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A 35 year old white man previously fit and well presented to the emergency department late one evening, with an episode of haemoptysis. He developed sudden left chest pain and breathlessness while having a drink in a local pub. The history obtained by the ambulance crew was that he coughed up half a litre of blood in the pub toilet.
On initial examination he was conscious but visibly distressed. He was noted to be tachypneic (respiratory rate 28 breath/min) and in severe pain over his chest and back. His initial pulse rate was 112 beat/min and his blood pressure was141/93.The well healed scar of a thoracotomy was noted over the left side of his chest.
His partner who was present explained it was for the repair of a “hole in the heart” 23 years ago, when he was aged 12. He had been on follow up for a few years after the surgery by the tertiary cardiac centre and then discharged to his primary care practitioner. The last chest radiograph he had was more than 10 years ago. He had otherwise been fit and well and participated actively in sport.
The patient had 100% oxygen administered by non-rebreathing mask with a reservoir bag and intravenous access was obtained with wide bore cannulas. Blood was taken for grouping and cross matching.
Despite high flow oxygen the best saturation obtained was 89% by pulse oximetry. A blood gas sample taken showed marked hypoxia and mild acidosis (table 1). Intravenous morphine was administered with temporary relief of pain requiring repeated titrated doses. An ECG showed sinus tachycardia. An urgent portable chest radiograph was done (fig1).
100% oxygen facemask with oxygen reservoir
Portable chest radiograph showing the aneurysm in the upper zone of the left lung field.
His condition rapidly deteriorated and he collapsed from torrential bouts of haemoptysis requiring endotracheal intubation, emergency blood, fluids, and cardiopulmonary resuscitation. He failed to respond to advanced life support resuscitation and was pronounced dead.
A postmortem examination showed an 8 cm thin walled aneurysm of the arch of aorta and proximal descending thoracic aorta that had ruptured into the upper lobe of the left lung and pleural cavity.
DISCUSSION
Haemoptysis as a presenting symptom of leaking aortic aneurysm after coarctation repair has been previously described in the literature.1 Aortic patch graft repair was first performed in the United Kingdom by Charles Drew in Westminster Hospital half a century ago.2 Between 1976 and 1982 patch aortoplasty was the routine procedure of choice.3
Aneurysm formation rate after the repair has been described in long term follow up studies (up to 15 years after surgery) to be between 3.8% and 27%.4,5 Our patient presented 23 years after his surgery with a ruptured aneurysm.
Some 32.8% of patients in one study who had patch graft aortoplasty for aortic coarctation underwent reoperation because of aneurysm formation at the site or opposite to the patch graft.6
The argument for lifelong radiological surveillance by plain radiology (chest radiograph), Doppler ultrasound, or computed axial tomography for asymptomatic patients with previous coarctation patch repair is very strong indeed from these reports. This can be along the lines of treatment for patients diagnosed to have early abdominal aneurysms.
General practitioners who have such patients on their lists are ideally suited to undertake this role and should review them on a regular basis with screening surveillance radiography.
In conclusion, vascular events like aneurysm ruptures and dissections are by their nature often catastrophic if they present late in the their clinicopathological course. They are literally like “ticking time bombs” pulsing to our heart rhythm. Early recognition of possible predisposing factors like age, atherosclerosis, hypertension, and previous risk related surgery (for example, aortic surgery) entails us to be vigilant in our follow up of the patient at risk of premature death and significant morbidity.
Contributors
Dilip Menon did the literature search, wrote the manuscript of the case report, and is guarantor for the paper. Tony Burdge did the postmortem examination and report and reviewed the manuscript of this case report.
Footnotes
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Competing interest: the first author was directly involved in the initial care of this patient whose condition he diagnosed only when the portable chest radiograph showed the abnormality demonstrated. In writing this case report, he seeks to share his experience and highlight this condition to the wider emergency and primary care medical community.