Korean Circ J.  2012 Apr;42(4):274-277. 10.4070/kcj.2012.42.4.274.

Late-Onset Postpneumonectomy Empyema Presenting as Right-Sided Heart Failure: Extrinsic Right Atrial Compression

• Namgung J
• Kwak JJ
• Choe H
• Kwon SU
• Doh JH
• Lee SY
• Ryoo JY
• Hur G
• Lee WR

• KMID: 2225021
• DOI: http://doi.org/10.4070/kcj.2012.42.4.274

Abstract

Although it is rare, the right atrium can be encroached on by abnormal mediastinal structures, including aortic aneurysms, carcinomas, hepatic cysts and diaphragmatic paralysis. Extrinsic compression of the right atrium causes significant hemodynamic compromise and can lead to fatal outcomes. We describe the case of a 66-year old man with a past history of pulmonary tuberculosis that had undergone right pneumonectomy 40 years previously. He then presented with signs and symptoms of right-sided heart failure. These new signs and symptoms were recognized to be secondary to extrinsic compression of the right atrium, which was due to late-onset postpneumonectomy empyema, and the signs and symptoms were successfully relieved by performing open drainage of the empyema.

Keyword

Empyema, pleural; Right-sided heart failure

MeSH Terms

Aortic Aneurysm
Drainage
Empyema
Empyema, Pleural
Fatal Outcome
Heart
Heart Atria
Heart Failure
Hemodynamics
Pneumonectomy
Respiratory Paralysis
Tuberculosis, Pulmonary

Figure

• 

  Fig. 1 A and B: a short-axis and an apical 4-chamber transthoracic echocardiography view demonstrated a pericardial effusion of over 2 cm around the free wall of the right ventricle. C: respiratory variations of transmitral Doppler inflow: a decrease of peak flow velocity with >25% (from 1.1 to 0.5 m/s) during inspiration. D: post contrast CT at the level of the left ventricle. The large mass with a mean CT number of 40 is empyema. Note the thick pleura with calcifications (arrows), and this represents a fibrothorax from the tuberculosis. The right atrium is markedly compressed by the empyema. A small to moderate amount of left pleural effusion is noted (the mean CT number is 25). E: axial image of chest MRI. A large mass in the right thorax compresses the right heart and vena cava. The mass has a lobular fibrous capsule of high signal intensity and a central low signal intensity. The thick fibrous capsule shows various degrees of enhancement (arrows). FA of 180 degrees, a TR of 976 milliseconds and a TE of 12 milliseconds. PE: pericardial effusion, Emp: empyema, RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricle.

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  Fig. 2 Partial resection of right 4th and 5th rib was peformed. The operative field showed a large amount of empyema debris filled in the right pleural cavity.

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