European Heart Journal Advance Access published January 26, 2016
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehv750
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An unusual cause of syncope while gardening Nina Osafo1, Kashish Goel 2, and Jeffrey Geske2 * 1
Meharry Medical College, Nashville, TN, USA; and 2Division of Cardiovascular Diseases, Mayo Clinic, 200 First street SW, Rochester, MN 55905, USA
* Corresponding author. Tel: +1 507 284 1648, Fax: +1 507 255 2550, Email: [email protected]
Reference 1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J cancer 2015;136:E359 –E386. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2016. For permissions please email: [email protected].
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on February 12, 2016
A 69-year-old female presented with four episodes of syncope in 2 months precipitated by bending forward while gardening. They were not associated with any prodromal symptoms, palpitations, or chest pain. On physical exam, a distinct lowfrequency diastolic heart sound was heard at the left lower sternal border. Transthoracic echocardiogram illustrated a large mobile mass extending from the inferior vena cava (IVC) to the right atrium with prolapse across the tricuspid valve into the right ventricle in diastole (Panel A). For further characterization of the mass, a cardiac and abdominal magnetic resonance imaging (MRI) revealed a large tumour extending from the right renal vein to the IVC (Panel B) and finally into the right atrium and ventricular apex (Panel C). Computed tomography (CT) scan of the abdomen revealed a large right renal mass (Panel D). Pre-operative coronary angiography did not demonstrate any flow-limiting lesions. Intra-operative transoesophageal echocardiogram showed the extent of tumour mass within the IVC (Panel E). A level IV tumour thrombectomy and tricuspid valve annuloplasty were performed under cardiopulmonary bypass with subsequent right radical nephrectomy, retroperitoneal lymphadenectomy, and vena cavotomy with closure. Macroscopic specimen was consistent with clear cell renal cell carcinoma and tumour extension (Panel F). We propose that bending forward resulted in complete IVC occlusion (due to the large tumour burden), leading to a precipitous drop in the preload, in turn decreasing the cardiac output (a leftward shift on the Starling curve) and cerebral perfusion, with resultant syncope. The worldwide annual incidence of renal cell carcinoma is 2.4% with 338 000 new cases diagnosed in 2012,1 out of which ,1% extend into the right atrium with rare extension into the right ventricle. Syncope has not previously been reported as the initial presentation of renal cell carcinoma.
CARDIOVASCULAR FLASHLIGHT
doi:10.1093/eurheartj/ehv750
.............................................................................................................................................................................
An unusual cause of syncope while gardening Nina Osafo1, Kashish Goel 2, and Jeffrey Geske2 * 1
Meharry Medical College, Nashville, TN, USA; and 2Division of Cardiovascular Diseases, Mayo Clinic, 200 First street SW, Rochester, MN 55905, USA
* Corresponding author. Tel: +1 507 284 1648, Fax: +1 507 255 2550, Email: [email protected]
Reference 1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J cancer 2015;136:E359 –E386. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2016. For permissions please email: [email protected].
Downloaded from http://eurheartj.oxfordjournals.org/ by guest on February 12, 2016
A 69-year-old female presented with four episodes of syncope in 2 months precipitated by bending forward while gardening. They were not associated with any prodromal symptoms, palpitations, or chest pain. On physical exam, a distinct lowfrequency diastolic heart sound was heard at the left lower sternal border. Transthoracic echocardiogram illustrated a large mobile mass extending from the inferior vena cava (IVC) to the right atrium with prolapse across the tricuspid valve into the right ventricle in diastole (Panel A). For further characterization of the mass, a cardiac and abdominal magnetic resonance imaging (MRI) revealed a large tumour extending from the right renal vein to the IVC (Panel B) and finally into the right atrium and ventricular apex (Panel C). Computed tomography (CT) scan of the abdomen revealed a large right renal mass (Panel D). Pre-operative coronary angiography did not demonstrate any flow-limiting lesions. Intra-operative transoesophageal echocardiogram showed the extent of tumour mass within the IVC (Panel E). A level IV tumour thrombectomy and tricuspid valve annuloplasty were performed under cardiopulmonary bypass with subsequent right radical nephrectomy, retroperitoneal lymphadenectomy, and vena cavotomy with closure. Macroscopic specimen was consistent with clear cell renal cell carcinoma and tumour extension (Panel F). We propose that bending forward resulted in complete IVC occlusion (due to the large tumour burden), leading to a precipitous drop in the preload, in turn decreasing the cardiac output (a leftward shift on the Starling curve) and cerebral perfusion, with resultant syncope. The worldwide annual incidence of renal cell carcinoma is 2.4% with 338 000 new cases diagnosed in 2012,1 out of which ,1% extend into the right atrium with rare extension into the right ventricle. Syncope has not previously been reported as the initial presentation of renal cell carcinoma.
