A 51-year-old male presented to hospital with hemoptysis. The patient had been diagnosed of coarctation of the aorta and aortic aneurysm distal to the coarctation. In 1998 he underwent surgical correction with a a left subclavian artery bypass to the descending thoracic aorta and the aneurysm was excluded with a dacron graft. He denied hypertension. A thoracic CT performed during this episode, revealed a huge aneurysm in the descending thoracic aorta with a maximal transverse diameter of 13 cm and anteroposterior diameter of 13 cm. The length of the aneurysm was 11.5 cm. Inside the aneurysm there was a big thrombus with several peripheral layers of calcium. The vessel lumen had a diameter of 5.5 cm. The subclavian bypass had no stenosis. The right subclavian artery had an aberrant origen. The aneurysm compressed the left atrium, the left pulmonary artery, left lung tissue and the left main bronchus with a segmentary compressive atelectasis. There was a "ground-glass" pattern in the posterior region of the left superior lobe suggesting pulmonary bleeding. There was no evidence of enlargement of bronchial arteries. Neither were bronchiectasis. Thus, the patient was diagnosed of high suspicion of fistula between aorta and bronchi of the left superior lobe. He was referred to a centre specializing in treatment of coarctation and he was offered a debranching plus TEVAR procedure. Open surgery was not an option due to high risk. The patient refused the intervention. Discussion adults with aortic coarctation should undergo intervention when the gradient across the coarctation is greater than or equal to 20 mmHg and there is hypertension, when there is an altered blood pressure response during exercise or in case of hypertrophic left ventricle. Treatment options are surgery, stent and balloon angioplasty. Complications following intervention include recoarctation, aortic aneurysm, aortic dissection and hypertension. Therefore, it is mandatory to follow up these patients closely and regularly after an intervention either surgical or percutaneous. Digging up in our patient history we found a previous CT in 2009, at that moment transversal diameter of the aneurysm was 9.4 cm and the anteroposterior 12.4 cm. There were no more data after 2009 till 2019. Aortic aneurysms are a rare cause of hemoptysis with a very bad prognosis if not treated. Though CT and MR may suggest that there is a fistula, the aortography is the gold standard technique. Another mechanisms related to hemoptysis are the rupture of small vessels because of the compression of lung tissue or bronchial collapse with subsequent infection. In this case, maybe the big thrombus helped to avoid the rupture of the aneurysm into the left bronchi which would be fatal. Conclusion Patients with repaired coarctation of aorta should be followed regularly, whatever procedure is performed, because some of the complications following repair can have a bad prognosis. Abstract 1109 Figure. hugeaneurysmEuroEcho2019
We present the case of a 63-year old woman with previous history of high-grade liposarcoma. of the lower extremity. She had been treated with radiotherapy and chemotherapy and then she underwent surgical treatment with wide local excision several months ago. She was awaiting a new surgical procedure to remove a right suprarrenal metastasis. The patient presented with lower extremity edema and abdomen and increasing weight in the previuos week. A thoracic and abdominal CT showed the suprarrenal mass had become of greater size. Enlargement of superior vena cava, partial filling defects in several segments of the right lung suggestive of acute pulmonary embolism. Extensive thrombosis from right iliac vein, common iliac vein, intrahepatic cava vein, inferior vena cava, right atrium and right ventricle. Bilateral pleural effusion and ascites. A transthoracic echocardiogram revealed a big mass (6.1 cm) in the right atrium prolapsing into the right ventricle. There was a mean diastolic gradient of 3 mmHg and maximal gradient of 6 mmHg in the tricuspid valve. Left ventricle systolic function was moderately depressed due to abnormal movement of the interventricular septum suggestive of pulmonary hypertension. The clinical course was characterized by rapid deterioration and the patient died from cardiogenic shock. The source of thrombi in the right side of the heart most of the times is venous thrombi that have embolized. Cancer patients have an increased risk of venous thromboembolism compared with the general population. The risk varies depending on the type and the stage of the cancer. Metastatic disease has the highest risk. Most clinically significant pulmonary embolisms originate as venous thromboembolism in the lower extremities or pelvic veins. However in most of the cases it is difficult to image the thrombus "in-transit". In this case the most striking feature is not imaging the thrombus "in-transit" but its massive size. Abstract P1451 Figure. liposarcoma Euro Echo 2019
Background Leftatrial appendageclosure is an alternative to systemic anticoagulation for stroke prevention in appropriate atrial fibrillation patients,however, it is not without complications. Most complications arise during the procedure and in the following days, however they can also be extended over time and therefore, we must be alert. Case summary We present the clinical case of a 68-year-old man admitted to our hospital three weeks after being discharged due to a percutaneous closure of the left appendage complicated with a pericardial tamponade resolved mediated pericadiocentesis with pericarditis clinic with persistent severe pericardial effusion. After a week without being able to remove the drainage tube, he required pericardiotomy due to superinfection with adequate subsequent evolution. In the following weeks he presented a recurrent left pleural effusion that required several evacuating thoracocentesis. After last thoracocentesis, he presented a cardiac perforation showing the catheter lodged in the pulmonary artery in the chest Computed Tomography, so he was again submitted to cardiac surgery for catheter extraction. Finally after stabilization, the patient could be discharged and after 6 months of follow-up he is stable and without new complications. Discussion Post-cardiac injury syndromes is a group of inflammatory pericardial syndromes including post-myocardial infarction pericarditis, post-pericardiotomy syndrome and post-traumatic pericarditis iatrogenic or not, that’s include pericarditis after invasive cardiac interventions. It is presumed that these syndromes have an autoimmune pathogenesis triggered by an initial damage and after a latent period of a few weeks are revealed. Our patient evidence of pericardial effusion with elevated CRP several weeks after a cardiac injury due to perforated during a percutaneous closure of the left appendage complicated with a pericardial tamponade resolved mediated pericadiocentesis. The persistent effusion motivated he imposibility of removed pericadiocentesis tube, and it superinfecction required an urgent pericardiotomy. After pericardial window, the effusion continued into the left pleural. The perforation of cardiac cavities after an evacuatorythoracocentesis is a described but unusual complication that requires surgical removal. Our patient survived a pericardiocentesis, several evacuatorythoracocentesis and two cardiac surgeries, all after a percutaneous closure of the left appendage. Conclusion Any invasive procedure presents a risk of iatrogenic complication, especially in elderly patients with comorbidities. We must be alert and start a treatment as soon as possible to solve the problem. Abstract P1340 Figure. Chest-CT_EECHO2019
Background Fatty masses of the heart are relatively uncommon. This report is about a rare case of extensive fat infiltration along the apical interventricular septum that causes separation of the right ventricular apex from left ventricular apex, simulating a bifid cardiac apex. Case summary The patient was a 58-year-old female who was admitted to the hospital because of palpitations and chest pain. A trasnsthoracic echocardiogram was performed and it showed a thickenned anterior pericardium so a cardiovascular magnetic resonance (CMR) was performed. CMR revealed a large amount of epicardial and pericardial fat without adipose tissue inside the right ventricle wall. In the cardiac apex this fat seemed a lipoma however CMR demonstrated the fat was not capsulated and besides, it extended, as if it were an infiltrative disorder, in the cardiac apex between both ventricles. Patient was discharged with an implantable loop recorder (ILR) in order to ruled out ventricular arrhythmia. During a two year follow-up, ILR has shown several symptomatic supraventricular paroxysmal tachycardia episodes and no other arrhythmic events have been reported. Also, the CMR has been repeated and it has shown similar results. Discussion Fatty masses of the heart are relatively uncommon. Among those masses are included cardiac lipomas, lipomatous infiltration of the right ventricle, arrhythmogenic right ventricular dysplasia (ARVD) and lipomatous hypertrophy of the interatrial septum. The findings in the CMR of our patient do not fulfill the criteria of the aforementioned disorders. Our patient shows a pattern of unusual fatty infiltration pattern of unclear etiology. The prognostic value of this type of heart disease is unknown. In our patient, although the follow-up has not been very long, it does not seem to have had any relevant consequences, so far. Conclusion This is a rare case of a patient with a large amount of epicardial and pericardial fat that seems to infiltrate between both ventricular apex, as a bifid cardiac apex. It is apparently asymptomatic. Abstract 108 Figure. CMR-Cardiac-fatty_EECHO-2019
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