Rapid-onset dyspnea and obstructive shock in a patient: what
The present case has been reported in the journal CHEST. A man in his 50s with no relevant medical history experienced rapidly progressive dyspnea over 2 days and presented to the ED. Upon arrival, he was found to be in moderate distress. Physical examination was notable for pallor, diaphoresis, bradycardia, distant heart sounds, and retractions with respiration.

ECG revealed complete heart block, rate 33 beats/min, without ST wave changes or electrical alternans.
The admission chest radiograph demonstrated an enlarged cardiac silhouette and clear lungs without consolidation or signs of pulmonary vascular congestion.

Bedside point-of-care ultrasound was then performed, with significant cardiac findings (Video 1A), but otherwise with findings of bilateral lung sliding and A line pattern, negative 2-point DVT testing of bilateral lower extremities.

A CT scan of the chest, abdomen, and pelvis revealed a large cardiac mass within the right atrium and extending into the right ventricle, partially obstructing RV inflow at the level of the tricuspid valve and circumferential pericardial effusion, along with a 4-cm retroperitoneal right perinephric mass.

IInitial attempts at fluid resuscitation had failed to improve systolic BP above mid-90 mm Hg or to improve oxygen saturation. Cardiology and cardiothoracic surgery therefore recommended that the patient proceed with emergent surgical resection of the obstructing mass and placement of dual-lead permanent pacemaker.

The patient’s surgery proceeded without complication and he had immediate improvement in BP upon decompression of the pericardial effusion. The tumor was debulked to relieve the obstruction, but was deemed not fully resectable. A dual-lead permanent pacemaker was also implanted.

Pericardial fluid cytology and tissue pathology revealed high-grade diffuse large B-cell lymphoma.

Learnings:-
• Primary intracardiac tumors of any kind are rare with an incidence of <0.1%. Although the majority of primary cardiac tumors are benign, autopsy series have shown that up to 8% of cancers metastasize to the heart by the time of death.

• Most intracardiac tumors are found by echocardiography performed in response to symptoms associated with tumor location.

• This case demonstrates the utility of bedside ultrasound in rapid evaluation and treatment of the unstable patient.

• Obstructive shock secondary to a large intracardiac mass is an uncommon but extremely dangerous diagnosis; however, if recognized early, can still result in positive clinical outcomes.

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