Case of the week 07:16 Mediastinal malignancy treatment complications

1
Case of the week 0716 Mediastinal malignancy
treatment complications
History Increasing Breathlessness. Past medical
history included a thymoma removal with
subsequent mediastinal radiotherapy. Previous
successful PCI to the LAD for radiation induced
coronary artery disease.
b

• CMR SSFP cines
• Signal dropout from the old style proximal LAD
  stent noted (arrow, a).
• Dilated atria, evidence of heart failure despite
  normal systolic function.
• A septal bounce suggesting ventricular coupling
  (d) and constriction even without pericardial
  thickening (TSE, c). Unilateral pleural effusion
  with lung tethering (b) (clinically at an old
  chest drain site)
• Real time cines (e) short axis Imaging for
  dynamic ventricular coupling is bizarre septal
  flattening not clearly in inspiration.
• Real time cine (f) coronal reveals a paralysed
  hemi-diaphragm. This is the cause of the almost
  paradoxical ventricular coupling the left
  phrenic nerve was excised at thymoma removal.

a
c
d
Perspective This case shows 3 post mediastinal
radiotherapy/surgery features radiation induced
coronary artery disease, probable pericardial
constriction, here without thickening and phrenic
nerve palsy. Thoracotomy with mobilisation of the
tethered lung and diaphragmatic plication was
considered but he improved with diuretics and is
now under regular review.
e
f
References here (full text) and here
Mark Westwood, Malcolm Walker, The Heart
Hospital, University College Hospital, London,
United Kingdom.