SESSION TITLE: Disorders of the Mediastinum Student/Resident Case Report Posters
SESSION TYPE: Student/Resident Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Hypotension and shock can result from multiple causes, including hypovolemia, low effective circulating volume due to peripheral vasodilation, and poor cardiac contractility due to intrinsic heart disease or external compression. If not identified promptly and managed aggressively, poor outcomes can ensue.
CASE PRESENTATION: 73 year-old male with past medical history of coronary artery disease s/p coronary artery bypass grafting 1 year prior presented with 1 week of progressive shortness of breath and weakness. One week previously he had been diagnosed with left pleural effusion at an outside hospital. On evaluation he was noted to be significantly hypotensive with an initial blood pressure of 66/42. The patient required aggressive fluid management and vasopressor support. CT scan of the chest showed re-accumulation of the left pleural effusion as well as a 6.3 x 8.4 x 3.7 cm anterior mediastinal mass with right ventricular compression. Transthoracic echocardiogram also showed right ventricle compression due to anterior mediastinal mass but no tamponade. CTA showed invasion of the pulmonary artery by the mass; it also surrounded the LIMA graft from previous bypass surgery. The patient underwent CT guided biopsy with pathology confirming a high grade T cell non-Hodgkin lymphoma. Due to pulmonary artery invasion and LIMA graft involvement, surgical decompression was ruled out. He received 1 cycle of CHOP which demonstrated tumor size reduction; however DIC developed and the recurrent left effusion became hemorrhagic, leading to both cardiogenic and hypovolemic shock and eventual death.
DISCUSSION: Right ventricular compression causing tamponade physiology has been described in cardiothoracic literature with case reports of hematomas causing shock that resolves after surgical intervention. Both echocardiogram and CT scan are useful modalities in identifying ventricle compression and clarifying the etiology. In this case, echocardiogram could not rule out ventricular invasion and CTA proved useful in delineating mass involvement and etiology. Unfortunately surgery could not be attempted but early use of chemotherapy was used to reduce tumor size with evidence of reduction on a follow up CT scan.
CONCLUSIONS: Rapid identification of shock etiology is critical to early aggressive intervention. In cases of external compression causing tamponade physiology, reversal of compression through surgical or non-surgical intervention is key to improving survival outcomes.
Reference #1: Alsafwah S, Minderman D, Mallisho M, Munir A. Mediastinal hematoma causing compression of the right ventricular outflow tract - the role of transthoracic echocardiography in diagnosis. The Canadian Journal of Cardiology. 2008;24(8):644.
Reference #2: Choia SY, Kim YH, Kwon JB, Park CB. Extrapericardial cardiac tamponade by a retrosternal haematoma after blunt chest trauma. European Journal of Cardiothoracic Surgery (2012) 41 (4): 958.
DISCLOSURE: The following authors have nothing to disclose: Nicole Quenelle
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