Chest X-ray showed moderate right-sided pleural effusion and suggested a peri- .... compression against calcified atherosclerotic plaques. Attempted forceful ...
A mass inside your heart: don’t forget the unexpected
diagnosis confirmed the HD. The postoperative period was uneventful. Albendazole treatment was completed over a total of eight weeks. After six months of follow-up, the patient showed neither clinical nor radiological signs of relapse. Hydatid cyst in the diaphragm should always be considered in the differential diagnosis of pericarditis or pericardial effusion, especially in regions where hydatid disease is endemic.
951 Idiopathic giant subaortic left ventricular aneurysm causing extrinsic compression of left coronary circulation and right pulmonary artery P. Barwad, A. Dubey, S.S. Kothari, V. Devagourou, V.K. Bahl. All India Institute of Medical Sciences (AIIMS), New Delhi, India Introduction: Myocardial infarction, dilated cardiomyopathy, sarcoidosis, Chaga’s disease and myocarditis are recognized causes of left ventricular (LV) aneurysm. Idiopathic LV aneurysms are rare and we describe here one of its rare presentation. Case report description: A 45 year male presented with exertional angina for the past 1 year, with acute exacerbation since one day. His electrocardiogram (ECG) showed ST depression in infero-lateral leads and elevation in lead aVR and V1. Troponin I was negative with cardiomegaly on chest radiograph. Echocardiogram showed enlarged LV with hypokinesia involving antero-lateral wall, LV ejection fraction was 35%. Additionally there was a narrow neck aneurysm arising from the LV outflow tract which was multilobulated and extended anterosuperiorly and laterally causing dynamic compression of right pulmonary artery (RPA). CT angiography also showed similar findings. Coronary angiogram showed severe external compression of left main coronary artery extending up-to mid part of left anterior descending artery and proximal part of left circumflex artery. Surgical aneurysmectomy was done which normalized the LV function on follow up, but residual aneurysm persists requiring a redo surgery.
1125
and develops in the early postoperative period. The management of ascending aortic pseudoaneurysm remains a challenge. Surgery has a high mortality, mainly due rupture of the pseudoaneurysm at the time of sternotomy. Percutaneous closure, which does not require sternotomy or extra-corporeal circulation, may have lower morbidity and mortality, but is not frequently performed . Unlike the distal aortic arch or descending aorta, the ascending aorta is not suitable for treatment with endografts, due to its larger dimensions and proximity of the coronary arteries. The take home message of this case is that contrast echocardiography is a powerful modality for accurate diagnosis of aortic syndromes. It was the contrastenhanced echo images, rather than the CT, that gave us confidence to proceed to percutaneous closure (a disastrous option in a dissection, which CT could not exclude convincingly).
953 Near-syncope due to extra-cardiac mass compressing the right atrium: an unusual presentation of a penetrating atherosclerotic ulcer with intramural hematoma of the ascending aorta K.D. Sjauw, M. Groenink, H.L. Tan. Academic Medical Center, University of Amsterdam, Department of Cardiology, Amsterdam, Netherlands Introduction: Due to progressive developments and availability of imaging modalities as CT and MRI, penetrating atherosclerotic ulcer (PAU) with or without aortic intramural haematoma (IMH) has been accepted as an increasingly recognised and potentially fatal entity within the spectrum called acute aortic syndrome (AAS). Case report description: A 71-year old woman without cardiac medical history presented to the Chest Pain Unit (CPU) after near-syncope due to low thoracic chest pain radiating to the right shoulder. Blood pressure was 96/70 mmHg. The electrocardiogram (ECG) showed sinus rhythm (83 bpm) and diffuse aspecific ST-segment abnormalities. Rhythm monitoring and an acute coronary syndrome rule out protocol were started. During monitoring episodes of atrial tachycardia (140-150 bpm) were observed, accompanied by blood pressure drops (70/35 mmHg) and ECG changes suspect of ischemia. Echocardiography remarkably revealed an obliterating left ventricle due to impeded preload caused by almost complete compression of the right atrium by an extra-cardiac mass. A CT scan was performed which surprisingly showed a PAU with IMH (from aortic root to bracheocephalic trunk) and extensive pericardial effusion and thrombus. The patient underwent emergency cardiac surgery, i.e. pericardial thrombus removal, and supracoronary ascending aorta replacement.
Figure 1
Discussion: Idiopathic LV aneurysm is rare, but well recognized. It usually presents as ventricular tachyarrhythmias or sudden cardiac death. In our patient a giant multilobulated subaortic aneurysm caused extrinsic compression of RPA and left coronary circulation leading to angina. Normalization of LV function at followup suggests relief of external compression of the coronaries. Conclusion: We present here the first case report of a large idiopathic subaortic left ventricular aneurysm causing extrinsic compression of left coronary circulation and RPA manifesting as coronary artery disease. Figure 1
952 Post-surgical ascending aorta pseudoaneurysm: a diagnostic and treatment challenge M.M. Gurzun 1 , A. Ionescu 2 . 1 Emergency Institut of Boli Cardiovasculare "C.C. Iliescu", Bucharest, Romania; 2 Regional Cardiac Centre Morriston Hospital, Swansea, United Kingdom A 58 year old man with severe symptomatic left main stenosis and severe aortic regurgitation had uneventful urgent coronary artery by-pass grafting and aortic valve replacement. Eight months later he was re-admitted with severe central chest pain. Electrocardiogram and blood tests (including troponin) were normal but chest X-ray demonstrated widened mediastinum. Cardiac CT (128-slice) showed a large periaortic collection with contrast extravasation and communicating with the ascending aorta. The radiologist felt the appearances were compatible with aortic dissection, but could not conclusively rule out a pseudoaneurysm. Transthoracic echocardiogram (TTE) showed an echo-free space behind the aortic root, with a thick wall and communicating with the aortic lumen. With intravenous transpulmonary contrast a cavity "wedged" between the posterior wall of the ascending aorta and the anterior wall of left atrium was clearly demonstrated. It became clear there was a narrow "neck" of the cavity, through which contrast could be seen streaming into the cavity, appearances diagnostic of an aortic pseudoaneurysm. Surgery was deemed to carry an unacceptably high risk, so percutaneous closure of the pseudoanurysm was performed, via the right femoral approach. An aortogram confirmed the pseudoaneurysm and an Amplatzer occluder was delivered to seal its ostium, followed by coil embolisation of the residual cavity. A final aortogram showed a stable device and total exclusion of pseudoaneurysm. The patient was discharged uneventfully and is well at 1year follow-up. The case illustrates a very rare late complication after aortic valve replacement. It is generally associated with composite grafts (valve and conduit)
Conclusion/Implications: Atypical symptoms and signs often hamper the diagnosis of an AAS, especially PAU and IMH. Since the prognosis in AAS depends on undelayed diagnosis and (often surgical) treatment, prompt diagnostic imaging is a conditio sine qua non. As for acute coronary syndromes, CPU’s with quick access to imaging modalities as CT and MRI, rather than general ER, may be best suited for swift and accurate evualution of these challenging cases.
954 Cardiac angiosarcoma with the presence of mycobacterium tuberculosis complex genetic material J.A. Sleszycka 1 , A. Sioma 1 , L. Mazurkiewicz 1 , A. Klisiewicz 2 , I. Michalowska 3 , S. Kocanda 4 , E. Walczak 5 , R. Langfort 6 , A. Klimczak 7 , J. Grzybowski 1 . 1 Institute of Cardiology, Department of Cardiomyopathies, Warsaw, Poland; 2 Institute of Cardiology, Echocardiography Department, Warsaw, Poland; 3 Institute of Cardiology, Department of Radiology, Warsaw, Poland; 4 Institute of Cardiology, Department of Cardiosurgery and Transplantology, Warsaw, Poland; 5 Institute of Rheumatology, Laboratory of Patomorphology, Warsaw, Poland; 6 Institute of Tuberculosis and Lung Diseases, Laboratory of Patomorphology, Warsaw, Poland; 7 Institute of Oncology, Warsaw, Poland Introduction: Primary cardiac angiosarcoma is a rare malignant tumour originates predominantly from the right side of the heart. Rapid clinical course and unfavourable outcome are expected. Among from several risk factors for thoracic angiosarcoma chronic post-tuberculosis pleurisy was postulated. Case report description: 38 year-old male with 3 months history of precordial pain and progressive fatigue was referred to the Department of Cardiomyopathies (DC). He had been diagnosed with acute pericarditis in another hospital a month
Downloaded from https://academic.oup.com/eurheartj/article-abstract/34/suppl_1/954/2863689/Cardiac-angiosarcoma-with-the-presence-of by guest on 24 August 2017
1126
A mass inside your heart: don’t forget the unexpected / Cath lab disasters – the interventionalists’ nightmares!
before. Nonsteroidal anti-inflammatory drugs and heart failure treatment had improved the disease symptoms then. He reported one week hectic fever on admission to DC. A dull percussion note and reduced vesicular breath sounds over the basal field of the right lung were found. Inflammatory markers were elevated. Chest X-ray showed moderate right-sided pleural effusion and suggested a pericardial effusion. Moreover, echocardiogram revealed a solid mass close to the right atrium. Bloody fluid was obtained through pericardiocentesis, no atypical cells were found. Cardiac magnetic resonance and chest computed tomography suggested a malignant process of pericardium close to the right atrium and right ventricle. During on-pump cardiac surgery the tumour originating from the right atrium was removed. Focal involvement of right ventricle precluded a complete tumour resection. Angiosarcoma was identified in pathological examination. Though genetic material of Mycobacterium tuberculosis complex was present in the tumour tissue, no granulomas were found. Bacteriological culture of tissue was negative. Patient received doxorubicin-based chemotherapy with no satisfactory response. Due to numerous brain metastases he required palliative radiotherapy 3 months after the surgery. Discussion: We describe the first case of Mycobacterium tuberculosis complex genetic material presence in cardiac angiosarcoma tissue, according to our knowledge. We excluded active tuberculosis in our patient and referred him for chemotherapy. However it has been already reported, seeming improvement after anti-inflammatory treatment is not characteristic of angiosarcoma. It caused a delay in the correct diagnosis of described patient. Conclusions: Although primary cardiac tumours are extremely rare, they should be considered in differential diagnosis of pericardial fluid. Tuberculosis may be deliberated as a risk factor for cardiac angiosarcoma in further research.
955 A cystic lesion encases the right coronary artery C.-W. Lee, H.H. Chang, A.H. Yang, W.C. Yu. Taipei Veterans General Hospital, Taipei, Taiwan Case report description: A 75-year-old man presented to our department with incidental finding of pericardial effusion. He suffered from general malaise and body weight loss in recent 3 months. He had chronic hepatitis B and an abdominal computed tomography (CT) disclosed a new soft tissue nodule 1.7x1.3 cm in size over the S7 of liver and pericardial effusion. A transthoracic echocardiography showed a cyst-like lesion about 2.6x2.9 cm over right atrioventricular (AV) groove and moderate pericardial effusion. (Panel A and B) The patient received subsegmentectomy of liver and the pathology was compatible with hepatocellular carcinoma. A follow-up echocardiography showed progression of the lesion one month later. A cardiac CT disclosed a soft tissue mass spreading along the right AV groove and encasing the right coronary artery (RCA). (Panel D) A positron emission tomography (PET) scan disclosed increase of radiolabeled 18F-2-fluoro-deoxy-D-glucose uptake along the right AV groove. (Panel C) Hence, video-assisted thoracoscopic biopsy was done and the pathology findings were compatible with diffuse large B cell lymphoma. (Panel D and E) The patient was diagnosed as primary cardiac lymphoma (PCL) and received chemotherapy. A follow-up echocardiography showed markedly decrease of the tumor size 3 months after chemotherapy. (Panel G and H) Conclusion: Our case presented as hepatic nodule and cystic lesion encasing RCA with pericardial effusion, and
finally diagnosed as double cancers, namely hepatocellular carcinoma and PCL. This case reminds us that an aggressive work-up can help a patient with unexplained intra-cardiac mass and pericardial effusion.
CATH LAB DISASTERS – THE INTERVENTIONALISTS’ NIGHTMARES! 1704 A successful percutaneous removal of a ruptured and detached intra-aortic balloon pump with vascular entrapment S. Chatzikyriakou, P. Georgiadou, J. Malakos, N. Doulas, T. Kousi, V. Voudris. Onassis Cardiac Surgery Center, 2nd Department of Cardiology, Athens, Greece Introduction: Intra-aortic balloon pump (IABP) rupture and entrapment is a rare complication which may necessitate major surgery. Case report description: A 74 years old man was admitted to our hospital for coronary angiography (CA) after successfull rescucitation. The CA revealed a 95% left main stenosis with an occluded first obtuse marginal branch and an occluded right coronary artery. Emergent coronary artery bypass grafting was performed. The patient remained stable under the support of IABP (7Fr 40cc RediGuard IAB, Arrow International Inc. USA) until the fourth post-operative day, when a dysfunction of the IABP was noted. After several attempts to remove IABP at the patient’s bedside, urgent fluoroscopy performed and showed the detached tip of intra-aortic balloon at the proximal third of the right common iliac artery (RCIA) and the IABP catheter shaft more distal. Left brachial artery (LBA) aortography revealed total occlusion of the RCIA. A pediatric balloon (8mm x 30mm Opta Pro Balloon,Cordis, Miami, FL) was advanced through the LBA to the proximal level of the RCIA, which was dilated and thus, facilitated IABP removal. Although no arterial dissection or rupture was observed, occlussive thrombi were visualized through the RCIA. Despite multiple dilatations with the balloon, total occlusion of RFA was ultimately demonstrated. Surgical thrombectomy was then, performed to restore patency and blood flow.
Figure 1. Procedure and findings of IABP removal
Discussion: A plausible mechanism for balloon rupture and thrombosis is its compression against calcified atherosclerotic plaques. Attempted forceful extraction or IABP technical deffect may have contributed to the detachment of the balloon from IABP catheter shaft. Conclusion: Percutaneous interventions may resolve successfully vascular complications during IABP support.
1705 A case of coronary-subclavian steal in patient with a history of coronary artery bypass grafting and carotid-subclavian bypass E.A. Surkova, A.N. Vachev, V.V. Suhorukov, O.V. Dmitriev, O.V. Tereshina, M.U. Stepanov, E.A. Golovin. Samara State Medical University, Samara, Russian Federation
Figure 1
Introduction: A coronary-subclavian steal phenomenon was described in patients who have undergone prior bypass surgery using the left internal mammary artery (LIMA). Case report description: A 74-year-old male with a prior 3-vessel coronary artery bypass grafting (CABG) in 2005 was admitted to the hospital with the deteriorating condition over the last four months. He had complaints of exertional chest pain which was usually gone upon taking nitroglycerin. He had a history of carotid-subclavian bypass in 1995. His prior CABG included LIMA graft to the left anterior descending artery (LAD), saphenous vein graft (SVG) to the obtuse marginal (OM), and SVG to posterior descending artery (PDA). On admission, right arm blood pressure (BP) was 130/80 mm Hg, left arm BP was 80/60 mm Hg. Initial echocardiogram showed left ventricle (LV) ejection fraction of 53%. Stressechocardiography was positive and demonstrated wall motion abnormalities in septal, antero-septal and anterior segments of LV. Duplex ultrasound revealed bilateral carotid stenosis of 55%, left subclavian artery subocclusion and stenosis of carotid-subclavian graft with maximal linear flow velocity up to 3.5 m/sec. Nevertheless both vertebral arteries had antegrade flow. Using cardiac catheterization severe 3-vessel coronary artery disease was diagnosed but PDA and OM SVG grafts and LIMA graft were patent. Angiography showed a severe stenosis of 95% of proximal left subclavian artery, stenosis of 59% of carotid-subclavian graft. LIMA graft had retrograde flow to the left subclavian artery and the first
Downloaded from https://academic.oup.com/eurheartj/article-abstract/34/suppl_1/954/2863689/Cardiac-angiosarcoma-with-the-presence-of by guest on 24 August 2017
