Jackie Shibata, Yiju Teresa Liu, Khadija Ismail

AIM

Point-of-care ultrasound can quickly identify a pulmonary artery dissection from a high parasternal short axis cardiac window.

This is especially useful for unstable patients who are unable to have a CT scan.

CASE REPORT

Illustrates how point-of-care ultrasound (POCUS) can be utilized to diagnose a pulmonary artery (PA) dissection, a rare and life-threatening condition.

BACKGROUND

Less than 100 cases of PA dissection are reported in the literature and most cases are diagnosed post-mortem by autopsy.[1,2]

However, as treatment for congenital heart diseases and pulmonary artery hypertension improve, more patients are living longer with conditions predisposing them to PA dissections.

Therefore, PA dissection must be considered for at-risk patients who present with cardiogenic shock, collapse or sudden cardiac death, as well as more nonspecific symptoms such as chest pain, dyspnea, or central cyanosis. [5, 6] Computed tomography (CT) and/or transthoracic echocardiography (TTE) are typically ordered to make this diagnosis. [7, 8]

To our knowledge, this is the first case describing the rapid diagnosis of a pulmonary artery dissection with POCUS.

METHODS

We present the case of a 37-year-old female with a history of idiopathic pulmonary artery hypertension, cor pulmonale with an ejection fraction of 80-85%, moderate pulmonary regurgitation, pulmonary artery aneurysm, pericardial effusion, diabetes mellitus, and chronic obstructive pulmonary disease who presented to the hospital with acute on chronic dyspnea requiring increased supplemental oxygen.

On exam, the patient was in respiratory distress with orthopnea.

Point-of-care echocardiography revealed a dilated main pulmonary artery (9cm) with a dissection flap.

In the high parasternal short axis view, the large aneurysm and dissection flap were visualized just beyond the pulmonary valve, proximal to the bifurcation of the right and left pulmonary arteries (Figure 1 & Video 1). Turbulent flow was seen within the main pulmonary artery trunk as well as the false lumen (Figure 2 & Video 2).

Cardiothoracic surgery was consulted for worsening cor pulmonale secondary to this pulmonary artery dissection and recommended stabilization and referral for a heart-lung transplant.

The patient was transferred to the cardiac care unit on a furosemide drip along with macitentan, tadalafil, treprostinil, coumadin, carvedilol and digoxin.

RESULTS

Point-of-care ultrasound was performed promptly upon arrival to the emergency department. Despite her respiratory distress and inability to have immediate CT scanning, the PA dissection was rapidly identified in the high parasternal short axis view with a focused cardiac ultrasound assessment.

This facilitated timely consultation and treatment.

CONCLUSION

Due to improved treatment of pre-disposing comorbidities, more patients are presenting with this rare, but serious condition.

To the best of our knowledge, this is the first case describing a pulmonary artery dissection identified by point-of-care echocardiography.

POCUS is especially useful for patients in extremis, unstable to lie flat or be transferred to a CT scanner, or when comprehensive echocardiography is not available

REFERENCES

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2. Steurer J, Jenni R, Medici TC, Vollrath T, Hess OM, Siegenthaler W. Dissecting aneurysm of the pulmonary artery with pulmonary hypertension. Am Rev Respir Dis. 1990 Nov;142(5):1219-21

3. Malm CJ, Ternström L, Jörgensen K, Dellgren G. Pulmonary artery dissection in a patient with undiagnosed pulmonary hypertension–A case report and review of literature. Heart Lung. 2015 Sep-Oct;44(5):453-7.

4. Hoye SL, Gale CP, Tolan DJ, Pepper CB. An unusual presentation of pulmonary artery dissection. Thorax. 2009 Apr;64(4):368.

5. Senbaklavaci O, Kaneko Y, Bartunek A, et al. Rupture and dissection in pulmonary artery aneurysms: incidence, cause, and treatment–review and case report. J Thorac Cardiovasc Surg. 2001 May;121(5):1006-8.

6. Khattar RS, Fox DJ, Alty JE, Arora A. Pulmonary artery dissection: an emerging cardiovascular complication in surviving patients with chronic pulmonary hypertension. Heart. 2005 Feb;91(2):142-5.

7. Bhatia V, Sharma S, Panda P, Sood RG. Role of Multi-Detector Computed Tomography (MDCT) in Diagnosis of Pulmonary Artery Dissection: A Rare but Fatal Entity. Ann Acad Med Singapore. 2014 Jan;43(1):64-5.

8. Areco D, Pizzano N. Pulmonary artery dissection: echocardiographic findings and diagnosis. Echocardiography. 2003 May;20(4):375-7.