Refractory Tamponade: - Use Of Ultrasound Contrast Agent to Distinguish Aortic Dissection from Cardiorrhexis

We report a case of a ruptured proximal aortic dissection with cardiac tamponade, which masqueraded as myocardial rupture or cardiorrhexis. An 84-year-old female had sudden onset of chest pain with loss of consciousness and a mechanical fall. Echocardiography demonstrated pericardial effusion with hematoma overlying the apicallateral wall and an echo free space suggestive of contained, ventricular free-wall rupture. However, intravenous injection of ultrasound contrast agent revealed no flow into the pericardial space excluding cardiorrhexis. Refractory hemodynamic compromise required an emergency pericardial window, but the patient remained unstable. Surgical exploration revealed a Debakey Type-A aortic dissection with communication into the pericardial space. To our knowledge, this is the first description of the use of ultrasound contrast microbubbles as a diagnostic strategy to exclude cardiorrhexis. The impact of tamponade treatment as the result of aortic dissections and the diagnostic challenge in differentiating it from other catastrophic causes of tamponade are reviewed.