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JAMA Surgery Clinical Challenge
October 2016

Inside or Outside of the Heart?

Author Affiliations
  • 1Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
  • 2Division of Cardiovascular Surgery, Cheng-Hsin General Hospital, Taipei, Taiwan
  • 3Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
JAMA Surg. 2016;151(10):981-982. doi:10.1001/jamasurg.2016.2049

A 61-year-old man presented with a progressive shortness of breath for 1 week. He was diagnosed with myocardial infarction 1 month earlier at another hospital and a coronary intervention was performed with 1 drug-eluted stent put in the left anterior descending artery. Progressive dyspnea at rest was noted in recent days. Review of systems and family history were unremarkable. Physical examination revealed tachycardia and tachypnea. His heart rate was 138 beats/min and respiratory rate, 25 breaths/min. Blood pressure was 92/58 mm Hg. Chest auscultation revealed bilateral rales. Heartbeat was regular, but with faint S1 and S2. The extremities were cold, while no pitting edema was found. Laboratory findings were within normal limits. Twelve-lead electrocardiography demonstrated persistent ST-T segment elevation in V2 to V6 leads. Transthoracic echocardiography showed a hypoechoic mass around the apical region (Figure 1A). Computed tomography of the chest revealed a large crescentic hypodense lesion surrounding the anterolateral wall of the left ventricle and apex (Figure 1B).

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