Near-syncope due to extra-cardiac mass compressing the right atrium: an unusual presentation of a penetrating atherosclerotic ulcer with intramural hematoma of the ascending aorta

Introduction: Due to progressive developments and availability of imaging modalities as CT and MRI, penetrating atherosclerotic ulcer (PAU) with or without aortic intramural haematoma (IMH) has been accepted as an increasingly recognised and potentially fatal entity within the spectrum called acute aortic syndrome (AAS). Case report description: A 71-year old woman without cardiac medical history presented to the Chest Pain Unit (CPU) after near-syncope due to low thoracic chest pain radiating to the right shoulder. Blood pressure was 96/70 mmHg. The electrocardiogram (ECG) showed sinus rhythm (83 bpm) and diffuse aspecific ST-segment abnormalities. Rhythm monitoring and an acute coronary syndrome rule out protocol were started. During monitoring episodes of atrial tachycardia (140-150 bpm) were observed, accompanied by blood pressure drops (70/35 mmHg) and ECG changes suspect of ischemia. Echocardiography remarkably revealed an obliterating left ventricle due to impeded preload caused by almost complete compression of the right atrium by an extra-cardiac mass. A CT scan was performed which surprisingly showed a PAU with IMH (from aortic root to bracheocephalic trunk) and extensive pericardial effusion and thrombus. The patient underwent emergency cardiac surgery, i.e. pericardial thrombus removal, and supracoronary ascending aorta replacement. ![Figure][1] Figure 1 Conclusion/Implications: Atypical symptoms and signs often hamper the diagnosis of an AAS, especially PAU and IMH. Since the prognosis in AAS depends on undelayed diagnosis and (often surgical) treatment, prompt diagnostic imaging is a conditio sine qua non. As for acute coronary syndromes, CPU's with quick access to imaging modalities as CT and MRI, rather than general ER, may be best suited for swift and accurate evualution of these challenging cases. [1]: pending:yes