P001: PERICARDIAL WINDOW: AN APERTURE TO ETIOLOGY OF ANEMIA
Harrison I Dermer; Harish Ram; University of Miami
Cardiac masses cause significant morbidity and mortality, with direct effects including chamber or valvular flow impedance from mechanical obstruction, or the development of arrhythmias. While primary cardiac neoplasm may occur, secondary metastases to the heart are most commonly observed in adults. Cardiac tamponade, in which a pericardial effusion restricts adequate ventricular filling, is a common and potentially lethal presenting sign. Thus, it is important to maintain clinical suspicion for cardiac mass in a patient with pericardial effusion in the context of additional symptoms concerning for malignancy. Imaging modalities are invaluable for presumptive diagnosis in this scenario due to the risks associated with direct myocardial tissue biopsy.
We present a case of a 48-year-old female with a history of fatigue. Her past medical history was significant for lymphoma treated in the past. Work up showed a pelvic mass in addition to a moderate size pericardial effusion and was scheduled for creation of pericardial window. Other significant findings included leukopenia, ascites, and sinus tachycardia. No significant peripheral edema or respiratory distress were observed.
After arterial line placement and intravenous induction was performed. She became hypotensive immediately post induction responsive to fluid + norepinephrine bolus, and norepinephrine infusion (3mcg/min) to maintain MAP>65mmHg. Intraoperative TEE redemonstrated the moderate size pericardial effusion in addition to ascites and bilateral pleural effusions. Non homogenous dense layering was noted surrounding the structures of base of the heart, suggesting of an infiltrative process. A presumptive diagnosis of cardiac metastasis was made. Surgical evacuation of 250cc serous fluid from the pericardial space resulted in echocardiographic resolution of the effusion and she was noted to have normal biventricular function with no valve abnormalities post procedure. Hemodynamic stability was maintained after discontinuation of vasopressor support. Emergence and extubation in the OR were uneventful despite persistent sinus tachycardia. Postoperatively the patient was transferred to ICU and pathologic result from biopsy of her mass confirmed primary diffuse large B cell lymphoma. Cytology results from intraoperative pericardial fluid sample is still pending.
This case highlights an instance of secondary cardiac malignancy discovered by intraoperative TEE in a patient who presented with fatigue thought to be secondary to anemia and nonspecific symptoms. Chest imaging revealed pericardial effusion with no suspicion for cardiac mass. It is imperative to maintain suspicion for cardiac mass for prompt diagnosis and delivery of targeted management in a situation such as this. Given the anatomic distortion of her right atrium, superior vena cava syndrome should be anticipated. It is also important to rule out clinical masquerades such as thrombus, which may be seen in patients with hypercoagulability or may also present concomitantly with a cardiac mass.