Case Report
A 73 year old man was referred to pneumologist for dyspnoea and atypical chest pain. Electrocardiogram (fig. 1), chest X-ray and cardiac enzymes were normal.
A CT of the thorax excluded pulmonary embolism. Ten days later was referred again to the hospital because of increasing dyspnea. An echocardiogram showed akinesia of the inferior wall with a small aneurysm and a ventricular septal rupture with left to right shunt.
The cardiac catheterisation showed a subtotal stenosis of the right coronary artery and a normal left coronary artery. The patient was scheduled for open heart surgery.
The patient was operated successfully and received a patch to close the VSR. No CABG was performed.
Patient history prior to current observation :
Ten days before current observation, a 73 year old man was seen at the emergency department. He was referred to the pulmonogist because of dyspnoea and atypical chest pain at the right side of the thorax.
His past history revealed a inguinal hernia, appendicitis and silicosis. Physical examination showed no abnormalities. The electrocardiogram fig. 1 was normal, showing a sinus rhythm, horizontal axis and only a termal negative T-wave in lead III. The chest X-ray was also normal. The cardiac enzymes were also normal. (CK 70 U/l, ASAT 17 U/l, ALAT 7 U/l, trop T < 0.01). A CT of the thorax was performed to exclude pulmonary embolism fig. 2. With this CT pulmonary embolism could be excluded. The patient was sent back home.
Clinical findings on admission, evolution and outcome :
Ten days later was referred again to the hospital because of increasing dyspnea. After the first event dyspnea had disappeared but re-appeared since four days. He was now referred to the cardiology department. There was increasing dyspnea, and orthopnea since four days. He did not have chest pain. The physical examination revealed shortness of breath, a blood-pressure of 90/65 mmHg and a heart rate of 114 bpm. The central venous pressure was elevated. The cardiac auscultation revealed normal heart sounds and a grade 3/6 holosystolic murmur at the apex and fourth intercostal space at the left. There were normal pulmonary breathings sounds. The chest X-Ray showed an enlargement of the heart and a consolidation in the right upper lobe. The electrocardiogram (fig. 3) showed a sinustachycardia and a small q in lead II. The cardiac enzymes were normal exept an elevation of the Troponin T (0.37 U/l) and NT-pro-BNP (5660 U/l). Transthoracic chocardiography showed akinesia of the inferior wall with a small aneurysm and a ventricular septal rupture with flow from left to right (fig. 4 fig. 5 fig. 6). Coronary angiography showed a subtotal stenosis of the right coronary artery and a normal left coronary artery. The patient was scheduled for open heart surgery.
The patient was operated successfully and received a patch to close the VSR. No CABG was performed.