Images in cardiology
A case of pulmonary thromboembolism and aortic dissection: The role of echocardiography
Um caso de tromboembolismo pulmonar e dissecção aórtica: importância do ecocardiograma
Inês Cruz
, Daniel Caldeira, Bruno Stuart, Rita Calé, Isabel João, Carlos Cotrim, Hélder Pereira
Corresponding author
Serviço de Cardiologia, Hospital Garcia de Orta, Almada, Portugal
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(B) sagittal view showing the dissection extending along the descending thoracic aorta (arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 71-year-old woman with a history of ischemic dilated cardiomyopathy, in NYHA class III, a cardiac resynchronization therapy device with defibrillator back-up having been implanted, and permanent atrial fibrillation, under oral anticoagulation therapy. She was admitted due to dyspnea, fatigue and angina on minimal exertion, pain and edema in the right leg and muscle weakness in both legs rendering her unable to walk, over the previous two weeks.</p><p id="par0010" class="elsevierStylePara elsevierViewall">On physical examination she was cooperative, with blood pressure 100/40 mmHg, heart rate 70 bpm, good peripheral pulses, crackling rales in the lung bases, and flaccid paraparesis and signs of deep vein thrombosis in the right leg. Her d-dimers were elevated and the chest X-ray revealed cardiomegaly and fluid overload.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the suspicion of pulmonary thromboembolism, she was referred for transthoracic echocardiography, which showed a dilated left ventricle and severe systolic dysfunction, moderate aortic regurgitation, dilated aortic root with an image suggestive of a double lumen, and a thrombus in the right pulmonary artery (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Thoracic computed tomography angiography confirmed the diagnosis of pulmonary thromboembolism and type A aortic dissection with involvement of the descending thoracic aorta (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Given the patient's high surgical risk a conservative approach was adopted, but the clinical course was unfavorable, leading to tetraparesis and renal failure, and she was discharged at her request to a continuing care home.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We highlight the role of transthoracic echocardiography, a readily available diagnostic exam, in the assessment of patients in the emergency department. This case also draws attention to the possibility of severe comorbidities and the desirability of using non-directed exams whenever possible.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical disclosures</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of human and animal subjects</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Confidentiality of data</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0005" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0010" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0015" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0020" "titulo" => "Right to privacy and informed consent" ] ] ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-11-07" "fechaAceptado" => "2012-12-14" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cruz I, et al. Um caso de tromboembolismo pulmonar e dissecção aórtica: importância do ecocardiograma. Rev Port Cardiol. 2013. <span class="elsevierStyleInterRef" id="intr0005" href="http://dx.doi.org/10.1016/j.repc.2012.12.010">http://dx.doi.org/10.1016/j.repc.2012.12.010</span>.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 968 "Ancho" => 2500 "Tamanyo" => 203480 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transthoracic echocardiogram showing (A) moderate aortic regurgitation, dilated aortic root and intimal flap with image suggestive of a double lumen; (B) thrombus in the right pulmonary artery (arrow).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AA: ascending aorta; AE: left atrium; APD: right pulmonary artery; VE: left ventricle.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 954 "Ancho" => 2167 "Tamanyo" => 169961 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thoracic computed tomography angiography with intravenous contrast: (A) transverse view showing an organized thrombus adhering to the wall of the right pulmonary artery (thin arrow) and filling of the true lumen of the aortic dissection (wide arrow); (B) sagittal view showing the dissection extending along the descending thoracic aorta (arrows).</p>" ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003200000006/v1_201308011249/S2174204913001141/v1_201308011249/en/main.assets" "Apartado" => array:4 [ "identificador" => "9915" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Images in cardiology" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003200000006/v1_201308011249/S2174204913001141/v1_201308011249/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001141?idApp=UINPBA00004E" ]
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| 2019 August | 26 | 14 | 40 |
| 2019 July | 48 | 11 | 59 |
| 2019 June | 24 | 14 | 38 |
| 2019 May | 35 | 12 | 47 |
| 2019 April | 25 | 16 | 41 |
| 2019 March | 27 | 17 | 44 |
| 2019 February | 37 | 23 | 60 |
| 2019 January | 16 | 6 | 22 |
| 2018 December | 29 | 14 | 43 |
| 2018 November | 52 | 11 | 63 |
| 2018 October | 105 | 31 | 136 |
| 2018 September | 59 | 12 | 71 |
| 2018 August | 49 | 13 | 62 |
| 2018 July | 42 | 3 | 45 |
| 2018 June | 59 | 8 | 67 |
| 2018 May | 61 | 10 | 71 |
| 2018 April | 82 | 14 | 96 |
| 2018 March | 93 | 9 | 102 |
| 2018 February | 59 | 9 | 68 |
| 2018 January | 75 | 2 | 77 |
| 2017 December | 87 | 14 | 101 |
| 2017 November | 52 | 14 | 66 |
| 2017 October | 57 | 14 | 71 |
| 2017 September | 47 | 10 | 57 |
| 2017 August | 54 | 10 | 64 |
| 2017 July | 49 | 7 | 56 |
| 2017 June | 62 | 11 | 73 |
| 2017 May | 114 | 11 | 125 |
| 2017 April | 40 | 1 | 41 |
| 2017 March | 64 | 38 | 102 |
| 2017 February | 135 | 3 | 138 |
| 2017 January | 55 | 7 | 62 |
| 2016 December | 60 | 11 | 71 |
| 2016 November | 65 | 1 | 66 |
| 2016 October | 73 | 6 | 79 |
| 2016 September | 73 | 5 | 78 |
| 2016 August | 28 | 1 | 29 |
| 2016 July | 12 | 4 | 16 |
| 2016 June | 15 | 5 | 20 |
| 2016 May | 21 | 6 | 27 |
| 2016 April | 30 | 1 | 31 |
| 2016 March | 62 | 16 | 78 |
| 2016 February | 89 | 21 | 110 |
| 2016 January | 62 | 12 | 74 |
| 2015 December | 77 | 8 | 85 |
| 2015 November | 59 | 10 | 69 |
| 2015 October | 91 | 6 | 97 |
| 2015 September | 69 | 10 | 79 |
| 2015 August | 62 | 13 | 75 |
| 2015 July | 119 | 4 | 123 |
| 2015 June | 51 | 3 | 54 |
| 2015 May | 46 | 8 | 54 |
| 2015 April | 50 | 13 | 63 |
| 2015 March | 56 | 4 | 60 |
| 2015 February | 63 | 7 | 70 |
| 2015 January | 66 | 11 | 77 |
| 2014 December | 62 | 13 | 75 |
| 2014 November | 45 | 8 | 53 |
| 2014 October | 141 | 9 | 150 |
| 2014 September | 57 | 10 | 67 |
| 2014 August | 41 | 5 | 46 |
| 2014 July | 50 | 9 | 59 |
| 2014 June | 62 | 8 | 70 |
| 2014 May | 65 | 7 | 72 |
| 2014 April | 65 | 10 | 75 |
| 2014 March | 74 | 17 | 91 |
| 2014 February | 58 | 15 | 73 |
| 2014 January | 84 | 15 | 99 |
| 2013 December | 56 | 10 | 66 |
| 2013 November | 99 | 15 | 114 |
| 2013 October | 78 | 14 | 92 |
| 2013 September | 66 | 21 | 87 |
| 2013 August | 90 | 30 | 120 |
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