Clinical communication
A case of pulmonary artery dissection diagnosed in the Emergency Department1

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Abstract

Pulmonary artery dissections typically occur at the site of a pulmonary artery aneurysm associated with pulmonary hypertension or connective tissue disease. Dyspnea on exertion, retrosternal chest pain, central cyanosis, and sudden hemodynamic decompensation are the four main clinical signs and symptoms associated with a pulmonary artery dissection. Diagnosis of a pulmonary artery dissection frequently occurs postmortem, as many of these patients experience sudden death when the main pulmonary artery dissects into the pericardium, causing acute cardiac tamponade. Pulmonary artery dissection has been diagnosed in living patients using transthoracic echocardiogram, computed tomography (CT) scanning, magnetic resonance imaging (MRI), and angiography. Surgery is curative. Emergency physicians should consider the diagnosis of pulmonary artery dissection in patients presenting with either retrosternal chest pain, dyspnea on exertion, central cyanosis, or sudden hemodynamic decompensation and who have a past medical history of pulmonary hypertension, pulmonary artery surgery, or a disease causing chronic inflammation of myocardial or vascular tissue.

Introduction

Pulmonary artery dissection is a rare but life-threatening disease, as sudden death typically results when the main pulmonary artery dissects into the pericardium causing acute cardiac tamponade 1, 2, 3, 4. The pulmonary artery may also dissect into the lung parenchyma or into the bronchial tree 3, 5.

Clinical presentation of a pulmonary artery dissection typically involves chest pain, central cyanosis, exertional dyspnea, and sudden hemodynamic decompensation in a previously stable patient with known risk factors or a known pulmonary artery aneurysm (6). Most cases of pulmonary artery dissection are diagnosed at autopsy. The following is a report of pulmonary artery dissection diagnosed in the ED with bedside echocardiography.

Section snippets

Case report

A 42-year-old man presented to the Emergency Department (ED) with the complaint of right-sided chest and neck pain for approximately 1 h. The patient described the pain as a tightness, and rated it at 7 out of 10 in severity. The pain radiated to his neck and left arm. The patient denied ever experiencing the pain before. The pain was not related to exertion and was not alleviated by rest. The patient denied any associated shortness of breath, diaphoresis, nausea, abdominal pain, or weakness of

Discussion

Dissection of the pulmonary artery is a rare but life-threatening disease that typically occurs at the site of a pulmonary artery aneurysm associated with pulmonary hypertension or connective tissue disease (1). In a necropsy review of 111 cases of pulmonary artery aneurysms, pulmonary hypertension because of cardiac malformation was present in 74 (66%) patients (7). Patent ductus arteriosus was the most common single cardiac lesion, occurring in combination with 23% of pulmonary artery

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    Congenital malformations are mostly responsible for secondary pulmonary hypertension [3], but it has been observed in hereditary disorders [4], acquired valvular lesion, and chronic pulmonary diseases (tuberculosis and syphilis) [1]. According to the literature [1–6], dissection always occurs at the site of maximal dilatation of the artery. In contrast to aortic dissection and because of the thinness and fragility of the external layer, the high pressure inside the false lumen tends to favor rupture of the free wall rather than tearing the intimal flap and opening a reentry site.

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1

Clinical Communications is coordinated by Ron Walls, MD, of Brigham and Women’s Hospital and Harvard University Medical School, Boston, Massachusetts

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