Acute Chest Pain: Is It Just a Heart Attack?
A 30-year-old man presented to the emergency department with progressive exertional dyspnea and pleuritic chest pain. His medical, surgical, social, and family histories were unremarkable for any cardiovascular disease or associated risk factors. He was treated for a pneumonia with a macrolide 3 weeks ago. Computed tomography (CT) (Figure 1) of the chest revealed a large soft tissue density mass (6.9 × 6.1 cm, 3060 Hounsfield units), extending from the level of the left atrium and lateral mitral annulus superiorly to the posterolateral aspect of the aortic root and main PA. Transthoracic echocardiography demonstrated a large pericardial effusion with a large extrinsic left atrial mass, adjacent to the main PA and the left sinus of Valsalva. Left ventricular ejection fraction was preserved (67%), without major valvular abnormalities. The inspiratory flow variations across the mitral and tricuspid valves were 58% and 64%, respectively (Figure 2). Cardiac magnetic resonance imaging (Figure 3) demonstrated a large mass invading the main and right PAs, resulting in severe intraluminary obliteration. In addition, a large right lower lobe pulmonary infarct was also noted. The patient was admitted to the cardiac intensive care unit for closer monitoring due to signs of pre-tamponade physiology.
Which of the following is the best next step in management of this patient?