Download High grade B-cell lymphoma causing severe right heart failure

[SCA-109] High grade B-cell lymphoma causing severe right heart failure: Transesophageal echo, not
transthoracic echo, assisted in diagnosis
Gandhi B, Spiess B
Virginia Commonwealth University , Richmond , VA, USA
Introduction: Patients who present in sudden severe heart failure, particularly right heart, of unknown origin
are a challenge to manage during cardiac surgery since the etiology often guides therapy. We present a case
of a patient with a history of lymphoma in severe right heart failure with a preoperative low quality
transthoracic echo (TTE) suggestive of an intracardiac thrombus. However, an intraoperative transesophageal
echo (TEE) revealed a large, solid mass suspicious for cancer that aided in critical decision making.
Case Presentation: A 70 year old female with a history of lymphoma was transferred from an outside hospital
for management of heart failure. She was in cardiogenic shock associated with multi-organ dysfunction. TTE
was suboptimal but suggested the presence of an intraventricular thrombus, and the patient was scheduled
for surgery. A central venous pressure (CVP) line was placed before anesthetic induction revealing a CVP of 28
mmHg. A post-induction TEE was performed and revealed a massive hyperechoic mass causing sub-total
occlusion of the right atrium (RA), right ventricle (RV) and the right ventricular outflow tract with invasion into
the myocardium (not seen with clot). No definable tricuspid valve was observed. The mass was adherent to
multiple parts of the right heart, preventing normal contractile function of the RA and RV. Our findings
suggested invasive cancer, and the surgical approach was changed to being diagnostic in nature. Biopsies of
highly vascular, friable tissue found all over the mediastinum were sent for pathology. No curative reason to
proceed could be appreciated since cannulation for cardiopulmonary bypass was not possible. Final diagnosis
of biopsies revealed a high grade B-cell lymphoma, leading to rapid demise of the patient two days later.
Discussion: Emergent cardiac surgery in a patient with cardiogenic shock secondary to right heart failure is
challenging. Rapid diagnosis of the etiology of heart failure is imperative, and the anesthesia team’s skilled use
of TEE can be instrumental. In our case a radically changed diagnosis was made due to the TEE study that
showed invasion of the tumor into heart structures. That detailed diagnosis significantly altered the surgical
approach. A high grade B-cell lymphoma consistent with her medical history was not suspected by TTE
preoperatively. TEE was able to demonstrate tumor morphology, unlike the preoperative TTE that had been
only able to discern a “clot-like” mass. A preoperative TEE could not be performed due to her unstable
nature. Although the patient ultimately died due to the nature of her lymphoma, this case illustrates the utility
of cardiac anesthesia’s diagnostic acumen in her overall care. If a TEE had been performed preoperatively in
an ICU setting, would the surgical exploration have gone forward? Expansion of cardiac anesthesia skill sets
into other perioperative settings for critically ill patients will be of great benefit.