A Tight Squeeze

Cardiac tamponade is a rare cause of shock in the medical intensive care unit. This paper describes the case of a focal cardiac tamponade caused by…

Abstract

Cardiac tamponade is a rare cause of shock in the medical intensive care unit. This paper describes the case of a focal cardiac tamponade caused by compression of the left atrium due to an esophageal stent. Echocardiography yielded a diagnosis when other diagnostic methods did not. (Level of Difficulty: Advanced.)

Graphical abstract

A 35-year-old female patient with renal cell carcinoma, metastatic to the mediastinum, and known to have a tracheoesophageal fistula (TEF) due to radiation therapy for superior vena cava (SVC) syndrome, presented for management of aspiration of her TEF, which had been refractory to previous tracheal stenting. A new Y-tracheobronchial stent was placed on hospital day (HD) 1. Despite this stent, she continued to have symptomatic aspiration through the TEF.

She underwent placement of an esophageal stent on HD16 and removal of the tracheobronchial stent on HD17. Twelve hours later, she rapidly developed hypoxia and hypotension, requiring intubation and vasopressors.

Following intubation, a chest computed tomography demonstrated new bilateral pleural effusions. The esophageal stent was positioned as endoscopically intended (Figures 1A and 1B). Studies from bilateral thoracenteses were consistent with transudation.

Figure 1.

Chest CT and Echocardiography Findings

(A) Axial and (B) Sagittal views demonstrate left atrial compression by the esophageal stent (red arrowheads). Pleural effusions are shown (blue arrowheads). Echocardiography demonstrates left atrial compression by the esophageal stent (C) and improvement after stent was removed (D). Also see Video 1. CT = computed tomography; ES = esophageal stent; LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.

Despite fluid resuscitation, antibiotics, and vasopressors, the patient remained hypotensive. Given an unclear precipitant and persistent shock, the cardiology service was consulted. There was no pulsus paradoxus by arterial line. Echocardiography demonstrated left atrial compression by an echogenic structure with central lucency, consistent with the esophageal stent (Figure 1C). The left atrium was nearly collapsed with hyperdynamic biventricular function. There was a small stable pericardial effusion.

Hypotension, hypoxemia, and bilateral pleural effusions after tracheal stent removal, combined with echocardiographic findings, raised concern for focal tamponade and obstructive shock physiology. Bedside placement of a Swan-Ganz catheter to define shock physiology could not be performed given SVC stenosis.

The gastroenterology service performed emergent esophageal stent removal. Thereafter, her hypotension resolved, and she was extubated. Repeat echocardiography showed resolution of left atrial compression and no evidence of pericardial tamponade (Figure 1D, Video 1).

Video 1.

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Bedside echocardiography before and after esophageal stent removal.

Cardiac tamponade is an uncommon cause of shock. Echocardiography served as a tool to exhaustively evaluate cardiogenic and obstructive shock causes. Left atrial compression and findings of acute left heart failure (pleural effusions) with normal biventricular function suggested the diagnosis of obstructive shock from focal tamponade.

The patient was predisposed to left atrial compression, given her mediastinal lymphadenopathy and radiation fibrosis. The causality between tracheal stent removal and her decompensation remained unclear; however, it was evident that the esophageal stent mediated obstruction, given her improvement after its removal.

The physical findings of pericardial tamponade as a cause for shock, such as pulsus paradoxus, distended neck veins, and distant heart sounds were obfuscated by mechanical ventilation (1). It is unclear whether these findings are useful in focal tamponade.

This case relates a rare complication of esophageal stent placement (2). We believe it proves instructive, as more patients are surviving with advanced malignancy and receiving a variety of endoscopic therapies.