Solid intracardiac mass complicating peritoneovenous shunting
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《血管的通路杂志》
a Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
b Section of Cardiac Pathology, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
Abstract
A 62-year-old man with liver cirrhosis and esophageal varices had received a peritoneovenous shunt (Denver shunt) in 1997. He was then re-admitted in 2005 with the clinical signs of recurrent ascites formation. The presence of a large intracardiac mass at the tip of the Denver shunt was demonstrated and the patient was referred to us for surgical removal of what was believed to represent a large right atrial thrombus potentially obstructing the shunt. After opening of the right atrium, a solid intracardiac mass at the tip of the Denver shunt was found, extending across the tricuspid valve and into the right ventricular cavity. After resection of the mass at its tip and appropriate shortening, the Denver shunt appeared to be patent. On histopathologic examination, the resected mass appeared as calcified fibrosis with hyalinized collagen fibers. However, later it was determined that ascites drainage by means of the Denver shunt remained insufficient and the patient received a transjugular intrahepatic portosystemic shunt (TIPS), which has improved his condition since then.
Key Words: Cardiac tumor; Cardiac mass; Right atrial mass; Echocardiography; Denver shunt; Peritoneovenous shunting
1. Case
A 62-year-old male patient was first diagnosed with liver cirrhosis and associated esophageal varices in 1996. In 1997, a peritoneovenous shunt (Denver shunt) [1–3] was implanted in him in a remote hospital, draining ascites from the abdominal cavity into the superior caval vein. His Denver shunt continued to function well until 2003, when ascites recurred and the shunt was found to be less effective since then. However, his clinical condition remained rather stable until early 2005, when he was admitted to the Department of Gastroenterology and Hepatology of the Charite, Rudolf Virchow University Hospital, Berlin, for problems related to substantial recurrent ascites formation. Here, a mass inside the right atrium of the heart (about 2x6 cm in size), extending from the superior caval vein down to and across the tricuspid valve, was discovered by both echocardiography and magnetic resonance imaging. The patient was referred to our department for surgical removal of what was believed to be a large right atrial thrombus, with the potential of also being the cause of the earlier shunt occlusion. He was operated on with the use of cardiopulmonary bypass and cardioplegic arrest. After opening of the right atrium, the whole intracardiac portion of the Denver shunt was found to be covered by a layer of hard, amorphous material, which formed enlargements at two sites: one at the tip (4x2.5 cm) (Figs. 1–2) and another at the entrance of the superior caval vein into the right atrium. The distal enlargement reached across the tricuspid valve. The distal mass (as well as the rest of the material covering the shunt) was removed and the shunt was shortened with his distal end now situated at the center of the right atrial cavity. Interestingly, after removal of the distal mass, clear serous fluid was draining out of the tip of the shunt, in principle, indicating patency of the Denver shunt. Histopathologic examination (Fig. 2b) identified the removed mass uniformly as a calcified fibrosis with hyalinized collagen fibers. Despite the surgical removal of the obstructive mass, later on it was determined that drainage of the ascites by means of the Denver shunt was not sufficient. Two months after surgery, the patient underwent implantation of a transjugular intrahepatic portosystemic shunt (TIPS) at Rudolf Virchow University Hospital which has improved his condition since then.
2. Comment
The cause of the extensive formation of a calcified fibrotic mass at the tip of a Denver shunt in this case remains unclear. Formation of blood thrombi, however, at the distal end of both LaVeen [4] and Denver shunts have been reported [5–7] and regular scanning for depositions on implanted materials residing within the cardiac cavities has been recommended. It can be speculated that the calcified fibrotic mass retrieved from the heart in this case, might have been the result of a biochemical reaction as it uniformly covered the whole surface of the Denver shunt. Since the fibrotic mass was extending across the plane of the tricuspid valve and into the right ventricle at the height of its narrowing (Fig. 2a), chronic contact with both the wall of the atrium and the tricuspid valve leaflets might have also contributed to the formation of the mass. In conclusion, implanted intracardiac devices or catheters should be investigated by echocardiography in regular intervals for early detection of appositions and to possibly prevent device malfunction. In the case of thrombotic appositions, for example, a lysis therapy might re-establish device function.
References
Hyde G, Dillon M, Bivins B. Peritoneal venous shunting for ascites: a 15-year perspective. Am Surg 1982; 48:123–127.
Lund RH, Moritz MW. Complications of Denver peritoneovenous shunting. Arch Surg 1982; 117:924–928.
Weaver DW, Wiencek RG, Bouwman DL. Percutaneous Denver peritoneovenous shunt insertion. Am J Surg 1990; 159:600–601.
Gosse P, Guez S, Roudaut R, Deville C, Dallocchio M. An unusual complication of the Le Veen shunt: a right atrial ventricular chamber pseudotumor. Clin Cardiol 1987; 10:370–371.
Ugolini V, Norcross JF, Schreiber JT, Kuntz RE, Taylor AL. Intracardiac thrombus causing peritoneovenous shunt failure: detection by two-dimensional echocardiography. J Am Coll Cardiol 1986; 7:1174–1176.
Vacek JL, Wolfe MW, Hightower BM, Smith GD, Finalson H. Right heart pseudotumor simulated by ascitic pseudocyst. An unusual complication of peritoneovenous shunting. Chest 1987; 91:138–139.
Hust MH, Grathwohl I, Fritz S, Metzler B, Felton C, Braun BB. Denver shunt causing abnormal right atrial mass: non-invasive determination of shunt patency by color-coded Doppler shuntography. J Am Soc Echocardiogr 1992; 5:73–76.(Michael J. Jurmann, Thors)
b Section of Cardiac Pathology, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
Abstract
A 62-year-old man with liver cirrhosis and esophageal varices had received a peritoneovenous shunt (Denver shunt) in 1997. He was then re-admitted in 2005 with the clinical signs of recurrent ascites formation. The presence of a large intracardiac mass at the tip of the Denver shunt was demonstrated and the patient was referred to us for surgical removal of what was believed to represent a large right atrial thrombus potentially obstructing the shunt. After opening of the right atrium, a solid intracardiac mass at the tip of the Denver shunt was found, extending across the tricuspid valve and into the right ventricular cavity. After resection of the mass at its tip and appropriate shortening, the Denver shunt appeared to be patent. On histopathologic examination, the resected mass appeared as calcified fibrosis with hyalinized collagen fibers. However, later it was determined that ascites drainage by means of the Denver shunt remained insufficient and the patient received a transjugular intrahepatic portosystemic shunt (TIPS), which has improved his condition since then.
Key Words: Cardiac tumor; Cardiac mass; Right atrial mass; Echocardiography; Denver shunt; Peritoneovenous shunting
1. Case
A 62-year-old male patient was first diagnosed with liver cirrhosis and associated esophageal varices in 1996. In 1997, a peritoneovenous shunt (Denver shunt) [1–3] was implanted in him in a remote hospital, draining ascites from the abdominal cavity into the superior caval vein. His Denver shunt continued to function well until 2003, when ascites recurred and the shunt was found to be less effective since then. However, his clinical condition remained rather stable until early 2005, when he was admitted to the Department of Gastroenterology and Hepatology of the Charite, Rudolf Virchow University Hospital, Berlin, for problems related to substantial recurrent ascites formation. Here, a mass inside the right atrium of the heart (about 2x6 cm in size), extending from the superior caval vein down to and across the tricuspid valve, was discovered by both echocardiography and magnetic resonance imaging. The patient was referred to our department for surgical removal of what was believed to be a large right atrial thrombus, with the potential of also being the cause of the earlier shunt occlusion. He was operated on with the use of cardiopulmonary bypass and cardioplegic arrest. After opening of the right atrium, the whole intracardiac portion of the Denver shunt was found to be covered by a layer of hard, amorphous material, which formed enlargements at two sites: one at the tip (4x2.5 cm) (Figs. 1–2) and another at the entrance of the superior caval vein into the right atrium. The distal enlargement reached across the tricuspid valve. The distal mass (as well as the rest of the material covering the shunt) was removed and the shunt was shortened with his distal end now situated at the center of the right atrial cavity. Interestingly, after removal of the distal mass, clear serous fluid was draining out of the tip of the shunt, in principle, indicating patency of the Denver shunt. Histopathologic examination (Fig. 2b) identified the removed mass uniformly as a calcified fibrosis with hyalinized collagen fibers. Despite the surgical removal of the obstructive mass, later on it was determined that drainage of the ascites by means of the Denver shunt was not sufficient. Two months after surgery, the patient underwent implantation of a transjugular intrahepatic portosystemic shunt (TIPS) at Rudolf Virchow University Hospital which has improved his condition since then.
2. Comment
The cause of the extensive formation of a calcified fibrotic mass at the tip of a Denver shunt in this case remains unclear. Formation of blood thrombi, however, at the distal end of both LaVeen [4] and Denver shunts have been reported [5–7] and regular scanning for depositions on implanted materials residing within the cardiac cavities has been recommended. It can be speculated that the calcified fibrotic mass retrieved from the heart in this case, might have been the result of a biochemical reaction as it uniformly covered the whole surface of the Denver shunt. Since the fibrotic mass was extending across the plane of the tricuspid valve and into the right ventricle at the height of its narrowing (Fig. 2a), chronic contact with both the wall of the atrium and the tricuspid valve leaflets might have also contributed to the formation of the mass. In conclusion, implanted intracardiac devices or catheters should be investigated by echocardiography in regular intervals for early detection of appositions and to possibly prevent device malfunction. In the case of thrombotic appositions, for example, a lysis therapy might re-establish device function.
References
Hyde G, Dillon M, Bivins B. Peritoneal venous shunting for ascites: a 15-year perspective. Am Surg 1982; 48:123–127.
Lund RH, Moritz MW. Complications of Denver peritoneovenous shunting. Arch Surg 1982; 117:924–928.
Weaver DW, Wiencek RG, Bouwman DL. Percutaneous Denver peritoneovenous shunt insertion. Am J Surg 1990; 159:600–601.
Gosse P, Guez S, Roudaut R, Deville C, Dallocchio M. An unusual complication of the Le Veen shunt: a right atrial ventricular chamber pseudotumor. Clin Cardiol 1987; 10:370–371.
Ugolini V, Norcross JF, Schreiber JT, Kuntz RE, Taylor AL. Intracardiac thrombus causing peritoneovenous shunt failure: detection by two-dimensional echocardiography. J Am Coll Cardiol 1986; 7:1174–1176.
Vacek JL, Wolfe MW, Hightower BM, Smith GD, Finalson H. Right heart pseudotumor simulated by ascitic pseudocyst. An unusual complication of peritoneovenous shunting. Chest 1987; 91:138–139.
Hust MH, Grathwohl I, Fritz S, Metzler B, Felton C, Braun BB. Denver shunt causing abnormal right atrial mass: non-invasive determination of shunt patency by color-coded Doppler shuntography. J Am Soc Echocardiogr 1992; 5:73–76.(Michael J. Jurmann, Thors)