Limits...
Complete heart block with diastolic heart failure and pulmonary edema secondary to enlarging previously diagnosed thrombosed aneurysm of sinus of valsalva in a patient with history of autosomal dominant polycystic kidney disease.

Eltawansy SA, Amor MM, Thomas MJ, Daniels J - Case Rep Cardiol (2015)

Bottom Line: His case was complicated with acute heart failure and pulmonary edema.Conclusion.In our case, aneurysm at sinus of Valsalva was progressively enlarging and presented with complete heart block.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA.

ABSTRACT
Autosomal dominant polycystic kidney disease (ADPKD) is associated with vascular aneurysms that can affect any part of the vascular tree, like ascending aorta or coronary arteries. Sinus of Valsalva is known as an anatomical dilation at the root of aorta above the aortic valve and very few cases show aneurysm at that site in patients with ADPKD. Sinus of Valsalva aneurysm (SVA) can present with rupture and acute heart failure and infective endocarditis or could be asymptomatic accidentally discovered during cardiac catheterization. We report a case of a 76-year-old male with a unique constellation of cardiovascular anomalies associated with ADPKD. Patient was previously diagnosed with aneurysms affecting ascending aorta, sinus of Valsalva, and coronary arteries. Several years later, he came with complete heart block which was discovered later to be secondary to enlargement of his previously diagnosed thrombosed SVA. His case was complicated with acute heart failure and pulmonary edema. Conclusion. Patients with ADPKD can present with extrarenal manifestations. In our case, aneurysm at sinus of Valsalva was progressively enlarging and presented with complete heart block.

No MeSH data available.


Related in: MedlinePlus

CT of the chest without contrast (March 19, 2014). (a) Left lung volume loss was noted in the left lung with underlying atelectatic change. A moderately sized pleural effusion was noted, which contained a second component measuring above that of simple fluid attenuation. These findings might represent an element of a hemorrhagic component. It was possible that this was atelectatic lung adjacent to the pleural effusion. An endotracheal tube was seen with the tip in the distal trachea near the carina. Low attenuation material was present within the left main stem bronchus, causing complete occlusion. Atelectatic changes were present in the right lung base with an early consolidation seen. Numerous nodules are seen throughout the lung fields. Scattered small blebs are noted in the right lung. (b) Heart was showing a heterogeneous mass (blue arrow), again noted to be associated with the left atrium and likely arising from the aortic root which measured 9.5 × 11.1 cm slightly larger in comparison to the MRA of the chest dated June 10, 2008; at that time it measured 8 cm in maximum diameter. There was a mediastinal shift to the left. (c) A calcified right hilar lymph node was noted. A prominent pretracheal lymph node measured 2 × 1.5 cm and could be a combination of 2 adjacent nodes. This was relatively stable. Another adjacent lymph node was measuring 9.7 cm slightly larger. A few other enlarged lymph nodes in the prevascular space were also present. Examination was difficult due to lack of intravenous contrast. (d) Vascular: atherosclerotic calcifications were seen in the aorta and its branches. There was a stable aneurysm of the thoracic aorta measuring 4.4 cm. (e) An enteric tube was seen coursing into the stomach with the tip off the field of view. Multiple splenic cysts were again noted, grossly stable in appearance. One of these cysts contains a calcification. Multiple hepatic cysts were again noted. A small hiatal hernia was seen. A heterogeneous complex cystic mass was again noted in the right hepatic lobe, which measured 9 × 8.3 cm, grossly stable in appearance compared to the most recent MRI from 2012. Multiple renal cysts were seen. Pancreatic calcifications were noted.
© Copyright Policy - open-access
Related In: Results  -  Collection


getmorefigures.php?uid=PMC4377395&req=5

fig4: CT of the chest without contrast (March 19, 2014). (a) Left lung volume loss was noted in the left lung with underlying atelectatic change. A moderately sized pleural effusion was noted, which contained a second component measuring above that of simple fluid attenuation. These findings might represent an element of a hemorrhagic component. It was possible that this was atelectatic lung adjacent to the pleural effusion. An endotracheal tube was seen with the tip in the distal trachea near the carina. Low attenuation material was present within the left main stem bronchus, causing complete occlusion. Atelectatic changes were present in the right lung base with an early consolidation seen. Numerous nodules are seen throughout the lung fields. Scattered small blebs are noted in the right lung. (b) Heart was showing a heterogeneous mass (blue arrow), again noted to be associated with the left atrium and likely arising from the aortic root which measured 9.5 × 11.1 cm slightly larger in comparison to the MRA of the chest dated June 10, 2008; at that time it measured 8 cm in maximum diameter. There was a mediastinal shift to the left. (c) A calcified right hilar lymph node was noted. A prominent pretracheal lymph node measured 2 × 1.5 cm and could be a combination of 2 adjacent nodes. This was relatively stable. Another adjacent lymph node was measuring 9.7 cm slightly larger. A few other enlarged lymph nodes in the prevascular space were also present. Examination was difficult due to lack of intravenous contrast. (d) Vascular: atherosclerotic calcifications were seen in the aorta and its branches. There was a stable aneurysm of the thoracic aorta measuring 4.4 cm. (e) An enteric tube was seen coursing into the stomach with the tip off the field of view. Multiple splenic cysts were again noted, grossly stable in appearance. One of these cysts contains a calcification. Multiple hepatic cysts were again noted. A small hiatal hernia was seen. A heterogeneous complex cystic mass was again noted in the right hepatic lobe, which measured 9 × 8.3 cm, grossly stable in appearance compared to the most recent MRI from 2012. Multiple renal cysts were seen. Pancreatic calcifications were noted.

Mentions: BNP (B-natriuretic peptide level) was 3419 ng/L. Heparin infusion was started as patient needed anticoagulation for the mechanical aortic valve. Tube feeding was started via the orogastric tube (OGT). Eplerenone tablet was resumed via the OGT in an effort to help improve the worsening cardiac function. The daily diuresis with resultant negative fluid balance improved pulmonary vascular congestion and right-sided pleural effusion but there was a persistent opacification of the left hemithorax. BNP level was going down. There was a mass-like opacity on the left hemithorax which was interpreted with the preliminary differential diagnosis like pleural effusion or pneumonic consolidation. The furosemide intake improved the pleural effusion on daily chest X-rays but in the meanwhile blood pressure was dropping from overdiuresis and kidney functions started to worsen from the fluid shift away from the kidneys. So the diuresis was stopped. Hypernatremia (NA 157 mmol/L) developed due to free water loss and free water was given via the orogastric tube. Amlodipine, furosemide, and eplerenone were held given the low blood pressure and worsening kidney functions. Intravenous fluids were tried very cautiously due the complicated heart failure and hypervolemia. The goal was to keep INR between 2 and 3 and warfarin was stopped when INR was over that goal; then patient was kept on heparin infusion only given the worsening left-sided pleural effusion with the fear of developing hemorrhage into it. There was cream-colored moderate-to-large amount of secretions which was suctioned from his endotracheal tube. Sputum culture came back with Klebsiella pneumonia; so pneumonia was thought to be present and vancomycin plus ceftriaxone that was shifted to tazobactam-piperacillin was started intravenously. Vancomycin then was stopped. Then antibiotic was narrowed down to ceftriaxone according to the sensitivity result of the sputum culture. The decision was to do CT scan of the chest but without contrast due to worsening kidney functions. The CT scan of the chest showed moderate left-sided pleural effusion plus enlargement of the previously recognized thrombosed SVA (Figures 4(a), 4(b), 4(c), 4(d), and 4(e)). This leads to the idea that heart block happened secondary to enlarging SVA. Tapping of left-sided pleural effusion came back with 100 cc that was nonhemorrhagic. The analysis came back exudative and was thought to be secondary to a possible pneumonia on the same side of the lung. It was negative for malignant cells.


Complete heart block with diastolic heart failure and pulmonary edema secondary to enlarging previously diagnosed thrombosed aneurysm of sinus of valsalva in a patient with history of autosomal dominant polycystic kidney disease.

Eltawansy SA, Amor MM, Thomas MJ, Daniels J - Case Rep Cardiol (2015)

CT of the chest without contrast (March 19, 2014). (a) Left lung volume loss was noted in the left lung with underlying atelectatic change. A moderately sized pleural effusion was noted, which contained a second component measuring above that of simple fluid attenuation. These findings might represent an element of a hemorrhagic component. It was possible that this was atelectatic lung adjacent to the pleural effusion. An endotracheal tube was seen with the tip in the distal trachea near the carina. Low attenuation material was present within the left main stem bronchus, causing complete occlusion. Atelectatic changes were present in the right lung base with an early consolidation seen. Numerous nodules are seen throughout the lung fields. Scattered small blebs are noted in the right lung. (b) Heart was showing a heterogeneous mass (blue arrow), again noted to be associated with the left atrium and likely arising from the aortic root which measured 9.5 × 11.1 cm slightly larger in comparison to the MRA of the chest dated June 10, 2008; at that time it measured 8 cm in maximum diameter. There was a mediastinal shift to the left. (c) A calcified right hilar lymph node was noted. A prominent pretracheal lymph node measured 2 × 1.5 cm and could be a combination of 2 adjacent nodes. This was relatively stable. Another adjacent lymph node was measuring 9.7 cm slightly larger. A few other enlarged lymph nodes in the prevascular space were also present. Examination was difficult due to lack of intravenous contrast. (d) Vascular: atherosclerotic calcifications were seen in the aorta and its branches. There was a stable aneurysm of the thoracic aorta measuring 4.4 cm. (e) An enteric tube was seen coursing into the stomach with the tip off the field of view. Multiple splenic cysts were again noted, grossly stable in appearance. One of these cysts contains a calcification. Multiple hepatic cysts were again noted. A small hiatal hernia was seen. A heterogeneous complex cystic mass was again noted in the right hepatic lobe, which measured 9 × 8.3 cm, grossly stable in appearance compared to the most recent MRI from 2012. Multiple renal cysts were seen. Pancreatic calcifications were noted.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4377395&req=5

fig4: CT of the chest without contrast (March 19, 2014). (a) Left lung volume loss was noted in the left lung with underlying atelectatic change. A moderately sized pleural effusion was noted, which contained a second component measuring above that of simple fluid attenuation. These findings might represent an element of a hemorrhagic component. It was possible that this was atelectatic lung adjacent to the pleural effusion. An endotracheal tube was seen with the tip in the distal trachea near the carina. Low attenuation material was present within the left main stem bronchus, causing complete occlusion. Atelectatic changes were present in the right lung base with an early consolidation seen. Numerous nodules are seen throughout the lung fields. Scattered small blebs are noted in the right lung. (b) Heart was showing a heterogeneous mass (blue arrow), again noted to be associated with the left atrium and likely arising from the aortic root which measured 9.5 × 11.1 cm slightly larger in comparison to the MRA of the chest dated June 10, 2008; at that time it measured 8 cm in maximum diameter. There was a mediastinal shift to the left. (c) A calcified right hilar lymph node was noted. A prominent pretracheal lymph node measured 2 × 1.5 cm and could be a combination of 2 adjacent nodes. This was relatively stable. Another adjacent lymph node was measuring 9.7 cm slightly larger. A few other enlarged lymph nodes in the prevascular space were also present. Examination was difficult due to lack of intravenous contrast. (d) Vascular: atherosclerotic calcifications were seen in the aorta and its branches. There was a stable aneurysm of the thoracic aorta measuring 4.4 cm. (e) An enteric tube was seen coursing into the stomach with the tip off the field of view. Multiple splenic cysts were again noted, grossly stable in appearance. One of these cysts contains a calcification. Multiple hepatic cysts were again noted. A small hiatal hernia was seen. A heterogeneous complex cystic mass was again noted in the right hepatic lobe, which measured 9 × 8.3 cm, grossly stable in appearance compared to the most recent MRI from 2012. Multiple renal cysts were seen. Pancreatic calcifications were noted.
Mentions: BNP (B-natriuretic peptide level) was 3419 ng/L. Heparin infusion was started as patient needed anticoagulation for the mechanical aortic valve. Tube feeding was started via the orogastric tube (OGT). Eplerenone tablet was resumed via the OGT in an effort to help improve the worsening cardiac function. The daily diuresis with resultant negative fluid balance improved pulmonary vascular congestion and right-sided pleural effusion but there was a persistent opacification of the left hemithorax. BNP level was going down. There was a mass-like opacity on the left hemithorax which was interpreted with the preliminary differential diagnosis like pleural effusion or pneumonic consolidation. The furosemide intake improved the pleural effusion on daily chest X-rays but in the meanwhile blood pressure was dropping from overdiuresis and kidney functions started to worsen from the fluid shift away from the kidneys. So the diuresis was stopped. Hypernatremia (NA 157 mmol/L) developed due to free water loss and free water was given via the orogastric tube. Amlodipine, furosemide, and eplerenone were held given the low blood pressure and worsening kidney functions. Intravenous fluids were tried very cautiously due the complicated heart failure and hypervolemia. The goal was to keep INR between 2 and 3 and warfarin was stopped when INR was over that goal; then patient was kept on heparin infusion only given the worsening left-sided pleural effusion with the fear of developing hemorrhage into it. There was cream-colored moderate-to-large amount of secretions which was suctioned from his endotracheal tube. Sputum culture came back with Klebsiella pneumonia; so pneumonia was thought to be present and vancomycin plus ceftriaxone that was shifted to tazobactam-piperacillin was started intravenously. Vancomycin then was stopped. Then antibiotic was narrowed down to ceftriaxone according to the sensitivity result of the sputum culture. The decision was to do CT scan of the chest but without contrast due to worsening kidney functions. The CT scan of the chest showed moderate left-sided pleural effusion plus enlargement of the previously recognized thrombosed SVA (Figures 4(a), 4(b), 4(c), 4(d), and 4(e)). This leads to the idea that heart block happened secondary to enlarging SVA. Tapping of left-sided pleural effusion came back with 100 cc that was nonhemorrhagic. The analysis came back exudative and was thought to be secondary to a possible pneumonia on the same side of the lung. It was negative for malignant cells.

Bottom Line: His case was complicated with acute heart failure and pulmonary edema.Conclusion.In our case, aneurysm at sinus of Valsalva was progressively enlarging and presented with complete heart block.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA.

ABSTRACT
Autosomal dominant polycystic kidney disease (ADPKD) is associated with vascular aneurysms that can affect any part of the vascular tree, like ascending aorta or coronary arteries. Sinus of Valsalva is known as an anatomical dilation at the root of aorta above the aortic valve and very few cases show aneurysm at that site in patients with ADPKD. Sinus of Valsalva aneurysm (SVA) can present with rupture and acute heart failure and infective endocarditis or could be asymptomatic accidentally discovered during cardiac catheterization. We report a case of a 76-year-old male with a unique constellation of cardiovascular anomalies associated with ADPKD. Patient was previously diagnosed with aneurysms affecting ascending aorta, sinus of Valsalva, and coronary arteries. Several years later, he came with complete heart block which was discovered later to be secondary to enlargement of his previously diagnosed thrombosed SVA. His case was complicated with acute heart failure and pulmonary edema. Conclusion. Patients with ADPKD can present with extrarenal manifestations. In our case, aneurysm at sinus of Valsalva was progressively enlarging and presented with complete heart block.

No MeSH data available.


Related in: MedlinePlus