How bad can life be? A case of concurrent cardiac tamponade and pulmonary embolus

Abstract

We present a rare case of a patient presenting with submassive pulmonary embolism (PE) further complicated by cardiac tamponade with the clinical dilemma on whether to perform thrombolysis or emergency pericardiocentesis to save her life. The aetiology of her pericardial effusion remains unclear but may possibly relate to post-PE pericarditis, a condition that resembles Dressler's syndrome. The pathophysiological processes of concurrent PE and cardiac tamponade combined to result in an unusual right ventricular shape on transthoracic echocardiography, and our findings raise the possibility of a fourth mechanism for the explanation of McConnell's sign - restricted free wall dilation via the moderator band.

Keywords: McConnell's sign; cardiac tamponade; pulmonary embolus; transthoracic echocardiography.

Figure 1

CT Pulmonary Angiogram after deterioration on day 5 demonstrating bilateral PE, new pericardial effusion and bilateral moderate pleural effusions.

Figure 2

Electrocardiography on arrival to ICU demonstrating widespread PR depression with reciprocal PR elevation in aVR, in addition to concave upward inferolateral ST elevation without significant reciprocal changes is more suggestive of pericarditis than ischaemia.

Figure 3

Transthoracic echocardiogram on arrival to ICU demonstrating moderate to large pericardial effusion, dilated right atrium and unusual right ventricular shape with aneurysmal free wall and vigorous contraction at the apex, both separated by the moderator band (atypical McConnell's sign).