• Echocardiography can demonstrate hepatic cyst–induced right atrial compression. • Hepatic cyst–induced blood flow stasis can cause internal jugular venous thrombus. • Laparoscopic deroofing of hepatic cysts is a safe and effective treatment

Bui, Quoc

Le, Tuyen V

Ngo, Tam N M

Nguyen, Duc H

Palmer, Cassady

Truong, Thai

Truong, Vien T

English

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Washington University School of Medicine Digital Commons@Becker 2020-Current year OA Pubs Open Access Publications 6-1-2021 A case of hepatic cyst-induced internal jugular venous thrombosis Tuyen V Le Thai Truong Tam N M Ngo Quoc Bui Cassady Palmer See next page for additional authors Follow this and additional works at: https://digitalcommons.wustl.edu/oa_4 Authors Tuyen V Le, Thai Truong, Tam N M Ngo, Quoc Bui, Cassady Palmer, Vien T Truong, and Duc H Nguyen A Case of Hepatic Cyst–Induced InternalJugular Venous ThrombosisTuyen V. Le, MD, Thai Truong, MD, Tam N. M. Ngo, MD, Quoc Bui, MD,Cassady Palmer, BS, MD, Vien T. Truong, MD, and Duc H. Nguyen, MD, Dong Ha and Ho ChiMinh City, Vietnam; St. Louis, Missouri; Cincinnati, OhioINTRODUCTIONWe report a case of hepatic cyst–induced cardiac complication.Multiple hepatic and renal cysts were visualized on abdominalcomputed tomography in a 69-year-old male patient. One of themassive hepatic cysts was seen compressing the right atrium, leadingto superior vena cava (SVC) syndrome and right internal jugularvenous thrombi. The patient presented with headache and right-sidedneck and bilateral upper extremity edema for 1 month. These symp-toms diminished following hepatic cyst deroofing accompanied bylong-term anticoagulant therapy. To our knowledge, this is the firstcase report of SVC syndrome and right internal jugular venousthrombi that resulted from hepatic cyst–induced blood flow stasis.CASE PRESENTATIONA 69-year-old man was admitted to the hospital for right-sided neckand bilateral upper extremity edema and headache for 1 month.Vital signs showed a heart rate of 70 beats/min, arterial blood pressureof 120/70 mm Hg, a respiratory rate of 20 breaths/min, and bodytemperature of 37C. Physical examination revealed swelling alongthe anterior border of the right sternocleidomastoid muscle anddistension of the right jugular vein (Figure 1). Chest and cardiac phys-ical examination were unremarkable. He had no history of tobacco orintravenous drug use. Abnormal laboratory findings included a highserum level of total bilirubin (23 mg/L), direct bilirubin (6.2 mg/L),and indirect bilirubin (16.8 mg/L). Results of complete blood count,renal function analysis, liver function analysis, coagulation test, andelectrocardiography were within normal limits.Carotid ultrasound demonstrated thrombi in the right internaljugular vein (Figure 2). Chest radiography finding revealed twodome-shaped elevations of the right hemidiaphragm suggestive ofintra-abdominal masses (Figure 3). Computed tomography showedmultiple variable-sized cysts in both kidneys (Figure 4) and the liverand massive hepatic cyst–induced right atrial compression(Figure 5). Echocardiography demonstrated a normal left ventricularFigure 1 Swelling along the anterior border of right sternocleido-mastoid muscle and distension of the right jugular vein (arrow).Figure 2 Thrombus visualized within the right internal jugularvein (RIJV; arrow). The vessel could not be compressed.RCCA, Right common carotid artery.From the Department of Cardiology, Quang Tri General Hospital, Dong Ha,Vietnam (T.V.L., D.H.N.); Department of Internal Medicine, University of Medicineand Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam (T.T.); Pham NgocThach University of Medicine, Ho Chi Minh City, Vietnam (T.N.M.N.); WashingtonUniversity School of Medicine, St. Louis, Missouri (Q.B.); and The Christ HospitalHealth Network and Lindner Research Center, Cincinnati, Ohio (C.P., V.T.T.).Keywords: Hepatic cyst, Thrombosis, Cardiac complicationConflicts of interest: The authors report no conflicts of interest relative to thisdocument.Copyright 2021 by the American Society of Echocardiography. Published byElsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).2468-6441https://doi.org/10.1016/j.case.2021.02.007170ejection fraction with no wall motion abnormalities or valvulardysfunction, and a masslike structure consistent with hepatic cystwas seen compressing the right atrium (Figure 6, Video 1).The patient underwent uncomplicated laparoscopic deroofing ofthe hepatic cysts. One liter of drainage fluid was obtained from thelargest cyst. Gram stain, culture, and cytology of the fluid were nega-tive. Simple liver cysts were lined by cuboidal epithelium and sup-ported by a fibrous wall found on histopathology. The patient wastreated with 7 days of subcutaneous low–molecular weight heparin(1 mg/kg every 12 hours) followed by a long-term vitamin K antago-nist. Postsurgical transthoracic echocardiography demonstrated elim-ination of compression and recovery of right atrial function(Figure 7, Video 2). Partial resolution of venous thrombi was seenby carotid ultrasound on day 7 following the anticoagulant therapy(Figure 8). This was accompanied by a significant alleviation of the pa-tient’s symptoms.DISCUSSIONHepatic cyst–induced cardiac complications are unusual. The rightheart is the most commonly involved site. Because of the anatomic vi-cinity, hepatic cysts may impinge the right atrium and ventricle,Figure 3 Two dome-shaped elevations of the right hemidiaph-ragm on the chest radiograph (arrow).Figure 4 Multiple variable-sized cysts in both kidneys (arrow).Figure 6 The hepatic cyst compressing the right atrium seen ontransthoracic echocardiography.VIDEO HIGHLIGHTSVideo 1: Hepatic cyst compressing the right atrium seen ontransthoracic echocardiography.Video 2: Postsurgical transthoracic echocardiographydemonstrating recovery of right atrial function and eliminationof compression.Viewthevideocontentonlineatwww.cvcasejournal.com.Figure 5 Right atrial compression by multiple massive hepaticcysts on computed tomography (arrow).CASE: Cardiovascular Imaging Case ReportsVolume 5 Number 3Le et al 171resulting in right heart dysfunction, with dyspnea on exertion as themost common symptom.1,2 Atrial premature beats have also been re-ported as a consequence of right atrial compression from hepaticcysts.3 Our patient presented with peripheral edema and headache,which resulted from the clinical manifestation of SVC syndromeoccurring once the blood flow in the SVC was partially or completelyobstructed. In addition, the detection of multiple bilateral renal cystson computed tomography suggested polycystic kidney disease.The therapeutic strategy for hepatic cysts depends on the presenta-tion of symptoms. It is recommended that asymptomatic cysts beobserved only, whereas symptomatic cysts should be managed bylaparoscopic deroofing.4 A laparoscopic approach is the procedureof choice for accessible cysts because of its safety and efficiency.5Recurrence rate following laparoscopic deroofing of solitary simplecysts is 14.3%.6 Potential complications of the procedure includehemorrhage, infection, and brachial vein thrombosis.5,6 Besides lapa-roscopic deroofing, our patient needed additional therapy for antico-agulation of thrombosis, which led to significant improvement.CONCLUSIONThe right heart is the most commonly involved site of hepatic cyst–induced cardiac complications. Clinical manifestations include dys-pnea on exertion, cardiac arrhythmia, peripheral edema, and venousthrombosis. Therapeutic strategy for symptomatic hepatic cysts asso-ciated with venous thrombosis is laparoscopic deroofing, followedby anticoagulation.REFERENCES1. O’Connor A, Lee M, McEntee G, McNamara DA. Massive hepatic cyst pre-senting as right-sided heart failure. Irish J Med Sci 2012;181:365-7.2. Panchal M, Alansari A, Wallack M, Visco F, Williams S, Sy AM. Hepatic cystcompressing the right atrial and ventricular inflow tract: an uncommon car-diac complication. Ann Hepatol 2018;17:165-8.3. Ker J. The liver and right atrium—hepatic cyst as a cause of arrhythmia. ClinMed Insights Cardiol 2010;4:63-7.4. Marrero JA, Ahn J, Reddy RK, American College of Gastroenterology. ACGclinical guideline: the diagnosis and management of focal liver lesions. Am JGastroenterol 2014;109:1328-47.5. Katkhouda N, Hurwitz M, Gugenheim J, Mavor E, Mason RJ, Waldrep DJ,et al. Laparoscopic management of benign solid and cystic lesions of theliver. Ann Surg 1999;229:460-6.6. Zacherl J, Scheuba C, Imhof M, Jakesz R, F€ugger R. Long-term results afterlaparoscopic unroofing of solitary symptomatic congenital liver cysts. SurgEndosc 2000;14:59-62.Figure 8 Partial resolution of thrombi in the right internal jugularvein (arrow) on day 7 following anticoagulant therapy on postop-erative carotid ultrasound.Figure 7 Recovery of right atrial function on postsurgical trans-thoracic echocardiography. Small hepatic cyst after laparo-scopic deroofing (arrow).172 Le et al CASE: Cardiovascular Imaging Case ReportsJune 2021

A case of hepatic cyst-induced internal jugular venous thrombosis

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A case of hepatic cyst-induced internal jugular venous thrombosis

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