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.