A case of pulmonary artery dissection diagnosed in the Emergency Department¹

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.