Ropers D, Daniel W G, Hobbach H-P, Walter T, Schuster P
Medizinische Klinik 2 (Kardiologie-Angiologie), Universität Erlangen-Nürnberg.
Dtsch Med Wochenschr. 2007 Apr 5;132(14):741-5. doi: 10.1055/s-2007-973610.
A 42 year-old man reported transient breathlessness and chest pain on the first day after a four-hour flight. During the following five months the symptoms recurred four times. After another episode he went to an outpatient department for further assessment.
Blood tests demonstrated slightly elevated LDH (343 U/l) and also a minor increase of the D-dimers (710 microg/l). Hypercholesterolemia was also found (LDL-cholesterol 180 mg/dl). The rest of the blood tests, including the cardiac enzymes, were within normal limits. The electrocardiogram (ECG) showed sinus rhythm, heart rate 85 bpm and pre-terminal T-negativity in the precordial leads V1 to V3. Resting echocardiography and chest X-ray showed no significant abnormalities. The exercise ECG demonstrated no further ECG changes. However, because of the symptoms and a cardiovascular risk profile (family history, hypercholesterolemia and smoking) a coronary angiography was performed, which excluded coronary artery disease but revealed a so-called "right-sided single coronary artery", the left and right coronary arteries originating with a common stem from the right sinus of valsalva. To define the exact course of the left main coronary artery (whether in front of the pulmonary artery, between the two great arteries, retroaortic or septal) a contrast-enhanced cardiac computed tomography (CT) was performed, which demonstrated an anomalous position of the left main coronary artery in front of the pulmonary artery. Bilateral pulmonary embolism was an additional and unexpected finding.
Oral anticoagulation was initiated after a coagulopathy had been excluded. The ultrasonography of the leg did not demonstrate any thrombosis. There was no evidence of malignant disease.
Mild symptoms and absence of right heart congestion do not exclude pulmonary embolism. Depending on the symptoms and history, pulmonary thrombembolism has to be considered, especially if cardiac or extra-cardiac causes have been eliminated. The diagnostic method of choice for the detection or exclusion of pulmonary embolism is contrast-enhanced multi-slice spiral CT.
一名42岁男性在一次4小时的飞行后的第一天报告有短暂的呼吸急促和胸痛。在接下来的五个月里，症状复发了四次。又一次发作后，他前往门诊进行进一步评估。
血液检查显示乳酸脱氢酶（LDH）略有升高（343 U/l），D-二聚体也略有增加（710微克/升）。还发现有高胆固醇血症（低密度脂蛋白胆固醇180毫克/分升）。其余血液检查，包括心肌酶，均在正常范围内。心电图（ECG）显示窦性心律，心率85次/分钟，胸前导联V1至V3出现终末前T波倒置。静息超声心动图和胸部X光检查未显示明显异常。运动心电图未显示进一步的心电图变化。然而，由于症状以及心血管风险状况（家族病史、高胆固醇血症和吸烟），进行了冠状动脉造影，排除了冠状动脉疾病，但发现了所谓的“右侧单冠状动脉”，左、右冠状动脉起源于一个共同的干，发自主动脉窦右侧。为了确定左冠状动脉主干的确切走行（是在肺动脉前方、两大动脉之间、主动脉后方还是间隔内），进行了对比增强心脏计算机断层扫描（CT），显示左冠状动脉主干位于肺动脉前方的异常位置。另外还意外发现了双侧肺栓塞。
排除凝血障碍后开始口服抗凝治疗。腿部超声检查未显示任何血栓形成。没有恶性疾病的证据。
轻微症状且无右心充血并不排除肺栓塞。根据症状和病史，必须考虑肺血栓栓塞，尤其是在排除心脏或心脏外病因之后。检测或排除肺栓塞的首选诊断方法是对比增强多层螺旋CT。
