BACKGROUND: 
Cardiogenic shock remains challenging in its therapy and aetiology.
CASE SUMMARY: 
A 74-year-old woman admitted for cardiogenic shock requiring mechanical ventilation and high-dose inotropics and vasopressors with an electrocardiogram showing left ventricular (LV) lateral wall ischaemia had diffuse coronary artery disease but TIMI III flow in the coronary tree. An echocardiogram showed a suspicious mass invading the left ventricle and computed tomography scan revealed an advanced lung cancer with LV wall and pulmonary artery invasion as the cardiogenic shock cause.
DISCUSSION: 
When managing cardiogenic shock, it is important to consider different and not obvious diagnosis. A high level of clinical suspicion and multimodality imaging assessment was very important in the present case to attain the diagnosis.info:eu-repo/semantics/publishedVersio

Cruz Ferreira, R

Morais, LM

Portugal, G

English

Repository of the Hospital Center of Central Lisbon

A Case Report: Unmasking a Singular Culprit for Cardiogenic Shock: Looking Beyond the Coronary Tree

Repositório do Centro Hospitalar de Lisboa Central, EPE

.......................................A case report: unmasking a singular culpritfor cardiogenic shock: looking beyond thecoronary treeLuı´s Almeida-Morais*, Guilherme Portugal, and Rui Cruz-FerreiraCentro Universita´rio de Cardiologia, Hospital de Santa Marta, Centro Hospitalar de Lisboa, Rua de Santa Marta, n 50, 1169-024 Lisbon, PortugalReceived 17 August 2018; accepted 20 March 2019; online publish-ahead-of-print 28 March 2019Background Cardiogenic shock remains challenging in its therapy and aetiology....................................................................................................................................................................................................Case summary A 74-year-old woman admitted for cardiogenic shock requiring mechanical ventilation and high-dose inotropics andvasopressors with an electrocardiogram showing left ventricular (LV) lateral wall ischaemia had diffuse coronary ar-tery disease but TIMI III flow in the coronary tree. An echocardiogram showed a suspicious mass invading the leftventricle and computed tomography scan revealed an advanced lung cancer with LV wall and pulmonary artery in-vasion as the cardiogenic shock cause....................................................................................................................................................................................................Discussion When managing cardiogenic shock, it is important to consider different and not obvious diagnosis. A high level ofclinical suspicion and multimodality imaging assessment was very important in the present case to attain thediagnosis.                                                                                                                                                                                                                   Keywords Cardiogenic shock • Lung cancer • Multimodality imaging • Case reportIntroductionCardiogenic shock is defined by a decrease in cardiac output and evi-dence of tissue hypoxia despite adequate intravascular volume.1 Thereduced cardiac output induces compensatory mechanisms that areusually not satisfactory and if no interventions are undertaken, multi-organ failure and death occur.2 In the contemporary era, cardiogenicshock patients’ management remains challenging. The most frequentcause for this condition is still ischaemic heart disease with a preva-lence of 6–10% following ST-elevation myocardial infarction.3Moreover, despite all advances in medical therapy, percutaneous cor-onary intervention and left ventricular (LV) assist devices, in-hospitalmortality rate remains high.4Learning points• Cardiogenic shock still represents a challenge condition todiagnose and managing.• Multimodality fast access imaging should be used in the non-typical cases of cardiogenic shock to clarify their aetiology.• A high level of clinical suspicion is needed for some challengingcases of cardiogenic shock.* Corresponding author. Tel: þ351 21 359 4000, Fax: þ351 213 144 916, Email: lmmorais88@gmail.comHandling Editor: Gianluigi SavaresePeer-reviewers: Albert Galyavich and Subhi AklehCompliance Editor: Amir AzizSupplementary Material Editor: Peysh A. PatelVC The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestrictedreuse, distribution, and reproduction in any medium, provided the original work is properly cited.European Heart Journal - Case Reports (2019) 3, 1–4 CASE REPORTdoi:10.1093/ehjcr/ytz009 Cardiac imaging......................................................................TimelineCase presentationA 74-year-old woman with past medical history of left breast cancersubmitted to radical mastectomy 10 years ago was admitted to theemergency department for acute dyspnoea. Clinical observationshowed tachycardia, blood pressure 89/54 mmHg, regular heartsounds, no heart murmurs, arterial oxygen saturation of 85%, tachyp-noea, accessory respiratory muscles use, and bilateral rales with lefthemithorax dullness at percussion. Electrocardiogram showed sinustachycardia, right bundle brunch block, and left anterior hemiblockwith 2 mm ST-elevation in leads aVL, aVR, and I (Figure 1). Clinicalcondition deteriorated requiring intensive care unit admission, ino-tropic and vasopressor support, and mechanical ventilation. Bedsidetransthoracic echocardiogram (TTE) showed impaired LV functionwith anterior and lateral wall akinesia. A presumptive diagnosis ofmyocardial infarction (MI) presenting as cardiogenic shock was madeand antithrombotic therapy including loading doses of aspirin(250 mg), ticagrelor (180 mg), and heparin (5000 UI) were adminis-tered. Emergent coronary angiogram was performed and showed dif-fuse non-significative three-vessels disease (Figure 2). Cardiacbiomarkers were elevated (high sensitivity troponin I 32 ng/mL, for anormal <0.07 ng/mL and BNP 528 pg/mL, for a normal <100 pg/mL).Based on radiological chest imaging, a mass in the left lung was sus-pected; TTE imaging review showed LV lateral and anterior wall aki-nesis due to infiltration by a heterogeneous echogenic mass (Figure3). Transoesophageal echocardiogram confirmed TTE findings, show-ing mild mitral regurgitation and a large mass invading the lateral LV.................................................................................................Investigations FindingsClinical presentation Acute dyspnoea and haemodynamiccollapseElectrocardiogram Right bundle branch block and lateral STelevationCoronary angiogram No coronary artery occlusionEchocardiogram Left ventricular dysfunction and kineticchangesComputedtomography scanNo pulmonary embolism. Left ventricle andpulmonary artery invading tumourFigure 1 Patient’s 12-lead electrocardiogram at presentation shows sinus tachycardia, right bundle brunch block, and left anterior hemiblock with2 mm ST-elevation in leads aVL, aVR, and I.2 L. Almeida-Morais et al.....................................wall. An urgent computed tomography (CT) scan was performedshowing a neoformation located in the lower and mid sections of theleft hemithorax, invading the lateral LV wall, pulmonary artery leftbranch, left pulmonary bronchi and anterior thoracic wall, compatiblewith an advanced lung cancer (Figure 4). Despite supportive care, clin-ical status worsened and the patient died in the following hours.DiscussionTo the authors; knowledge, this is the first report of lung can-cer mimicking a MI with cardiogenic shock. Despite the absenceof typical chest pain, the present case was at first assessed as acardiogenic shock complicating a MI. The electrocardiogramand echocardiogram findings, and later the cardiac enzymes,suggested left ventricle ongoing ischaemia. However, the coron-ary angiography revealed no coronary artery occlusion or sig-nificant stenosis explaining the clinical presentation. Coronaryarteries presented diffuse disease with small vessels and a richcollateral circulation. Revision of the echocardiography imagesrevealed a suspicious mass attached to the left ventricle, whatimmediately conducted to further imaging modalities. Bothtransoeosophageal echocardiogram and CT scan were helpfulto the diagnosis and haemodynamic impact of a tumoural massinvading the LV wall and pulmonary artery. We believe that theFigure 2 Coronary angiography shows three vessel diffuse disease with TIMI flow III in all vessels.Figure 3 Transthoracic echocardiography four-chamber subcostal view showing a echogenic mass adjacent to the lateral left ventricular wall.Unmasking a singular culprit for cardiogenic shock 3...........................................................cardiogenic shock mechanism in this case is explained in partby the dysfunction caused by the LV anterior and lateral akin-esia with LV dysfunction, but also by the pulmonary artery ob-struction which impairs adequate pre-load to the left ventricle.Moreover, the pro-inflammatory and high metabolic rate statusthat characterizes an advanced and invasive tumour might alsocontribute for the haemodynamic collapse.Supplementary materialSupplementary material is available at European Heart Journal - CaseReports online.Slide sets: A fully edited slide set detailing this case and suitable forlocal presentation is available online as Supplementary data.Consent: The author/s confirm that written consent for sub-mission and publication of this case report including image(s)and associated text has been obtained from the patient in linewith COPE guidance.Conflict of interest: none declared.References1. Alonso DR, Scheidt S, Post M, Killip T. Pathophysiology of cardiogenic shock.Quantification of myocardial necrosis, clinical, pathologic and electrocardiographiccorrelations. Circulation 1973;48:588–596.2. van Diepen S, Katz JN, Albert NM, Henry TD, Jacobs AK, Kapur NK, Kilic A,Menon V, Ohman EM, Sweitzer NK, Thiele H, Washam JB, Cohen MG; AmericanHeart Association Council on Clinical Cardiology; Council on Cardiovascular andStroke Nursing; Council on Quality of Care and Outcomes Research; andMission: Lifeline. Contemporary management of cardiogenic shock: a scientificstatement from the American Heart Association. Circulation 2017;136:e232–e268.3. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H, CaforioALP, Crea F, Goudevenos JA, Halvorsen S, Hindricks G, Kastrati A, Lenzen MJ,Prescott E, Roffi M, Valgimigli M, Varenhorst C, Vranckx P, Widimsky P; ESCScientific Document Group. 2017 ESC Guidelines for the management of acutemyocardial infarction in patients presenting with ST-segment elevation: the taskforce for the management of acute myocardial infarction in patients presentingwith ST-segment elevation of the European Society of Cardiology (ESC). EurHeart J 2018; 39:119–177.4. Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R,Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A. Consensus on circulatoryshock and hemodynamic monitoring. Task force of the European Society ofIntensive Care Medicine. Intensive Care Med 2014;40:1795–1815.Figure 4 Thoracic computed tomography scan showing a heterogeneous mass, with necrotic material, originating from the inferior left lung lobeinvading the anterior and lateral wall of the left ventricle, left branch of the pulmonary artery, left bronchi and anterior chest wall.4 L. Almeida-Morais et al.

http://repositorio.chlc.min-saude.pt/bitstream/10400.17/3413/1/Eur%20Heart%20J%20Case%20Rep.pdf

A Case Report: Unmasking a Singular Culprit for Cardiogenic Shock: Looking Beyond the Coronary Tree

Abstract

Similar works

Full text

Available Versions

Repository of the Hospital Center of Central Lisbon

Repositório do Centro Hospitalar de Lisboa Central, EPE