A Conference And A Case

 

All of you practicing echocardiography know this situation: You put the transducer to the chest and you are absolutely astonished at what you see. You find something really “unusual”, “very large”, “more than severe” or “never seen before”. Such cases obviously fascinate. After all it is a fact of life that we are captivated by the bizarre. But such cases also have another twist to them: They are ideal to learn echocardiography!

Today’s case is the first of several cases that we will bring from time to time that deal with astonishing and unusual echoes.

The first case will also give us the opportunity to introduce you to the crew of our emergency department. They are the ones who are on the forefront of the bizarre and unusual, so they are also the right people to present this case. Here they are!

Enjoy!

yours Thomas

 

Alexander & Hans enter the stage:

So here’s what happened
An 80 year-old man was transferred to our emergency department after out of hospital cardiac arrest. Cardiopulmonary resuscitation had initially been successful. He was in pretty bad shape: ventilated and severely hypotensive (pH 6.9, lactate 12.0mmol/l, BE -11.2mmol/l). Not a good prognosis. But what made things even worse was his echo.

Instant diagnosis
Here is an atypical parasternal long axis view:
We are sure you can immediately see what should NOT be there: a huge mass in front of the ascending aorta.
 

Once we recovered from our first astonishment, we went on to look at the mass more systematically.

Here are some of the features that describe the mass:
Very large, inhomogeneous, outside the heart or the pericardium, the origin is from the right of the thorax and no pericardial effusion is present.

Our first conclusion
The tumor is malignant for sure, of extra-cardiac location and does (as of now) not infiltrate the heart. To appreciate the full extent of the mass here is the spiral-CT of the chest:

 
Still some open questions
However, one question remains: Why did the patient have cardiac arrest? Well, there is one other important finding on the echocardiogram: did you catch it? The right ventricle was enlarged and the left ventricle had a “D shape” (see image above).

These findings suggest pulmonary embolism.  And indeed CT confirmed massive pulmonary embolism (see arrow). This was certainly the cause for cardiac arrest.

What we learned
Well, you can imagine how the story ended, he passed away shortly after we performed this echo despite thrombolysis and all measures we could think of. As it turned out - the patient had been diagnosed with malignant myxofibrosarcoma several weeks ago. But what is the lesson? Sure, you can be fascinated by the impressive findings on an echo, but this does not mean that you should forget to perform a sound and thorough standard exam as well.

Some final thoughts on the conference
We hope this case will help you to treat your own patients! Now some more info on the ASE meeting and how you can meet us there ...