedematous infiltration, leading to pericardial effusion. While small pericardial effusions are common with chronic hypothyroidism, a large pericardial effusion with tamponade is a rare life-threatening complication that requires prompt recognition and management. Clinicians must promptly identify myxedema and replace thyroid hormone to prevent progression of pericardial effusion to tamponade, maintaining especially high suspicion in those at risk of poor access to healthcare or inadequate health literacy. Presentation: 6/3/2024

Pericardial tamponade: a new perspective on echocardiographic features and application of a prediction score.

Few clinical decision rules have been used to guide clinical management and predict outcomes in patients with pericardial tamponade. The objectivesof this study are to identify the echocardiographic features associated with adverse outcomes in patients with pericardial effusions requiring pericardiocentesis and to apply a previously described four-point clinical and echocardiographic score to predict clinical outcomes over 24-hr, 30-day, and 1-year intervals. We performed a retrospective cohort review of patients who had transthoracic echocardiogram (TTE) performed and underwent pericardiocentesis within 48h of emergency department presentation at two large tertiary care institutions. We constructed different stepwise logistic regression models and examined the associations of TTE characteristics and clinical features with ICU admission, hospital length of stay (h-LOS), and survival. The data set was then employed against a previously proposed scoring system to predict factors associated with clinical outcomes over 24hr, 30days, and 1year. Two hundred thirty-nine patients were included in the final analysis. Echocardiographic characteristics of patients with pericardial tamponade who underwent pericardiocentesis are as follows: 69.1% right ventricular (RV) diastolic collapse, 62.3% exaggerated mitral valve (MV) inflow velocities, 56.4% inferior vena cava (IVC) plethora, and 53.4% right atrial (RA) systolic collapse. Increase in systolic blood pressure and increased variation in MV inflow velocity were associated with reduced ICU admission [OR: 0.94 (CI 0.90, 0.99), 0.28 (CI 0.09, 0.89), respectively]. In addition, a history of malignancy increased the length of hospital stay by about 3.89days (CI 1.43-6.35, p < 0.01) and prior pericardiocentesis history was associated with 4.82-day increase in hospital stay (CI 1.19-8.45, p = 0.01). In utilizing the previously published prediction score, we found no statistically significant correlation in predicting survival. RV diastolic collapse and exaggerated MV inflow velocity were the most common echocardiographic findings in patients requiring pericardiocentesis. Contrary to prior studies, exaggerated MV inflow velocity was associated with reduced ICU admission. In addition, a previously described prediction score did not correlate with decreased survival in this cohort.

Demystifying Right Atrial Diastolic Collapse: A Sensitive and Specific Marker of Cardiac Tamponade

The echocardiographic markers that occur in sequence in cardiac tamponade are inferior vena cava plethora, right atrial diastolic collapse, exaggerated inspiratory variation in mitral and tricuspid velocities and finally right ventricular diastolic collapse. Contrary to popular belief, the degree of atrial inversion does not correlate with the presence or absence of tamponade physiology, however, the right atrial inversion time (exceeding one-third of the cardiac cycle) significantly improves the sensitivity of atrial collapse in predicting tamponade. We present here an important demonstration of fundamental physiology of respirophasic variation of right atrial collapse in cardiac tamponade.

Tissue Doppler vs. conventional parameters for diagnosis of tamponading pericardial effusion: a cross-sectional study in tertiary referral center

BackgroundConventional signs of tamponade include right ventricular and atrial collapse and respiratory variation in mitral inflow velocities. Despite being reliable, they are qualitative in nature and are not well correlated with clinical signs of deterioration or improvement. Tamponade is invariably preceded and associated with diastolic dysfunction, and tissue Doppler imaging (TDI) can help in early detection of it, earlier than conventional signs. For this purpose, 36 patients presenting with pericardial effusion have been subjected to echocardiography, including effusion dimensions, presence or absence of routine signs of tamponade and TDI-derived LV and RV E/E′ ratios, as well as clinical signs of tamponade to test the diagnostic accuracy of echocardiographic parameters against them.ResultsRight atrial and ventricular collapse were the least accurate in the detection of tamponade, while effusion dimension > 14 mm was the most accurate among conventional parameters to point toward tamponade. RV and LV diastolic dysfunction as evidenced by E/E′ ratio showed 100% sensitivity in predicting tamponade, while LV E/E′ ratio showed the highest specificity (100%) in the same context. The higher diagnostic accuracy of LV E/E′ ratio might be also related to the presence of chronic kidney disease patients, with an already jeopardized LV function.ConclusionsTDI technology is now available in most of the portable echocardiography machines and can serve as part of point-of-care echocardiography in the early detection of cardiac tamponade and in decision making for pericardiocentesis. Larger studies can help in consolidating the impression driven from our small-scale cross-sectional study.

THU601 Massive Pericardial Effusion As Sole Symptom For Uncontrolled Hypothyroidism.

Abstract Disclosure: D.A. Lopez: None. M. Caban: None. C. Camacho: None. Y. Fuentes: None. M. Sanchez: None. K. Velez: None. Hypothyroidism is a common endocrine disorder with worldwide prevalence resulting from deficiency of thyroid hormone that can affect multiple organs. It can be asymptomatic and subclinical or symptomatic with fatal complications. Hypothyroidism can present with symptoms such as fatigue, slow movement and slow speech, cold intolerance, constipation, weight gain, and bradycardia. Hypothyroidism can be the cause of pericardial effusion due to increase membrane permeability. Massive pericardial effusion or pericardial tamponade is rare. Pericardial effusion can also be caused by autoimmune conditions, infections, uremia, medications, iatrogenic, and trauma. This is a case of 68-year-old Hispanic female with past medical history of hypothyroidism that was admitted to the hospital due to large pericardial effusion. These findings were found incidentally by her primary care physician during a preoperative evaluation for cataract surgery. Chest X-ray showed massive enlargement of the cardiac silhouette. Echocardiogram was ordered presenting large circumferential pericardial effusion with moderate diastolic right atrial collapse reason why patient was sent to the hospital. Physical examination showed distant heart sounds but absent jugular venous distention. Vital signs were within normal limits. Beck's triad was absent. Electrocardiogram showed a sinus rhythm with low QRS voltage. Patient denied any recent procedure, trauma, myocardial infarction, malignancy, or fever. Complete blood count was without leukocytosis, normal hemoglobin levels and platelet count. Basic metabolic panel presented without electrolyte disturbances and preserved renal function. Evaluation for causes of pericardial effusion was made including autoimmune conditions. Results showed negative ANA, Rheumatoid factor, Anti-dsDNA antibody, Anti-Scl-70 antibody, anti-U1-ribonucleoprotein, anti-Ro, and anti-La. Inflammatory markers were within normal limits. TSH level were in 22.5μIU/mL (0.03-5.0μIU/mL) with undetectable Free T4 pointing towards uncontrolled hypothyroidism as the cause of her large pericardial effusion. Patient denied other symptoms of hypothyroidism. She agreed not being compliant with levothyroxine. Pericardiocentesis was done and 750ml of pericardial fluid was removed. A catheter was placed and 200ml of fluid was drained on the second day. Catheter was removed and Echocardiogram showed immediate resolution of the diastolic right atrial collapse. She was sent home with adequate medical therapy and intense education of hypothyroidism. As a take home message, this unique case presents the importance of being compliant to medical therapy since the initial presentation of uncontrolled hypothyroidism could be a fatal complication as pericardial effusion. This could’ve been prevented if compliance with medications was encourage since the beginning of this disorder. Presentation: Thursday, June 15, 2023

Agreement on Interpretation of Point-of-Care Ultrasonography for Cardiac Tamponade Among Emergency Physicians.

Cardiac tamponade is an impending calamitous disorder that emergency physicians need to consider and diagnose rapidly. A pericardial effusion with right atrial systolic collapse (earliest sign) or right ventricular diastolic collapse (most specific sign) and a plethoric inferior vena cava are indicators of cardiac tamponade physiology and may be identified with point-of-care ultrasonography (POCUS). The goal of this study is to assess the agreement among emergency physicians with varying levels of sonographic training and expertise in interpreting echocardiographic signs of cardiac tamponade in adult patients. Methods: Emergency physicians at different levels of training as sonographers were surveyed at didactic conferences at three major academic medical centers in northern New Jersey. Two cardiologists were also included in the study for comparison. Survey respondents were shown 15, 20-second video clips of patients who had presented to the emergency department (ED) with or without significant pericardial effusions and were asked to rate whether tamponade physiology was present or not. Data were collected anonymously on Google Forms (Google LLC, Mountain View, CA)and included self-reported levels of POCUS expertise and level of training. Data were analyzed using Fleiss' kappa (k). All patients had an echocardiogram performed by the department of cardiology within 24 hours of the POCUS, and the results are presented in the paper. Results: There were 97 participant raters, including attendings, fellows, and resident physicians specializing in adult emergency medicine and two cardiologists. There was a fair degree of inter-rater agreement among all participants in interpreting whether tamponade physiology was present or not. This low level of agreement persisted across self-reported training levels and self-reported POCUS expertise, even at the expert level in both emergency medicine and cardiology specialties. According to the results of our study, there appears to be a low level of agreement in the interpretation of cardiac tamponade in adult patients. The lack of agreement persisted across specialties, self-reported training levels, and self-reported ultrasonographic expertise. This low level of agreement seen amongboth specialists indicates that emergency physicians are not limited in their ability to determine cardiac tamponade on POCUS. This highlights the technical nature of POCUS clips and strengthens the importance of physical exam findings when diagnosing cardiac tamponade in emergency department patients. Further research utilizing POCUS for the diagnosis of tamponade is warranted.

Successful Intrapericardial Fibrinolysis on Acute Recurrent Purulent Pericarditis with Impending Cardiac Tamponade during Pandemic Situation: A Rare Case Report

Introduction: Acute recurrent purulent pericarditis is an uncommon pericardium infection that can be life-threatening due to pus production, leading to cardiac tamponade. Case presentation: We report a 36-year-old man referring to our hospital with impending cardiac tamponade who needed urgent pericardiocentesis. The patient's complaints were worsening dyspnea and palpitations in the last two days. The patient had been hospitalized for the same complaint and had pericardiocentesis due to cardiac tamponade approximately three weeks earlier. Physical exam, ECG, and CXR suggest impending cardiac tamponade. Echocardiography indicated massive right and left pericardial effusion and right atrial collapse. The Covid-19 screening test was positive; however, RT-PCR revealed a negative result. The patient was diagnosed with recurrent acute purulent pericarditis with impending cardiac tamponade requiring urgent pericardiocentesis. After the procedure, 1.5 million units of intrapericardial fibrinolytic were administered to patients. His improved hemodynamic and clinical symptoms indicate a successful procedure. Conclusion: This case highlights the challenges of managing an acute recurrent purulent pericarditis patient due to Staphylococcus A. infection in the current pandemic era, including distinguishing it from other contagious diseases due to nonspecific dyspnea, limited therapeutic options, and the effectiveness of intrapericardial fibrinolytic in improving the overall patient conditions, and reducing the mortality rate.

Cardiac Tamponade in Idiopathic Capillary Leak Syndrome: Philippines’ First

Background: Clarkson’s disease, more known as idiopathic systemic capillary leak syndrome (SCLS) is a rare condition characterized by hypotensive episodes due to capillary hyperpermeability, which may be manifested by fluid accumulation in any organ or potential space, causing range of complications: respiratory failure (from pulmonary edema or pleural effusion), mesenteric hypoperfusion (from hepatic congestion and severe intestinal edema), compartment syndrome and rhabdomyolysis, and even shock from hypovolemia or cardiac tamponade. Very few cases of cardiac tamponade have been reported and certainly a serious and life-threatening complication. Case Summary: A 44-year-old female, reported to have intermittent episodes of angioedema aggravated by menstruation and infection, came in due to persistent hypotension. Patient presented with flu-like symptoms and tested positive for COVID – 19 infection. Initial laboratories revealed hemoconcentration, slightly elevated creatinine and hypoalbuminemia. Electrolytes and urinalysis were normal. 2D echocardiography showed large pericardial effusion with right atrial and ventricular collapse suggestive of cardiac tamponade, hence patient underwent emergency pericardial windowing. Initial chest X-ray was normal but repeat study showed pleural effusion on the 4th day of admission which was drained surgically. Additional diagnostic tests revealed negative for hepatitis, Mycoplasmal and Epstein-Barr virus. Direct and indirect Coomb’s test were also negative and Lupus panel was unremarkable. Serum free light chain panel showed suspicious for low level monotypic serum free lambda light chains (based only on the free light ratio). Immunopathology results showed no overt evidence of monoclonal bands. Protein electrophoresis pattern showed decreased albumin fraction and increased alpha, beta, and gamma fractions. C1 inhibitor was slightly elevated while serum tryptase was within normal values. Patient was managed as a case of idiopathic systemic capillary leak syndrome or Clarkson’s disease. Aside from judicious fluid resuscitation and vasopressors assist Methylprednisolone pulse therapy (MPPT) and intravenous immunoglobulin (IVIg) were administered. Patient was discharged with tapering doses of oral steroids and scheduled monthly IV immunoglobulin infusion. Conclusion: Cardiac tamponade, an uncommon yet severe and life-threatening complication of systemic capillary leak syndrome (SCLS) or Clarkson’s disease, requires immediate intervention. While the exact cause remains unclear, research suggests that during acute SCLS episodes and hyperinflammatory states, fluid accumulation in the pericardial space can impede ventricular filling, leading to hemodynamic compromise.

Right atrial collapse in the absence of pericardial effusion.

A 16-year-old male with severe pectus excavatum (PEx; Panel A) was referred to our institution due to progressive exertional dyspnea, palpitations, and chest wall discomfort. Transthoracic echocardiography performed at an outside institution reported minimal compression of the right heart chambers without haemodynamic disturbances. Considering the severity of the deformity and cardiopulmonary symptoms, surgical repair with intraoperative transesophageal echocardiography (TEE) surveillance was indicated. Intraoperative TEE showed severe extrinsic compression of the right atrium (RA) due to the depression of the anterior chest wall, with RA collapse starting in early diastole and extending into end-diastole (Panel B, Video 1). No pericardial effusion was noted. After PEx repair, TEE imaging noted no further evidence of RA collapse (Panel C). On postoperative Day 2, the patient was discharged without complications, and in subsequent 6 weeks follow up, he reported significant improvement in symptoms. Sustained RA collapse is a highly sensitive and specific marker for cardiac tamponade, usually indicating emergency situations in which intrapericardial pressure transiently exceeds intracardiac pressure. In early stages of cardiac tamponade, RA collapse is observed during end-diastole when the RA pressure is at its lowest. The phenomenon gradually extends throughout most of the diastole with the increase of intrapericardial pressure. In our unique case of a PEx patient, RA collapse occupying entire diastolic period was observed due to external compression in the absence of cardiac tamponade, and completely resolved with surgical repair. This finding supports the need for a comprehensive assessment of the right-sided chambers compression in symptomatic PEx patients.

CARDIAC TAMPONADE WITHOUT THE BECK TRIAD: A COMPLICATION OF SEVERE HYPOTHYROIDISM

CARDIAC TAMPONADE WITHOUT THE BECK TRIAD: A COMPLICATION OF SEVERE HYPOTHYROIDISM

MICROSCOPIC POLYANGIITIS PRESENTING WITH CARDIAC TAMPONADE

MICROSCOPIC POLYANGIITIS PRESENTING WITH CARDIAC TAMPONADE

Timing of pericardiocentesis and clinical outcomes: Is earlier pericardiocentesis better?

Pericardial tamponade is critical clinical diagnosis that requires prompt management and intervention. However, it is unknown if early pericardiocentesis is associated with better or worse patient outcomes. A retrospective chart review was performed on all emergency department patients from two large academic hospitals with pericardial tamponade who underwent pericardiocentesis during the index hospitalization between March 2015-August 2020. We included only those who underwent pericardiocentesis within 24 h of their ED presentations. Subjects were stratified based on the time of pericardiocentesis, with early intervention defined as pericardiocentesis within <12 h and late intervention as those 12-24 h. Clinical outcomes of interest were; procedural complications, intensive care unit (ICU) admission, hospital length of stay (LOS), in hospital mortality, 30-day and first year survival. The effect of early vs. late intervention on survival was analyzed using log-rank tests for univariate analyses, Cox proportional hazard models for multivariable analyses and propensity matching. 205 patients with a mean age of 60 years, and 53.2% female were included. The median door-to-pericardiocentesis time for the early and late group were 5.0 h [interquartile range (IQR) 3.3-7.4] and 18.5 h (IQR 15.9-21.0), respectively. Transthoracic echocardiography (TTE) in patients in the early group more frequently demonstrated right atrial collapse (78.7% vs 58.6%) and exaggerated mitral inflow velocity variances (84.8% vs 70.0%). Early pericardiocentesis was associated with a hazard ratio of 2.909 (95% CI: 0.926-9.137, p = 0.067) for 30-day survival and 3.124 (95% CI, 1.648-5.924, p < 0.001) for 1-year survival. Early pericardiocentesis was associated with decreased 1-year survival. Future prospective analysis adjusting for patients' complexities is required.

Myocardial Edema Provides a Link Between Pulmonary Arterial Hypertension and Pericardial Effusion.

Myocardial Edema Provides a Link Between Pulmonary Arterial Hypertension and Pericardial Effusion.

Pericardiocentesis over 3 years at a tertiary referral Australian hospital

Abstract Funding Acknowledgements Type of funding sources: None. Background Pericardiocentesis is a lifesaving intervention performed both percutaneously or surgically. We analysed 3 years of experience in a major tertiary hospital in Sydney Australia. Purpose To examine the indications, safety and delivery of a pericardiocentesis service at a major teaching hospital. Methods We retrospectively audited consecutive patients who underwent pericardiocentesis for pericardial effusion[PE] at a major teaching hospital from February 2018 to December 2020. Eligible patients were identified from the electronic medical records with this coding diagnosis. Results 89 patients identified with mean age 60.8 ± 18.9years and 58.4%(51/89) male. Follow-up to August 2021 showed 41.5% had died, with an index hospitalisation mortality of 19%(17/89). Malignancy was the most common aetiology 30.3%(27/89) and attributable cause of hospitalisation death in 29.4%. Alternate causes included pericarditis 14.6%, idiopathic 13.4%, percutaneous-coronary-intervention(PCI) 5.6%(6/89) and electrophysiology 4.5%(4/89) complications. Three patients had aortic dissection (3.3%) and two were fatal. Clinical tamponade was present in 66.2%(55/89), PE identification occurred via echocardiography(TTE) in 55% cases (49/89) and incidental CT-diagnosis in 20.2%. TTE findings: right atrial collapse 54%(47/87), right ventricular collapse 60.9%(53/87), fixed and dilated inferior vena cava 64.7%. Pericardiocentesis was performed by cardiology trainees in 90.5% cases, 64.5% with consultant supervision and during working hours in 57.3% of cases. Percutaneous drainage was successful in 96%(72/75) of cases and was performed in the coronary care unit (30.3%), catheterisation laboratory (23.5%), emergency department (19.1%) and ICU (11.2%). Subxiphoid approach in 70%(62/89) was the most common then trans-apical 15%(13/89), parasternal 3%(3/89) and surgical 16%(14/89). TTE confirmed drain position in 76%(54/71), fluoroscopy in 28.5%(6/21) and agitated saline in 38.9%(30/77). Haemo-serous fluid noted in 77%(67/87) with average initial fluid drainage 480 ± 326mls and mean drain removal time 54 ± 33hrs. 17%(15/89) required re-drainage with adenocarcinoma found in 33.3%(5/15). Background antiplatelet treatment in 30.6%(27/88) and of these 67%(18/27) were on dual antiplatelets. 33%(29/89) patients were anticoagulated and 31.3%(9/29) required reversal prior to drainage. Complications were rare, 4%(3/75) had right heart chamber perforation needing emergency surgery. Two were post complex PCI (one died during admission from multiorgan failure) and one with pericarditis . Conclusions Pericardiocentesis is a safe and effective procedure for tamponade treatment and largely guided by echocardiography in our experience. Complications are rare and prognosis depends on aetiology with malignancy the most common. Drainage is often successfully performed emergently where the patient is located. Tamponade resulting from procedural complications are rare in our cohort.

C51. Impending Rupture in Acute Type A Aortic Dissection : Case Report

Abstract Background Acute aortic dissection is a life threatening condition that remains a challenge to diagnose and treat. 67% patients was presented with Acute type A aortic dissection (ATAAD) and often accompanied with some complications. Case Summary A 40-year-old male with risk factor hypertension was presented with sudden sharp tearing-like chest pain and radiating to the back 3 hours before admission. He had transient decrease of consciousness and waken up spontaneously. He was compos mentis, with normal JVP, normal heart sound, no pulsus deficit, hypotension, cold acral and oliguria. He got fluid rehydration and the BP was stabilized. Haemoglobin was normal with increase D-Dimer. The ECG was normal and chest radiography revealed cardiomegaly and widening mediastinum. From eyeballing echocardiogram showed moderate pericardial effusion without right atrial and right ventricle collapse. A CT scan angiography was performed and revealed an Aortic Dissection Stanford A Debakey I. Discussion The development of an evidence-based strategy to rule out aortic dissection in patients presenting chest pain would be useful to diagnose patients with chest pain. Rapid diagnosis of dissection is most likely when CT is a part of the diagnostic testing. Hypotension and shock occurred in &amp;gt; 25% of patients with type ATAAD and in this patient was associated transient loss of consciousness. This patient was in impending rupture condition. The definitive treatment for this patient was emergency aortic repair surgery. We was succeded to stabilize the patient then referred to a cardiothoracic surgeon in 24 hours later.

C51. Impending Rupture in Acute Type A Aortic Dissection : Case Report

Abstract Background Acute aortic dissection is a life threatening condition that remains a challenge to diagnose and treat. 67% patients was presented with Acute type A aortic dissection (ATAAD) and often accompanied with some complications. Case Summary A 40-year-old male with risk factor hypertension was presented with sudden sharp tearing-like chest pain and radiating to the back 3 hours before admission. He had transient decrease of consciousness and waken up spontaneously. He was compos mentis, with normal JVP, normal heart sound, no pulsus deficit, hypotension, cold acral and oliguria. He got fluid rehydration and the BP was stabilized. Haemoglobin was normal with increase D-Dimer. The ECG was normal and chest radiography revealed cardiomegaly and widening mediastinum. From eyeballing echocardiogram showed moderate pericardial effusion without right atrial and right ventricle collapse. A CT scan angiography was performed and revealed an Aortic Dissection Stanford A Debakey I. Discussion The development of an evidence-based strategy to rule out aortic dissection in patients presenting chest pain would be useful to diagnose patients with chest pain. Rapid diagnosis of dissection is most likely when CT is a part of the diagnostic testing. Hypotension and shock occurred in &amp;gt; 25% of patients with type ATAAD and in this patient was associated transient loss of consciousness. This patient was in impending rupture condition. The definitive treatment for this patient was emergency aortic repair surgery. We was succeded to stabilize the patient then referred to a cardiothoracic surgeon in 24 hours later.

CARDIAC TAMPONADE WITHOUT CHARACTERISTIC ECHOCARDIOGRAPHIC FEATURES DUE TO HIGH RIGHT HEART PRESSURE FROM PULMONARY HYPERTENSION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Introduction: Cardiac tamponade occurs when pericardial effusion leads to equalization of intrapericardial pressure and diastolic intracardiac pressure, which reduces the systemic venous-to-right atrial pressure gradient, leading to depression in cardiac output. The lower this gradient, the greater the risk for cardiac tamponade. Cardiac tamponade manifests clinically as shock, jugular venous distention, and muffled heart sounds, known collectively as Beck's triad. Typical findings on echocardiogram are right atrial and ventricular collapse.[2] These findings may not be seen in patients with elevated right-sided intracardiac pressure and can lead to misdiagnosis or delay in diagnosis of cardiac tamponade.[1] We present a patient with a cardiac tamponade to highlight this point. CASE PRESENTATION: Case presentation: A 46 year old male with hypoxia and respiratory failure from COVID-19 pneumonia supported with mechanical ventilation for several weeks developed refractory shock of multifactorial etiology. The patient was known to have pulmonary hypertension with dilated right atrial and ventricular pressure in addition to paradoxical septal motion, as seen on echocardiogram of recent past. Clinical examination revealed jugular venous distention and muffled heart sounds. Electrocardiogram detected sinus tachycardia and low cardiac voltage. Echocardiogram revealed large pericardial effusion without right atrial or ventricular collapse, and therefore cardiac tamponade was not considered as the cause of shock. As shock remained refractory to multiple vasopressors and inspiratory variation of the mitral valve inflow was noted on echocardiogram, it was decided to initiate pericardial drainage. However, the patient went into cardiac arrest before it could be performed. DISCUSSION: Discussion: A clinical diagnosis of cardiac tamponade can be made in the presence of Beck's triad. However, echocardiogram is most often relied on to make the diagnosis. The most sensitive echocardiographic findings of cardiac tamponade are right atrial and ventricular collapse.[2] Though sensitive, these changes may not be present in a patient who has preexisting elevated right sided intracardiac pressure. In such cases, the diagnosis must be based on clinical evidence and can be aided by the findings of exaggerated changes in mitral/tricuspid inflow during respiration. CONCLUSIONS: Conclusion: A hallmark finding of cardiac tamponade is right atrial or ventricular collapse on echocardiogram. However, these findings may be absent in the setting of elevated right-sided intracardiac pressure. The absence of right atrial or ventricular collapse in our patient can be attributed to the elevated right-sided intracardiac pressure due to pulmonary hypertension.[3] In such cases, the diagnosis of cardiac tamponade should be made on clinical grounds and pericardial drainage should not be delayed. REFERENCE #1: 1. Adams JR, Tonelli AR, Rokadia HK, Duggal A. Cardiac tamponade in severe pulmonary hypertension. A therapeutic challenge revisited. Ann Am Thorac Soc. 2015;12(3):455-460. REFERENCE #2: 2. Spodick DH. Acute cardiac tamponade. N Engl J Med. 2003;349(7):684-690. REFERENCE #3: 3. Vallabhajosyula, S., Kanuri, S., Sundaragiri, P., & Alla, V. (2014). Management of cardiac tamponade in severe pulmonary hypertension. Chest, 146(4). DISCLOSURES: No relevant relationships by George Apergis, source=Web Response No relevant relationships by Dushyant Damania, source=Web Response No relevant relationships by Aaron Douen, source=Web Response No relevant relationships by Padmanabhan Krishnan, source=Web Response No relevant relationships by George Mbolu, source=Web Response No relevant relationships by Ryan Panetti, source=Web Response

Cardiac Ultrasound for Pediatric Emergencies.

Cardiac point-of-care ultrasound (POCUS) provides real-time views of the heart to answer specific questions in a timely manner. This is a valuable tool for managing pediatric patients, from those with congenital heart disease to those who are critically ill. The main echocardiographic findings of pericardial tamponade consist of a pericardial effusion, diastolic right ventricular collapse, systolic right atrial collapse, and a plethoric inferior vena cava with minimal respiratory variation. The main echocardiographic findings of hypertrophic cardiomyopathy consist of increased wall thickness (concentric or eccentric), systolic anterior motion of the anterior mitral leaflet, and a dynamic sub-aortic left ventricular outflow tract obstruction. Additional uses of cardiac POCUS include assessment of dilated cardiomyopathy and the detection of pediatric congenital heart disease, including detection of a patent ductus arteriosus. The use of POCUS in the pediatric population is supported by societal position statements and is expected to develop further with increasingly robust education and training. [Pediatr Ann. 2021;50(10):e424-e431.].

ACUTE RESPIRATORY FAILURE WITH FATAL OUTCOME DUE TO PENICILLIUM CHRYSOGENUM IN A MAN FROM GUATEMALA WITH A SEMINOMA (GERM CELL TUMOR )

TOPIC: Chest Infections TYPE: Global Case Reports INTRODUCTION: This type of mycosis has a rare presentation and even as an oportunistig pathogen is not common. The diagnosis is difficult because there is not a specific clinical finding, and carries a high-mortality risk despite an aggressive therapy. We presented a case of a patient with acute hypoxic respiratory failure with lung involvement, and pericardial tamponade in a patient without past medical history. This was a challenging diagnosis and required a multidisciplinary approach CASE PRESENTATION: 29-year-old man farmer, without past medical history presents with dyspnea on exertion associated with non-specific symptoms for the last two-months. The dyspnea on exertion has progressed to the extent to be present at rest. On the physical exam there are distant heart sounds, and diffuse lung crackles. CT-non contrast of chest showed disseminated miliary nodes with ground glass opacities at the bilateral bases and a large pericardial effusion. There was presence of a large pericardial effusion with right ventricular and atrial collapse in the trans-thoracic echocardiogram. Conidia in chains were found with KOH in the pericardial drainage. A bronchoscopy with bronchoalveolar lavage, brushing and transbronchial biopsy was performed and fungal structures were observed. Later, a lung biopsy was performed and Penicillium chrysogenum grew and was observed with lactophenol blue and confirmed by mass spectrometry (MALDI-TOF). Aggressive treatment with liposomal amphotericin-B plus voriconazol was started. Despite treatment the patient expired and seminomatous germ cell tumor was given, which supported the immunosuppression state of the patient DISCUSSION: The infections caused by the Penicillium species are rare, and can presented as cutaneous, pulmonary or disseminated infections due to the fact that it is a ubiquitous fungus and the spores are easily disseminated. The diagnosis of P.chrysogenum was challenging due low suspicious, lack of knowledge of the immunosuppressive state of the patient, and low prevalence in an immunocompetent patient. The microbiological growth was achieved in lung tissue with the addition of the finding of the seminomatous germ cell neoplasia. We did not consider P.chrysogenum as a contaminating due to the presence of conidia and hyphae in the pericardial fluid and bronchial tissue. Treatment usually includes liposomal Amphotherecin-b, Itraconazole, Voriconazole, and the addition to removal of the source of infection. However, despite prompt interventions the prognosis is poor. CONCLUSIONS: P.chrysogenum is a rare, ubiquitous, oportunistic fungus that was unsuspected due to the lack of knowledge of the immunosuppression status of the patient and despite of the aggressive treatment, the outcome was fatal REFERENCE #1: Barcus AL, Burdette SD, Herchline TE. Intestinal invasion and disseminated disease associated with Penicillium chrysogenum. Ann Clin Microbiol Antimicrob [Internet]. 2005 Dec 21 [cited 2021 Apr 22];4:21. Available from: /pmc/articles/PMC1343575/ REFERENCE #2: Avilés-Robles M, Gómez-Ponce C, Reséndiz-Sánchez J, Rodríguez-Tovar AV, Ceballos-Bocanegra A, Martínez-Rivera Á. Disseminated penicilliosis due to Penicillium chrysogenum in a pediatric patient with Henoch–Schönlein syndrome. Int J Infect Dis. 2016 Oct 1;51:78–80. REFERENCE #3: Ramírez I, Hidrón A, Cardona R. Successful treatment of pulmonary invasive fungal infection by Penicillium non-marneffei in lymphoblastic lymphoma: case report and literature review. Clin Case Reports [Internet]. 2018 Jun 1 [cited 2021 Apr 22];6(6):1153–7. Available from: /pmc/articles/PMC5986030/ DISCLOSURES: No relevant relationships by Jose Aguilar, source=Web Response No relevant relationships by Jorge Luis Aguilar Castellanos, source=Web Response No relevant relationships by SARA BARILLAS, source=Web Response no disclosure on file for jose castillo; No relevant relationships by MARIA EUGENIA CHOC DE AJANEL, source=Web Response No relevant relationships by Jose Cifuentes, source=Web Response No relevant relationships by Cesar Conde-Pereira, source=Web Response No relevant relationships by Gabriel Rios, source=Web Response no disclosure on file for angel soto

Female With Hypotension

A 50-year-old woman with a history of diabetes and meningeal tuberculosis presented with 3 days of shortness of breath and fatigue. Abnormal vital signs included tachycardia (pulse rate of 135 beats/min) and a temperature of 38.1 °C (100.6 °F). Physical examination revealed altered mental status and cold, clammy extremities. Laboratory investigations were significant for lactate levels of 2.5 mmol/L and WBC count of 18 cells/nL. Point-of-care ultrasound revealed a loculated pericardial effusion (Figure 1 and Video E1, available online at http://www.annemergmed.com) and a dilated inferior vena cava without right atrial collapse (Figure 2 and Video E2, available online at http://www.annemergmed.com).