Clinical Case Poster session 6 Article Swipe
YOU?
·
· 2017
· Open Access
·
· DOI: https://doi.org/10.1093/ehjci/jex291
· OA: W4239231875
Introduction and case report description: A 43-years old man was admitted to emergency department because of chest pain and dyspnoea.He had no prior cardiological history.His ecg demonstrated an anterior ST elevation.At presentation, he was on acute pulmonary edema with heart rate of 90/min, BP 140/100 mmHG and Sat O2 95%.Blood sample revealed a mild leukocytosis, elevated levels of CPR and troponin.He was treated immediately with aspirin, ticagrelor, diuretics, oxygen and transported in the cath lab.Description of the problem, procedures, techniques and equipment used.Fast transthoracic echocardiography (TTE) presented a poor diagnostic window but showed an important impairment of left ventricular ejection fraction, with no valvulopathy.The urgent angiography revealed no coronary obstruction with a TIMI 2 flow in left main and anterior descendent.For important hemodynamic deterioration, he was treated with noninvasive ventilation and add of IABP and inotropic agents.On suspicious of an undetected cause of infarction, a transoesophageal echocardiography (TEE) was performed.TEE revealed a thin inhomogeneous and mobile mass attached over the left sinus of Valsalva jut into the ostium of left main with no compromission of aortic cusp.Questions, problems or possible differential diagnosis.According to the high hemodynamic instability and continuous refractory signs of ischaemia, patient was referred to a transplant center to put him on ECMO as a bridge to decision.After a moderate response, he was studied with a complete CT scan, which revealed a hypodense sleeve between aortic root and LVOT with obstruction on left coronary sinus and thick disomogenous left ventricular wall with hyperdense signal.Collaterally CT demonstrated hypodensity spots on renal parenchyma, right frontal anterior and left parietaloccipital brain.Despite hemodynamic supports, he didn't demonstrate any improvement and died 48-hours after ECMO instauration.Many open questions were present in this case because of the presentation, localization, aspect and history.No signs of sepsis were present; patient was apyretic and multiple blood cultures remained sterile.He did not present any clearly vegetation on aortic cusps or on the other valves; in fact, mass was present visible only in the left sinus of Valsalva.The presence of multifocal lesions was at the beginning misunderstood and read as a possible endocarditis or thrombosis but then interpreted as different embolization of the initial mass.At the end, differential diagnosis considered was cardiac papillary fibroelastoma (CPF), infective vegetation and thrombus.Answers and discussion.This young patient presented a CPF with multiple embolization causing anterior STEMI and multiples ischaemic lesions in renal and brain parenchyma.Coronary angiography is associated with an added risk because the catheter may dislodge a fragment of the tumor and lead to coronary or systemic embolization.In this case, because of the importance of acute heart failure deriving from myocardial infarction and cerebral lesions, prognosis was poor.Conclusions and Implications for Clinical Practice: The present case highlights the importance of thinking to embolizing fibroelastoma as a rare differential diagnosis of myocardial infarction in young adult.
