Adi Osman, Fong Chan Pei, Ahmad Azma Haryaty, Panebianco Nova
Department, Hospital Raja Permaisuri Bainun, Ipoh, PRK, Malaysia.
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Eur Heart J Case Rep. 2022 Aug 5;6(8):ytac329. doi: 10.1093/ehjcr/ytac329. eCollection 2022 Aug.
Mediastinal mass is an entity with variable pathology and clinical spectrum. Anterior mediastinal mass can result in severe symptoms due to involvement of surrounding vital structures such as the great vessels, trachea-bronchial tree, and heart. We highlight a case of cardiac tamponade in a patient with an anterior mediastinal mass that was paradoxically worsened after decompressive pericardiocentesis.
A 21-year-old male presented to the emergency department (ED) with breathlessness and hypotension. Bedside focused cardiac ultrasound revealed cardiac tamponade which was made worse with an anterior mediastinal mass compressing the right heart chambers. The patient was intubated for respiratory failure, following which an ultrasound-guided pericardiocentesis was performed. Unexpectedly, his hemodynamic status worsened after aspiration of 1000 mL of pericardial fluid. A repeat focused cardiac ultrasound showed reduced pericardial effusion, but worsening of right heart chambers compression by the mediastinal mass. Re-expansion of the pericardium space with 600 mL of normal saline improved the patient's vital signs, and reduced the right heart compression. Computed tomography was deferred due to the patient's hemodynamic instability. Despite resuscitation with fluids and initiation of vasopressor, the patient's condition deteriorated. He succumbed to his illness due to obstructive shock causing multi-organ failure. The autopsy showed a large anterior mediastinal mass, and histopathological examination confirmed the diagnosis of lymphoma.
This case demonstrated the therapeutic challenges of managing a shock patient with anterior mediastinal mass, and massive pericardial effusion causing cardiac tamponade.
纵隔肿物是一种病理和临床谱各异的疾病。前纵隔肿物可因累及周围重要结构，如大血管、气管支气管树和心脏，而导致严重症状。我们着重介绍一例前纵隔肿物患者发生心脏压塞的病例，该患者在进行减压心包穿刺术后病情反而恶化。
一名21岁男性因呼吸困难和低血压被送往急诊科。床旁心脏超声检查显示存在心脏压塞，且前纵隔肿物压迫右心腔使病情加重。患者因呼吸衰竭行气管插管，随后进行了超声引导下的心包穿刺术。出乎意料的是，抽出1000毫升心包积液后，他的血流动力学状态恶化。再次进行的床旁心脏超声检查显示心包积液减少，但纵隔肿物对右心腔的压迫加重。注入600毫升生理盐水使心包腔重新扩张，改善了患者的生命体征，并减轻了对右心的压迫。由于患者血流动力学不稳定，计算机断层扫描检查被推迟。尽管进行了液体复苏并开始使用血管升压药，但患者的病情仍恶化。他因梗阻性休克导致多器官衰竭而死亡。尸检发现一个巨大的前纵隔肿物，组织病理学检查确诊为淋巴瘤。
本病例展示了治疗伴有前纵隔肿物和大量心包积液导致心脏压塞的休克患者所面临的挑战。
