Abstract
Byline: Hardik Fichadiya, Internal Medicine, Rutgers NJMS/ Trinitas Regional Med Cntr, Elizabeth, NJ; Rachel Abboud, Cardiology, St. Joseph's Univ Hosp, Paterson, NJ; Muhammad Atif Masood Noori, Internal Medicine, Rutgers NJMS/ Trinitas Regional Med Cntr, Elizabeth, NJ; Abdullah Masood, Internal Medicine, Rutgers NJMS/ Trinitas Regional Med Cntr, Elizabeth, NJ; Sherif Elkattawy, Internal Medicine, Rutgers NJMS/ Trinitas Regional Med Cntr, Union, NJ; Arshan Khan, Internal Medicine, Ascension St. John Hosp, Detroit, MI; Harshwardhan Khandait, Internal Medicine, Rutgers NJMS/ Trinitas Regional Med Cntr, Elizabeth, NJ; Jesani Shruti, Internal Medicine, Rutgers NJMS/ Trinitas Regional Med Cntr, Elizabeth, NJ; Meherwan B Joshi, Cardiology, Rutgers NJMS/ Trinitas Regional Med Cntr, Elizabeth, NJ Introduction: Penetrating Aortic Ulcer (PUA) is an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the medial layer of the aortic wall. As per our literature review, only one case of PUA causing hemopericardium has been reported. Case Presentation 66-year-old male with an unknown past medical history was bought in by the emergency medical services following a cardiac arrest. Initial rhythm was pulseless electrical activity and return of spontaneous circulation was achieved after ten mins of cardio-pulmonary resuscitation on the field. Initial echocardiogram was significant for a 4.6 cm ascending aorta with large hemopericardium causing tamponade physiology. CT chest with contrast revealed an ectatic ascending aorta with mild irregularity along the posteromedial wall, concerning for aortic leak secondary to a penetrating aortic ulcer (as indicated by the yellow arrow in the image below). Controlled pericardiocentesis was planned as a bridging therapy while awaiting transfer to a specialized cardiothoracic unit. But, the systolic blood pressure (SBP) rose to 170 mmHg when the chest tube was first inserted, worsening the hemopericardium. The patient's condition rapidly deteriorated, causing another cardiac arrest and death. Discussion The recommended treatment for Type A and B PUA-associated Intra Mural Hematoma is urgent surgical aortic graft placement. For hemodynamically unstable patients who cannot be taken for urgent surgery, The 2015 European Society of Cardiology guidelines recommend controlled pericardiocentesis to maintain a target SBP of 90 mmHg as a temporary measure. Conclusion In addition to aortic dissection, PAU should be considered in the differentials of patients with dilated ascending aorta and hemopericardium. An acute rise in blood pressure above 90 mmHg during pericardiocentesis is associated with worsening tamponade.