The Common Vein

3 years ago

38 year woman with SLE, migraine, seizure, HTN, SVT (s/p ablation) asthma and PSA (crack cocaine and opioids) who presented to  ER after a fall with transient LOC. Was brought to ER and noted to have R face/arm/leg weakness and dysarthria in setting of hypertensive emergency (SBP>220, troponemia). Was given IV tPA for NIHSS 11 after SBP controlled with labetolol. Multiple similar prior episodes prompting presentation for stroke work-up. Of note, tox screen +ve cocaine.

PMH: SLE, migraine, Seizure history, HTN, SVT s/p ablation, asthma, polysubstance abuse

The patient was critically ill with:
Acute right sided paresis
Acute on chronic kidney injury
Type II NSTEMI
Acute hypokalemia
Acute hypomagnesemia
Acute cocaine toxicity with acute hypertensive emergency.

CTEcho at the time

Normal LV size  with mildly increased  wall thickness;  LV
systolic function  is normal with estimated  LVEF 60%;  all walls move normally.
RV size and systolic  function are  normal.
Severely dilated  LA ( 60 ml/m2);   RA is moderately  dilated.
The pulmonary artery  and pulmonary  flow are not adequately
evaluated.
Valves appear structurally  normal,  but there is 2+  MR and 2+ TR;
Estimated PA systolic  pressure is  35 mmHg assuming  an RA pressure of 3 mmHg. IVC is normal size  with normal respiratory  variation  suggesting normal RA pressure.
No pericardial effusion.

Color flow Doppler  of the interventricular  septum throughout  the
study, but especially  on images #82  and #93 demonstrate  several
color Doppler continuous  signals that  are low velocity  and are most consistent a coronary-cameral  fistula  (coronary to  RV chamber).
Note that recent  Coronary CT Pulmonary  Antiogram has  demonstrated  massive dilatation  of the coronary  arteries, which  would be consistent with the  probable presence  of coronary -cameral fistula).