Consulting cardiologist arrives. He reviews the history and testing and is still convinced the patient has cardiac ischemia. Given the negative results of the CT-scan he judges that the picture is atypical but consistent with ischemia, probably caused by coronary artery disease. He also considers the other available results. Although the CT-scan has ruled out pulmonary embolism, the prominent aortic valve shadow is worrisome. He requests a transthoracic echocardiogram (TTE).
Commentary: Since the cardiologist takes pulmonary embolism to be ruled out by the CT-scan, he still considers cardiac ischemia most likely. However, the shadow on the aortic root is puzzling and he decides this merits further investigation.
Conclusion of scenario: The TTE shows a widened mediastinum and that the aortic root is dilated to 4.5 cm. The patient’s condition is unchanged. Because of the degree of clinical pain, the cardiologist and emergency room clinician decide that immediate coronary artery intervention (stent or bypass) is necessary. They consult with the nearest cardiac surgical unit for immediate transfer and transport helicopter arrives. The cardiologist accompanies the patient to the surgical unit.