International Journal of Cardiology 182 (2015) 457–458
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
An unusual cause of right heart failure V. van Laak a, S. Dreysse b, E. Fleck b, R. Gebker b,⁎ a b
German Heart Institute Berlin, Department of Internal Medicine/Cardiology, Germany Charité University Medicine Berlin, Department of Internal Medicine/Infectious Diseases and Respiratory Medicine, Germany
a r t i c l e
i n f o
Article history: Received 11 December 2014 Accepted 29 December 2014 Available online 30 December 2014 Keywords: Right heart failure Arteriovenous fistula
A 48 year old woman was admitted to our department for cardiac catheterization. She was complaining of dyspnea on light exertion and chest pain for 3 months and increasing headaches for about 4 weeks. The symptoms started acutely after microsurgical nucleotomy at L5/S1. Acute pulmonary embolism was excluded shortly after the onset of symptoms in a CT scan of the lung. A pulmonary consultant saw no signs of pulmonary failure. During the 3 months before admittance to our department, our patient had also been seen by a cardiologist who saw signs of chronic right heart failure and a mild tricuspid insufficiency. Sinus tachycardia with a frequency of about 120 beats/min was noticed. The patient was known to take thyroid hormones due to a thyroid insufficiency. Her fT3 values were elevated leading to the diagnosis of alimentary thyrotoxicosis and a treatment with metoprolol due to exaggerated symptoms after initial propranolol treatment and reduction in thyroid hormone intake was initiated. Later the patient was admitted to another hospital with abdominal pain and peripheral edema. An MRI and ultrasound of the abdomen demonstrated an enlarged liver with focal nodular hyperplasia and signs of global heart failure. After the initiation of heart failure therapy the patient was transferred to our hospital to exclude coronary artery disease as cause of her progressive heart failure.
On admittance she was complaining of dyspnea at slight exertion, which was aggravated when lying down, as well as headaches, peripheral edema and abdominal pain. Clinical examination revealed a systolic heart murmur over the tricuspid valve, signs of heart failure with peripheral edema, jugular venous distension and a very loud systolic bruit over the entire abdomen. Due to the acute onset and progressive course of the symptoms after the microsurgical nucleotomy and the prior diagnostics with signs of right heart failure we suspected an arteriovenous fistula possibly as a result of the surgery causing a massive volume overload to the right heart. We performed an MRI angiography which demonstrated a large AV-fistula between the left common iliac artery and vein (Fig. 1A and B). The patient underwent percutaneous invasive angiography with implantation of a covered stent into the common iliac vein (Fig. 1C and D). The vein was chosen for covered stent implantation because of the close proximity of the AV-fistula to the bifurcation of the common iliac artery. During the initial MRI a cardiac examination was also performed demonstrating signs of right heart failure with dilatation of the right cardiac chambers, tricuspid regurgitation, pericardial and pleural effusion (Fig. 1E). Cardiac output was measured at 11 l/min. Immediately after successful percutaneous closure of the AV-fistula the patient reported improvement of dyspnea and exercise capability. Four months after the intervention the patient remains asymptomatic and cardiac MRI documented normalization of right ventricular and right atrial size as well as nearly complete regression of pleural and pericardial effusion (Fig. 1F). Despite its low incidence, iatrogenic vascular injury related to minimally invasive lumbar disc surgery is a possible complication with serious hemodynamic consequences [1,2]. As in this case the connection between surgery and hemodynamic symptoms may not be immediately evident. The combination of a thorough clinical examination including auscultation of the abdomen and non-invasive angiography was essential in making a correct diagnosis. Finally, the arteriovenous fistula was managed well using an endovascular approach [3]. Conflict of interest
⁎ Corresponding author at: Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail address: [email protected] (R. Gebker).
http://dx.doi.org/10.1016/j.ijcard.2014.12.139 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
The authors report no relationships that could be construed as a conflict of interest.
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V. van Laak et al. / International Journal of Cardiology 182 (2015) 457–458
Fig. 1. A) Arterial phase of a peripheral MR-angiography demonstrating immediate enhancement of the dilated left common iliac vein and complete inferior vena cava suggesting relevant shunt. IVC = inferior vena cave, Ao = aorta. B) Posterior view of 3D reconstruction of MR-angiography demonstrating AV-fistula (white arrow) between left common iliac artery and vein. C) Invasive angiography with contrast injection via pigtail-catheter in the left common iliac artery showing prompt transfer of contrast into the venous system via a large AV-fistula. D) After the implantation of a covered stent into the left common iliac vein only minimal shunt could be detected. E) Cardiac MRI demonstrating signs of right heart failure with dilatation of the right cardiac chambers, pericardial and pleural effusion. The patient also had mild ascites (not shown here). F) Cardiac MRI three months after stent implantation shows normalization of right ventricular and right atrial size as well as nearly complete regression of pleural and pericardial effusion.
References [1] T.W. Kwon, et al., Large vessel injury following operation for a herniated lumbar disc, Ann. Vasc. Surg. 17 (4) (2003) 438–444. [2] S. Papadoulas, et al., Vascular injury complicating lumbar disc surgery. A systematic review, Eur. J. Vasc. Endovasc. Surg. 24 (3) (2002) 189–195.
[3] M. van Zitteren, et al., A shift toward endovascular repair for vascular complications in lumbar disc surgery during the last decade, Ann. Vasc. Surg. 27 (6) (2013) 810–819.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
An unusual cause of right heart failure V. van Laak a, S. Dreysse b, E. Fleck b, R. Gebker b,⁎ a b
German Heart Institute Berlin, Department of Internal Medicine/Cardiology, Germany Charité University Medicine Berlin, Department of Internal Medicine/Infectious Diseases and Respiratory Medicine, Germany
a r t i c l e
i n f o
Article history: Received 11 December 2014 Accepted 29 December 2014 Available online 30 December 2014 Keywords: Right heart failure Arteriovenous fistula
A 48 year old woman was admitted to our department for cardiac catheterization. She was complaining of dyspnea on light exertion and chest pain for 3 months and increasing headaches for about 4 weeks. The symptoms started acutely after microsurgical nucleotomy at L5/S1. Acute pulmonary embolism was excluded shortly after the onset of symptoms in a CT scan of the lung. A pulmonary consultant saw no signs of pulmonary failure. During the 3 months before admittance to our department, our patient had also been seen by a cardiologist who saw signs of chronic right heart failure and a mild tricuspid insufficiency. Sinus tachycardia with a frequency of about 120 beats/min was noticed. The patient was known to take thyroid hormones due to a thyroid insufficiency. Her fT3 values were elevated leading to the diagnosis of alimentary thyrotoxicosis and a treatment with metoprolol due to exaggerated symptoms after initial propranolol treatment and reduction in thyroid hormone intake was initiated. Later the patient was admitted to another hospital with abdominal pain and peripheral edema. An MRI and ultrasound of the abdomen demonstrated an enlarged liver with focal nodular hyperplasia and signs of global heart failure. After the initiation of heart failure therapy the patient was transferred to our hospital to exclude coronary artery disease as cause of her progressive heart failure.
On admittance she was complaining of dyspnea at slight exertion, which was aggravated when lying down, as well as headaches, peripheral edema and abdominal pain. Clinical examination revealed a systolic heart murmur over the tricuspid valve, signs of heart failure with peripheral edema, jugular venous distension and a very loud systolic bruit over the entire abdomen. Due to the acute onset and progressive course of the symptoms after the microsurgical nucleotomy and the prior diagnostics with signs of right heart failure we suspected an arteriovenous fistula possibly as a result of the surgery causing a massive volume overload to the right heart. We performed an MRI angiography which demonstrated a large AV-fistula between the left common iliac artery and vein (Fig. 1A and B). The patient underwent percutaneous invasive angiography with implantation of a covered stent into the common iliac vein (Fig. 1C and D). The vein was chosen for covered stent implantation because of the close proximity of the AV-fistula to the bifurcation of the common iliac artery. During the initial MRI a cardiac examination was also performed demonstrating signs of right heart failure with dilatation of the right cardiac chambers, tricuspid regurgitation, pericardial and pleural effusion (Fig. 1E). Cardiac output was measured at 11 l/min. Immediately after successful percutaneous closure of the AV-fistula the patient reported improvement of dyspnea and exercise capability. Four months after the intervention the patient remains asymptomatic and cardiac MRI documented normalization of right ventricular and right atrial size as well as nearly complete regression of pleural and pericardial effusion (Fig. 1F). Despite its low incidence, iatrogenic vascular injury related to minimally invasive lumbar disc surgery is a possible complication with serious hemodynamic consequences [1,2]. As in this case the connection between surgery and hemodynamic symptoms may not be immediately evident. The combination of a thorough clinical examination including auscultation of the abdomen and non-invasive angiography was essential in making a correct diagnosis. Finally, the arteriovenous fistula was managed well using an endovascular approach [3]. Conflict of interest
⁎ Corresponding author at: Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. E-mail address: [email protected] (R. Gebker).
http://dx.doi.org/10.1016/j.ijcard.2014.12.139 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
The authors report no relationships that could be construed as a conflict of interest.
458
V. van Laak et al. / International Journal of Cardiology 182 (2015) 457–458
Fig. 1. A) Arterial phase of a peripheral MR-angiography demonstrating immediate enhancement of the dilated left common iliac vein and complete inferior vena cava suggesting relevant shunt. IVC = inferior vena cave, Ao = aorta. B) Posterior view of 3D reconstruction of MR-angiography demonstrating AV-fistula (white arrow) between left common iliac artery and vein. C) Invasive angiography with contrast injection via pigtail-catheter in the left common iliac artery showing prompt transfer of contrast into the venous system via a large AV-fistula. D) After the implantation of a covered stent into the left common iliac vein only minimal shunt could be detected. E) Cardiac MRI demonstrating signs of right heart failure with dilatation of the right cardiac chambers, pericardial and pleural effusion. The patient also had mild ascites (not shown here). F) Cardiac MRI three months after stent implantation shows normalization of right ventricular and right atrial size as well as nearly complete regression of pleural and pericardial effusion.
References [1] T.W. Kwon, et al., Large vessel injury following operation for a herniated lumbar disc, Ann. Vasc. Surg. 17 (4) (2003) 438–444. [2] S. Papadoulas, et al., Vascular injury complicating lumbar disc surgery. A systematic review, Eur. J. Vasc. Endovasc. Surg. 24 (3) (2002) 189–195.
[3] M. van Zitteren, et al., A shift toward endovascular repair for vascular complications in lumbar disc surgery during the last decade, Ann. Vasc. Surg. 27 (6) (2013) 810–819.
