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Netherlands Heart Journal logoLink to Netherlands Heart Journal
. 2008 Dec;16(12):429–430. doi: 10.1007/BF03086193

Retrocardiac mass causing collapse

AJ IJsselmuiden 1, DF van Wijk 1, GA Somsen 1
PMCID: PMC2612114  PMID: 19127323

A 78-year-old man with a history of hypertension presented to the emergency room after the sudden onset of near-collapse, dyspnoea, dizziness, and nausea. Symptoms had started while the patient was stooped over in an attempt to reach for an item underneath his bed. The patient reported upper abdominal pain, radiating to his back. Prior to his presenting symptoms he had no complaints, nor had he suffered from trauma.

On physical examination his pulse was 105 beats/min, the average highly fluctuating, blood pressure was 190/107 mmHg on his left arm and 124/83 mmHg on his right arm. Moreover, his extremities showed signs of severe cyanosis. Laboratory results showed a high white blood cell count (15.4×109/l) and normal haematocrit and coagulation studies. Chest X-ray revealed a widened mediastinum (figure 1A) and computed tomography angiography showed a large hypodense mass anterior of the thoracic aorta (15×8 cm) with compression of the heart, severe pulmonary vein compression (figure 1B) and pleural fluid at the right lung base, as well as a narrowed and dislocated oesophagus (figure 1C). There was no extravasation of contrast. Transthoracic echocardiography revealed compression of the left atrium due to a large retro-cardiac mass, with a hypodense core, compression of the pulmonary veins and severe obstruction of the transmitral flow. Bronchoscopy showed no abnormalities. On gastroscopy a slight bluish discoloration of the posterior oesophagus was seen. Multiple biopsies of the retrocardiac mass showed red blood cells, but no clues for a definite diagnosis. Therefore, a posterior thoracotomy was performed, revealing an old in-capsulated haematoma which was subsequently removed. No bleeding foci were found. After surgery symptoms resolved, the haemodynamic situation improved and remained stable. However, six days later the patient died from a Staphylococcus aureus sepsis caused by an operation area or central line infection. No consent was obtained for post-mortem studies.

Figure 1A.

Figure 1A

Chest X-ray showing a widened mediastinum.

Figure 1B.

Figure 1B

Computer tomographic angiography showing a large retrocardiac mass with compression of the heart, severe compression of the pulmonary vein (arrow) and right-sided pleural fluid.

Figure 1C.

Figure 1C

Computer tomographic angiography showing a narrowed and displaced oesophagus (arrow).

A retrocardiac organised haematoma is a rare entity and has been described in relation to an aortic aneurysma, which was not the case in the present patient.1 The volume effect of the tumour caused transient compression of vascular structures, such as the left atrium and pulmonary veins, resulting in obstruction of the transmitral flow leading to a decrease in cardiac output, haemodynamic instability and symptoms. Differential diagnostic considerations of a retrocardiac mass include aortic aneurysm, mucoepidermoid carcinoma of the tracheobronchial tree, mediastinal pheochromocytomas, lymphoma, neurogenic tumour, pancreatic pseudocyst, abscess, oesophageal lymph-angioma and paraoesophageal varices.1-5

A retrocardiac mass is usually well demonstrated with a CT scan. The symptoms caused by a mass are not always correlated with its location and size.3 Treatment generally consists of surgical resection. Compression of vascular structures should be considered in the diagnostic work-up of patients presenting with posture related (near) collapse and upper abdominal pain.

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References

  • 1.Overton JE, Senior RM, Lefrak SS, Susman N. Retrocardiac mass. Chest 1979;76:317-8. [DOI] [PubMed] [Google Scholar]
  • 2.Kumar A, Ricaurte JC, Rosa U, Peter Smith P. Retrocardiac Mass in a Patient with Cirrhosis. Chest 1997;112:1679-80. [DOI] [PubMed] [Google Scholar]
  • 3.Parker RJ, Cadman PJ, Wathen CG. Lymphangioma: a rare cause of a mediastinal mass. Thorax 2004;59;820. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Beiras-Fernandez A, Uberfuhr P, Kaczmarek I, Nikolaou K, Weis F, Ramp T, et al. Mediastinal pheochromocytoma with single coronary blood supply: a case report. Heart Surg Forum 2007;10:E196-8. [DOI] [PubMed] [Google Scholar]
  • 5.Kim TS, Lee KS, Han J, Im JG, Seo JB, Kim JS, et al. Mucoepidermoid carcinoma of the tracheobronchial tree: radiographic and CT findings in 12 patients. Radiology 1999;212:643-8. [DOI] [PubMed] [Google Scholar]

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