Not a Simple Cyst: Hepatic Cyst Causing Intra-cardiac Shunting Relieved by Percutaneous Drainage

Abstract

Hepatic cysts are a relatively benign and asymptomatic group of disorders, which are usually found incidentally during imaging studies. We present a case of a large hepatic cyst causing intra-cardiac shunting during a workup of hypoxemia. A 68 year old male, with recently diagnosed marginal zone lymphoma of the lung, presented to the ED for dyspnea on exertion and hypoxia requiring 100% FiO2 by high-flow nasal cannula. ABG showed severe A-a gradient with PaO2 of 42 and SaO2 of 82, concerning for cardiac shunt. Transesophageal echocardiogram showed right to left inter-atrial shunt, across a patent foramen ovale (PFO), following injection of agitated saline. Further workup with CT Chest PE protocol ruled out pulmonary embolus and right-sided cardiac catheterization did not show evidence of pulmonary hypertension. Interestingly, the patient would desaturate when laying on his right side. The CT Chest and echocardiogram caught a portion of a hepatic cyst near the right atrium. A dedicated abdominal CT scan showed multiple complex cystic lesions within the liver, largest in the dome and right lobe of liver measuring 21.7x14.8 cm. The lesion in the dome of the liver caused mass effect on the right atrium. Differential of the cystic lesions were benign hepatic cysts, hydatid disease or biliary cyst adenomas. Cardiology attempted catheter-based closure of the PFO, but were unsuccessful due to the high-pressure gradient. Hepatobiliary surgery consult did not suggest resection given medical comorbidities; thus, percutaneous drainage was recommended. There was hesitation to drain the hepatic cysts percutaneously due to the possibility of echinococcus. The patient had a travel history outside of the United States and was recently exposed to farm animals. Echinococcus serum antibody IgG was tested and returned negative. Percutaneous drain was placed in the largest cyst by Interventional Radiology with 600 mL of brown serosanguinous fluid drained upon insertion. Patient had immediate symptomatic relief and oxygen requirements were weaned to room air within hours. There have been cases where large hepatic cysts caused compression of the right atrium as well as causing cardiac arrhythmias, which resolved with surgical cyst resection. There has been one other reported case of a hepatic cyst causing intra-cardiac shunting across a PFO with symptomatic relief through surgical cyst resection. We present a case in which a large hepatic cyst causing cardiopulmonary abnormalities was successfully treated with non-surgical and minimally invasive techniques.Figure 1Figure 2Figure 3