Bedside echocardiography showed the findings consistent with Takotsubo cardiomyopathy. Echocardiographic images are shown in subxiphoid (A) and apical four chamber (B) views. Note the apical ballooning appearance (asterisk) of the left ventricle (LV).
Initial ECG shows tall, peaked T waves, most prominently in V3 and V4, as well as QRS widening. These findings are consistent with hyperkalemia, which was promptly treated. Follow-up ECG post-treatment shows narrowing of the QRS complexes and normalization of peaked T waves.
The initial chest x-ray showed an abnormal superior mediastinal contour (blue line), suggestive of a possible aortic injury. The CT angiogram showed extensive circumferential irregularity and outpouching of the distal aortic arch (red arrows) compatible with aortic transection. In addition, there was a circumferential intramural hematoma, which extended through the descending aorta to the proximal infrarenal abdominal aorta (green arrow). There was also an extensive surrounding mediastinal hematoma extending around the descending aorta and supraaortic branches (purple arrows).
The initial EKG showed wide complex, irregular tachycardia > 200 bpm (EKG 1). Given the possibility of Wolff-Parkinson-White (WPW), procainamide was given to the patient. The patient’s heart rate responded and decreased to 120-140 bpm with narrowing of the QRS complex. A repeat EKG showed narrow complex tachycardia without P waves approximately 120 bpm (EKG 2). Once the procainamide infusion was complete, the patient had converted to sinus rhythm with a delta wave now apparent, consistent with WPW (EKG 3).
Bedside ultrasound revealed the presence of a left atrial mass that appeared to be tethered to the mitral valve. The mass was best viewed on ultrasound in the apical four-chamber window with the phased array probe placed over the patients’ point of maximal impact (PMI), with the patient in left lateral decubitus position.
The ECG shows diffuse ST- elevation. The patient also has mild PR-depression, most notably in the inferior and lateral leads. The patient also has minimal PR elevation in lead aVR. The patient was diagnosed with acute pericarditis (ECG stage 1).