Diagnostic echocardiography in an unstable intensive care patient

Abstract

A previously fit and well 57-year-old gentleman who had recently undergone a colonoscopy and biopsy of a polyp presented with a 4-day history of progressive breathlessness and abdominal discomfort. The day after admission, he became haemodynamically unstable, developed ischaemic legs and suffered a brief cardiac arrest. Blood tests demonstrated a coagulopathy and hypoglycaemia. Continued haemodynamic instability post-arrest and clinical findings of high right-sided heart pressures were investigated by bedside screening echocardiogram. This demonstrated a massive pericardial effusion causing tamponade of the right ventricle. Heavily blood stained pericardial fluid was drained, with marked improvement in haemodynamic stability. Retrospective review of the admission-electrocardiogram (ECG) and chest X-ray demonstrated electrical alternans and cardiac enlargement. The differential diagnosis included bowel malignancy causing a haemorrhagic metastatic pericardial effusion and a type A aortic dissection. Therefore a computerised tomography (CT) scan of chest, abdomen, pelvis and aorta was performed. This was negative for disseminated malignancy and showed a type B aortic dissection, but was inconclusive for a type A aortic dissection. A subsequent transoesophageal echocardiogram confirmed the diagnosis of type B dissection and ruled out a type A dissection. The histology of the colonic polyp was negative for malignancy, but it was subsequently discovered that the patient had metastatic adenocarcinoma from a primary lung cancer diagnosed from pleural fluid cytology. With hindsight the presenting clinical picture was of type B aortic dissection with concurrent but not directly related pericardial tamponade.