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Cardiovascular Disease |

Restricting the Diagnosis: Right Ventricular Failure Three Years After Bilateral Lung Transplant

Jonathan Wiesen, MD; Ali Ataya, MD; Marie Budev, DO; David Mason, MD; Charles Lane, MD
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Cleveland Clinic Foundation, Cleveland, OH


Chest. 2013;144(4_MeetingAbstracts):126A. doi:10.1378/chest.1702999
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Abstract

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Right ventricular (RV) failure is uncommon after lung transplantation since the RV usually remodels and has normal function shortly after transplant. The differential diagnosis of RV failure post transplant is relatively broad. We are presenting an unusual case of new onset right ventricular failure 3 years post transplant.

CASE PRESENTATION: A 69 year old male with no prior cardiac history, a normal left heart catheterization 3 years prior, and an echocardiogram after transplant showing normal biventricular function, presented with a 2 month history of gradually worsening abdominal distention, lower extremity edema, and shortness of breath. He had undergone bilateral lung transplant three years earlier for idiopathic pulmonary fibrosis, and his post-operative course was complicated by bilateral loculated pleural effusions with trapped lung on the left. This required placement of bilateral tunneled pleural catheters and ultimately a left sided decortication. Physical examination was notable for jugular venous distention without a prominent “v” wave, a distended abdomen with a positive fluid wave, and 3+ lower extremity edema. Laboratory testing revealed an increased creatinine (3.1 mg/dL). Chest roentgenogram showed bilateral pleural effusions and a circular opacity overlying the heart. Echocardiography demonstrated a preserved ejection fraction (65%), a small right ventricle and a large pericardial cyst compressing the right atrium and ventricle, leading to a gradient of 9mm Hg between the atrium and ventricle with features of functional tricuspid stenosis and tamponade. As the patient had clinical signs of tamponade and RV dysfunction, a pericardial window was performed with drainage of the cyst. Cultures and cytology from the pericardial fluid were negative. The patient was treated with aggressive diuresis, and his oxygen requirements and renal function returned to baseline. He followed up in outpatient clinic with symptomatic improvement and echocardiogram showing decreased size of the pericardial effusion and improved RV size and function.

DISCUSSION: Pericardial effusions rarely occur after the first year of transplant. The differential for RV failure after a thoracic surgical procedure should include tamponade due to pericardial bleeding or a contained cyst as in this case.

CONCLUSIONS: This is the first reported case of a pericardial cyst causing a functional tricuspid stenosis leading to severe tamponade after lung transplant and decortication.

Reference #1: Kramer et al. Recovery of the right ventricle after single lung transplantation in pulmonary hypertension. The American Journal of Cardiology. 1994, 73(7) 494-500.

DISCLOSURE: The following authors have nothing to disclose: Jonathan Wiesen, Ali Ataya, Marie Budev, David Mason, Charles Lane

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