Medical Image of the Week: Mediastinal Metastases Causing Right Ventricular Outflow Obstruction

Figure 1. Computed tomography (CT) of chest showed large right mediastinal mass (arrow) causing mass effect on the heart.

Figure 2.  Echocardiography showing large extra-cardiac mass (white arrow) compressing on right ventricle and its outflow tract (black arrow).

A 36-year-old man with a history of testicular choriocarcinoma with metastases to the lung presented with a 2-days history of hemoptysis. Initial diagnosis of the malignancy was made about 5 months earlier and he was treated with platinum based chemotherapy with a partial response.

He reported two days of significant hemoptysis, associated with shortness of breath and pleuritic chest pain and rapidly developed acute hypoxic respiratory failure requiring emergent intubation and mechanical ventilation. Computed tomography (CT) of chest showed large right mediastinal mass with diffuse reticular and nodular opacities predominantly in the left lung (Figure 1).

A pulmonary angiogram was performed that showed multiple active bleeding sites in the bronchial arterial system. These were treated with embolization. He developed shock and during investigations the echocardiogram showed a significant compression of the superior vena cava, right atrium and right ventricle by the malignant mass (Figure 2). Despite aggressive therapy and resuscitative therapies he continued to deteriorate and did not survive the hospital stay.

Mediastinal tumors are a rare cause of extrinsic right ventricular outflow tract (RVOT) obstruction. Echocardiography is an important tool in the assessment of hemodynamic effects caused due to such pathology including degree of compression and pressure gradients.

Kai Rou Tey MD¹, Bhupinder Natt MD²

¹Department of Internal Medicine, University of Arizona College of Medicine- South Campus, Tucson, AZ USA

²Division of Pulmonary, Critical Care, Allergy and Sleep, University of Arizona Medical Center, Tucson, AZ USA

Cite as: Tey KR, Natt B. Medical image of the week: mediastinal metastases causing right ventricular outflow obstruction. Southwest J Pulm Crit Care. 2016:12(1):22-3. doi: http://dx.doi.org/10.13175/swjpcc145-15 PDF

Medical Image of the Week: Persistent Left Superior Vena Cava

Figure 1. Left subclavian central line courses in a left paramediastinal location.

Figure 2. Axial CT image of the chest shows a vessel coursing lateral to the aortic arch consistent with a persistent left superior vena cava.

A 19 year old man with acute lymphocytic leukemia was admitted to the ICU with septic shock. Due to areas of cellulitis on the right side of the chest and neck and femoral venous thrombi, a left subclavian central access was attempted. The chest x-ray obtained after line placement is shown below (Figure 1). Blood gas done from the line was consistent with venous blood and venous tranduction was seen. A CT of the chest (Figure 2) confirmed the diagnosis of persistent left superior vena cava (PLSVC).

A persistent left superior vena cava is the most common congenital thoracic venous anomaly, seen in 0.3-0.5% of the population (1). Incidence is increased in patients with congenital heart disease to 5%. In most patients a right sided SVC is also present; hence the term SVC duplication has also been used. Embryologically a PLSVC is formed when the left anterior cardinal vein is not obliterated during fetal development to form the ‘Ligament of Marshall’. It usually drains in to the coronary sinus.

Diagnosis is usually made incidentally on CT scan, echocardiography or,like in our case, after a left sided central access. Practically, its presence may complicate left sided central access including Swan Ganz Catheter placement, implantable cardioverter defibrillator (ICD) placement and during cardiac surgery including during administration of retrograde cardioplegia or cardiac transplant.

Emad Hammode MD¹, Khaled Hamed MD¹, Mohammad Hudeeb MD¹, Veronica Arteaga MD²

¹Department of Internal Medicine

²Department of Thoracic Imaging

University of Arizona Medical Canter

Tucson, AZ

Reference

1. Povoski SP, Khabiri H. Persistent left superior vena cava: review of the literature, clinical implications, and relevance of alterations in thoracic central venous anatomy as pertaining to the general principles of central venous access device placement and venography in cancer patients. World J Surg Oncol. 2011;9:173. [CrossRef] [PubMed]

Reference as: Hammode E, Hamed K, Hudeeb M, Arteaga V. Medical image of the week: persistent left superior vena cava. Southwest J Pulm Crit Care. 2014;9(4):242-3. doi: http://dx.doi.org/10.13175/swjpcc132-14 PDF

Medical Image of the Week: Fontan Procedure

Figure 1. Thoracic CT scan showing Fontan anatomy, with the superior vena cava (SVC) connected to the pulmonary arteries (yellow arrow) and a single atrium and ventricle (red arrow).

Figure 2. SVC venography shows SVC connected to the pulmonary artery.

A 25-year-old man with a history of transposition of the great vessels (L-TGA) was admitted for persistent hemoptysis. He had a history of a double inlet left ventricle, pulmonary hypertension and was postoperative for a Fontan procedure completed at age of 2. No anatomical source for the hemoptysis was found.  A thoracic CT showed the Fontan anatomy: SVC connected to the pulmonary artery as per the Glenn connection (IVC drained to right pulmonary artery through the Fontan pathway) and a single ventricle and atrium (Figure 1). SVC venography showed the SVC connected to the pulmonary artery (Figure 2). The hemoptysis resolved after started sidenafil and bosentan for pulmonary hypertension.

Mohammed Alzoubaidi MD, Carmen Luraschi Monjagatta MD, Maria Tumanik DO, Naomi Jean Young MD

University of Arizona

Department of Pulmonary and Critical Care Medicine

Internal Medicine, South Campus.

Family Medicine, South Campus

Tucson, AZ

Reference as: Alzoubaidi M, Monjagatta CL, Tumanik M, Young NJ. Medical image of the week: Fontan procedure. Southwest J Pulm Crit Care. 2013;7(2):112-3. doi: http://dx.doi.org/10.13175/swjpcc114-13 PDF

Medical Image of the Week: Duplicate Superior Vena Cava

Figure 1. AP chest X-ray demonstrating duplicate superior vena cava (SVC) with central lines in both the right and left superior vena cava (arrows at catheter tips). The chest x-ray shows the characteristic left-sided course of the catheter passing through a persistent left SVC (straight arrow).

Figure 2. Contrast enhanced CT of chest revealing left -sided SVC (arrow).

A persistent left SVC is the most common thoracic venous anomaly and usually opens into the right atrium via the coronary sinus.  A central line inserted into the left SVC may be mistaken for placement in other sites such as the subclavian or carotid artery, the mediastinum, the pericardium or pleural space. A duplicate SVC may cause difficulty in introducing central venous catheters or pulmonary artery catheters because of the narrow opening of the coronary sinus to reach the right atrium. In addition, a duplicate SVC is associated with important cardiac conditions such as atrial septal defects and ventricular arrhythmias.

Dena L’Heureux MD, Josh Malo MD and Linda Snyder MD

Division of Pulmonary, Allergy, Critical Care and Sleep Medicine

University of Arizona

Tucson, AZ

Reference as: L'Heureux D, Malo J, Snyder L. Medical image of the week: duplicate superior vena cava. Southwest J Pulm Crit Care. 2013;6(4):178-9. PDF