Pulmonary Artery Aneurysm Evolving In Fatal Consequences
Patient Demographics: We describe the case of a 66 years old caucasian male presented with sudden onset of chest pain described as severe and associated with a month-long history of progressive shortness of breath.
Relevant History: He had a history of pulmonary thromboembolism and deep vein thrombosis known since 1999 and successfully treated by the combination of Inferior Vena Cava Filter installation and anticoagulant therapy.
Pre-Operative Plan: General examination was unremarkable. There were no signs of cardiac failure. Chest radiography revealed enlargement in the right heart silhouette. The Transthoracic echocardiography showed an aneurysm of the main pulmonary artery (PA) measuring approximately 5.9 cm and dilatation of the left and right pulmonary arteries. Enlargement of the left atrium and the right heart chambers as well as moderate tricuspid regurgitation were detected. The PA aneurysm was not associated with pulmonary regurgitation. Post-contrast chest computed tomography (CT) was done and showed a dilated main PA with a maximum diameter of 6 cm and its 2 branches, with a huge (partially calcified) aneurysm of the right branch (about 24× 14 cm) partially occupied by a mural thrombus compressing the left atrium, together with marked pericardial effusion. Surgical correction of the aneurysm with placement of a pulmonary allograft was recommended, but was refused by the patient.
Discussion of what was actually done and the challenges, deaths and complications encountered: Pericardiocentesis was undertaken on day 2, immediately followed by subxiphoid drainage, wherein 2500 cc of fluid was aspirated. On day 3, the patient suddenly developed marked dyspnea and tachycardia, and passed into shock with marked hypoxemia and hypocapnia, suggesting a massive pulmonary embolism. The echocardiography revealed an intimal flap noted in the lateral wall of the pulmonary trunk, with suggestion of flow within the flap. Then, he went into cardiac arrest and died. Pathologic examination showed mild myxoid degeneration of the endothelial surface and confirmed the presence of dissection within the aneurysmal wall. Clinical presentation of pulmonary aneurysms remains nonspecific and dissection must be suspected in the face of sudden hemodynamic decompensation in a patient with documented pulmonary artery aneurysm.