Unilateral pulmonary venous occlusion caused by a localized pericardial clot
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IMAGING IN INTENSIVE CARE MEDICINE
Unilateral pulmonary venous occlusion caused by a localized pericardial clot Sundar Krishnan* , Matthew J. Maxwell and Brett A. Myers © 2018 Springer-Verlag GmbH Germany, part of Springer Nature and ESICM
On postoperative day 1 after bioprosthetic aortic valve replacement and coronary artery bypass grafting, a 53-year-old man suffered cardiac arrest requiring chest compressions. This was followed by an increase in oxygen requirement. Chest X-ray revealed early signs of unilateral pulmonary edema (Fig. 1a). On transesophageal echocardiography (TEE) a clot was visualized in the transverse sinus, with lateral and posterior extension of the clot causing compression of the left atrial appendage (LAA). Turbulent flow was noticed in the left upper pulmonary vein (LUPV) on color Doppler, with peak velocities of 160 cm/s on pulse wave Doppler
(Fig. 1b). On mediastinal exploration, approximately 15 ml of clot was found around the left pulmonary veins, behind the LAA, and adherent to the distal anastomosis on the ramus intermedius. After clot removal, the LUPV and the LAA were more clearly visualized, and the clot burden in the transverse sinus was significantly reduced. Blood flow in the LUPV was laminar, with a peak velocity of 90 cm/s (Fig. 1c). A localized pericardial clot causing pulmonary venous compression can lead to unilateral pulmonary edema. Unilateral pulmonary edema can also occur as a result of
Fig. 1 a Chest X-ray showing increased opacification on the left side. Pulse-wave Doppler interrogation of left upper pulmonary venous inflow b prior to and c after pericardial clot evacuation
*Correspondence: sundar‑[email protected] Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA
pulmonary venous occlusion through thrombosis, constriction after ablation, or fibrosing mediastinitis. Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00134-018-5184-y) contains supplementary material, which is available to authorized users. Author contributions SK: manuscript preparation and review. MJM: manuscript preparation and review. BAM: manuscript preparation and review.
Compliance with ethical standards Conflicts of interest Sundar Krishnan reported no conflicts of interest. Matthew J Maxwell reported no conflicts of interest. Brett A Myers reported no conflicts of interest. Received: 5 April 2018 Accepted: 12 April 2018
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