- Email: [email protected]
A Tight Squeeze
JACC: CASE REPORTS
VOL. 1, NO. 1, 2019
ª 2019 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).
IMAGING VIGNETTE CLINICAL VIGNETTE
A Tight Squeeze Focal Tamponade and Obstructive Shock From Esophageal Stenting Deepak Atri, MD,a Claire Shappell, MD,b Paul B. Dieffenbach, MD,b Yee-Ping Sun, MDa
ABSTRACT Cardiac tamponade is a rare cause of shock in the medical intensive care unit. This paper describes the case of a focal cardiac tamponade caused by compression of the left atrium due to an esophageal stent. Echocardiography yielded a diagnosis when other diagnostic methods did not. (Level of Difficulty: Advanced.) (J Am Coll Cardiol Case Rep 2019;1:70–2) © 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A
35-year-old female patient with renal cell carcinoma, metastatic to the mediastinum, and known to have a tracheoesophageal fistula (TEF) due to radiation therapy for superior vena cava (SVC) syndrome, presented for management of aspiration of her TEF, which had been refractory to previous
tracheal stenting. A new Y-tracheobronchial stent was placed on hospital day (HD) 1. Despite this stent, she continued to have symptomatic aspiration through the TEF. She underwent placement of an esophageal stent on HD16 and removal of the tracheobronchial stent on HD17. Twelve hours later, she rapidly developed hypoxia and hypotension, requiring intubation and vasopressors. Following intubation, a chest computed tomography demonstrated new bilateral pleural effusions. The esophageal stent was positioned as endoscopically intended (Figures 1A and 1B). Studies from bilateral thoracenteses were consistent with transudation. Despite fluid resuscitation, antibiotics, and vasopressors, the patient remained hypotensive. Given an unclear precipitant and persistent shock, the cardiology service was consulted. There was no pulsus paradoxus by arterial line. Echocardiography demonstrated left atrial compression by an echogenic structure with central lucency, consistent with the esophageal stent (Figure 1C). The left atrium was nearly collapsed with hyperdynamic biventricular function. There was a small stable pericardial effusion. Hypotension, hypoxemia, and bilateral pleural effusions after tracheal stent removal, combined with echocardiographic findings, raised concern for focal tamponade and obstructive shock physiology. Bedside placement of a Swan-Ganz catheter to define shock physiology could not be performed given SVC stenosis. The gastroenterology service performed emergent esophageal stent removal. Thereafter, her hypotension resolved, and she was extubated. Repeat echocardiography showed resolution of left atrial compression and no evidence of pericardial tamponade (Figure 1D, Video 1).
From the aDepartment of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and the bDepartment of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston Massachusetts. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 10, 2019; revised manuscript received May 9, 2019, accepted May 9, 2019.
ISSN 2666-0849
https://doi.org/10.1016/j.jaccas.2019.05.019
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:70–2
Atri et al.
71
Cardiac Tamponade from the Esophagus
Cardiac tamponade is an uncommon cause of shock. Echocardiography served as a tool to exhaustively evaluate cardiogenic and obstructive shock causes. Left atrial compression and findings of acute left heart failure (pleural effusions) with normal biventricular function suggested the diagnosis of obstructive shock from focal tamponade. The patient was predisposed to left atrial compression, given her mediastinal lymphadenopathy and radiation fibrosis. The causality between tracheal stent removal and her decompensation remained unclear; however, it was evident that the esophageal stent mediated obstruction, given her improvement after its removal. The physical findings of pericardial tamponade as a cause for shock, such as pulsus paradoxus, distended neck veins, and distant heart sounds were obfuscated by mechanical ventilation (1). It is unclear whether these findings are useful in focal tamponade. This case relates a rare complication of esophageal stent placement (2). We believe it proves instructive, as more patients are surviving with advanced malignancy and receiving a variety of endoscopic therapies.
F I G U R E 1 Chest CT and Echocardiography Findings
(A) Axial and (B) Sagittal views demonstrate left atrial compression by the esophageal stent (red arrowheads). Pleural effusions are shown (blue arrowheads). Echocardiography demonstrates left atrial compression by the esophageal stent (C) and improvement after stent was removed (D). Also see Video 1. CT ¼ computed tomography; ES ¼ esophageal stent; LA ¼ left atrium; LV ¼ left ventricle; RA ¼ right atrium; RV ¼ right ventricle.
72
Atri et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:70–2
Cardiac Tamponade from the Esophagus
ADDRESS FOR CORRESPONDENCE: Dr. Deepak Atri, Department of Medicine, Division of Cardiovascular
Medicine, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115. E-mail: [email protected]. Twitter: @DeepakAtriMD.
REFERENCES 1. Faehnrich JA, Noone RB Jr., White WD, et al. Effects of positive-pressure ventilation, pericardial effusion, and cardiac tamponade on respiratory variation in transmitral flow velocities. J Cardiol
2. Sganzerla P, Passaretti B, Perlasca E, Giovannelli A. An unusual case of acute fatal pulmonary congestion: oesophageal stenting. Int J Cardiol 2007;117:e64–5.
KEY WORDS renal cell carcinoma, tracheoesophageal fistula, transthoracic echocardiography
Vasc Anesth 2003;17:45–50. AP PE NDIX For a supplemental video, please see the online version of this paper.
VOL. 1, NO. 1, 2019
ª 2019 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).
IMAGING VIGNETTE CLINICAL VIGNETTE
A Tight Squeeze Focal Tamponade and Obstructive Shock From Esophageal Stenting Deepak Atri, MD,a Claire Shappell, MD,b Paul B. Dieffenbach, MD,b Yee-Ping Sun, MDa
ABSTRACT Cardiac tamponade is a rare cause of shock in the medical intensive care unit. This paper describes the case of a focal cardiac tamponade caused by compression of the left atrium due to an esophageal stent. Echocardiography yielded a diagnosis when other diagnostic methods did not. (Level of Difficulty: Advanced.) (J Am Coll Cardiol Case Rep 2019;1:70–2) © 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A
35-year-old female patient with renal cell carcinoma, metastatic to the mediastinum, and known to have a tracheoesophageal fistula (TEF) due to radiation therapy for superior vena cava (SVC) syndrome, presented for management of aspiration of her TEF, which had been refractory to previous
tracheal stenting. A new Y-tracheobronchial stent was placed on hospital day (HD) 1. Despite this stent, she continued to have symptomatic aspiration through the TEF. She underwent placement of an esophageal stent on HD16 and removal of the tracheobronchial stent on HD17. Twelve hours later, she rapidly developed hypoxia and hypotension, requiring intubation and vasopressors. Following intubation, a chest computed tomography demonstrated new bilateral pleural effusions. The esophageal stent was positioned as endoscopically intended (Figures 1A and 1B). Studies from bilateral thoracenteses were consistent with transudation. Despite fluid resuscitation, antibiotics, and vasopressors, the patient remained hypotensive. Given an unclear precipitant and persistent shock, the cardiology service was consulted. There was no pulsus paradoxus by arterial line. Echocardiography demonstrated left atrial compression by an echogenic structure with central lucency, consistent with the esophageal stent (Figure 1C). The left atrium was nearly collapsed with hyperdynamic biventricular function. There was a small stable pericardial effusion. Hypotension, hypoxemia, and bilateral pleural effusions after tracheal stent removal, combined with echocardiographic findings, raised concern for focal tamponade and obstructive shock physiology. Bedside placement of a Swan-Ganz catheter to define shock physiology could not be performed given SVC stenosis. The gastroenterology service performed emergent esophageal stent removal. Thereafter, her hypotension resolved, and she was extubated. Repeat echocardiography showed resolution of left atrial compression and no evidence of pericardial tamponade (Figure 1D, Video 1).
From the aDepartment of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and the bDepartment of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston Massachusetts. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 10, 2019; revised manuscript received May 9, 2019, accepted May 9, 2019.
ISSN 2666-0849
https://doi.org/10.1016/j.jaccas.2019.05.019
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:70–2
Atri et al.
71
Cardiac Tamponade from the Esophagus
Cardiac tamponade is an uncommon cause of shock. Echocardiography served as a tool to exhaustively evaluate cardiogenic and obstructive shock causes. Left atrial compression and findings of acute left heart failure (pleural effusions) with normal biventricular function suggested the diagnosis of obstructive shock from focal tamponade. The patient was predisposed to left atrial compression, given her mediastinal lymphadenopathy and radiation fibrosis. The causality between tracheal stent removal and her decompensation remained unclear; however, it was evident that the esophageal stent mediated obstruction, given her improvement after its removal. The physical findings of pericardial tamponade as a cause for shock, such as pulsus paradoxus, distended neck veins, and distant heart sounds were obfuscated by mechanical ventilation (1). It is unclear whether these findings are useful in focal tamponade. This case relates a rare complication of esophageal stent placement (2). We believe it proves instructive, as more patients are surviving with advanced malignancy and receiving a variety of endoscopic therapies.
F I G U R E 1 Chest CT and Echocardiography Findings
(A) Axial and (B) Sagittal views demonstrate left atrial compression by the esophageal stent (red arrowheads). Pleural effusions are shown (blue arrowheads). Echocardiography demonstrates left atrial compression by the esophageal stent (C) and improvement after stent was removed (D). Also see Video 1. CT ¼ computed tomography; ES ¼ esophageal stent; LA ¼ left atrium; LV ¼ left ventricle; RA ¼ right atrium; RV ¼ right ventricle.
72
Atri et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:70–2
Cardiac Tamponade from the Esophagus
ADDRESS FOR CORRESPONDENCE: Dr. Deepak Atri, Department of Medicine, Division of Cardiovascular
Medicine, Brigham and Women’s Hospital and Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115. E-mail: [email protected]. Twitter: @DeepakAtriMD.
REFERENCES 1. Faehnrich JA, Noone RB Jr., White WD, et al. Effects of positive-pressure ventilation, pericardial effusion, and cardiac tamponade on respiratory variation in transmitral flow velocities. J Cardiol
2. Sganzerla P, Passaretti B, Perlasca E, Giovannelli A. An unusual case of acute fatal pulmonary congestion: oesophageal stenting. Int J Cardiol 2007;117:e64–5.
KEY WORDS renal cell carcinoma, tracheoesophageal fistula, transthoracic echocardiography
Vasc Anesth 2003;17:45–50. AP PE NDIX For a supplemental video, please see the online version of this paper.