Cardiac Silhouette Research Articles

Evaluation of Cardiologic Alterations in Radiographs of Dogs with Pneumonia Before and After Treatment

Pneumonia, a common respiratory disease in small animals, causes significant hypoxemia in dogs due to reduced lung capacity and cardiac output. In addition, pneumonia may lead to cardiac complications. With this approach, the evaluation of the alterations in cardiac silhouette and main vessel views in dogs underwent treatment for pneumonia aimed in this study. For this purpose, radiographic data from 28 dogs with pneumonia diagnosed and treated were analyzed. The study evaluated the cardiological views in radiographs of dogs with pneumonia before and after treatment. The measurements included left atrial size, long axis, short axis, 4th thoracic vertebra, aorta width, caudal vein cava width, and thoracic width. Pre-treatment and post-treatment radiographs showed no alteration in the long and short axes of VHS, 4th Thoracic Vertebra, aorta and caudal vena cava width, and thoracic width. But the left atrial size was observed to be larger in pre-treatment radiographs than in post-treatment ones. Moreover, a strong positive correlation was detected between LA and LA/TV4 in pre- and post-treatment measurements, as well as for measurement differences between pre- and post-treatment radiographs. As a consequence, the radiographs used to monitor the treatment process of pneumonia may give an alert for cardiac complications in dogs with pneumonia as a first line.

A-002 Analytical Validation of the Zybio High Sensitivity Cardiac Troponin I CLIA Assay

Abstract Background High-sensitivity cardiac troponin (hs-cTn) plays a pivotal role in the early diagnosis of Acute Coronary Syndrome (ACS). With technological advancements, the sensitivity of troponin assays has significantly improved. The International Federation of Clinical Chemistry (IFCC) criteria for hs-cTn assays include a total imprecision (Coefficient of Variation, CV) ≤10% at the gender-specific 99th percentile value and detectable levels in ≥50% of a healthy population. This study aims to evaluate the performance of Zybio's hs-cTnI assay against these high-sensitivity standards Methods This study involved 1661 individuals undergoing routine health checks at Chongqing Medical University Third Hospital. Exclusion criteria included recent medication use, abnormal NT-proBNP levels, significant cardiac silhouette changes in chest X-rays, age <20, incomplete data, pregnancy, or history of severe chronic diseases. Participants were classified into apparent healthy and healthy groups based on blood pressure, lipid profiles, and electrocardiogram results. Laboratory examinations included hs-cTn and NT-ProBNP concentrations using Zybio's chemiluminescence instrument EXI2400 and associated reagent kits, with other parameters measured using standard biochemical and high-performance liquid chromatography methods. Results Of the 1247 participants (556 males, 691 females) included in the final analysis, 1157 showed detectable hs-cTnI levels above the limit of detection (LOD), yielding an overall detection rate of 92.78%. Detection rates were 93.71% in males and 92.04% in females. The total imprecision (CV) of hs-cTnI at gender-specific 99th percentile values over 20 days was below 10%, meeting the high-sensitivity criteria. This finding was consistent across lower and higher concentration ranges. Conclusions The Zybio hs-cTnI assay demonstrated a high detection rate in a healthy population, with 92.78% detectability overall, 93.71% in males, and 92.04% in females. The assay met the high-sensitivity criteria of IFCC, with a total imprecision (CV) of less than 10% at the gender-specific 99th percentile levels. These results validate the utility of Zybio's hs-cTnI assay for clinical application in the early diagnosis of ACS.

Diagnosis Dilemma; Patient with Breathlessness & Befogged Appearing Cardiomegaly on Chest Xray

A sixty-year-old south Indian woman complained of dyspnoea on excretion, unexpected weight gain and other symptoms and signs of hypothyroidism that had been present over a year. When examined physically, the blood pressure was 110/70mmg. The heartbeat was regular at 82beats/min and oxygen saturation at room air was 96%. The point of highest impulse was found to be in the fifth intercostal space, 10 cm to the left of the midsternal line, on examination there was no murmur or friction rub audible, and the heart sounds were within normal limits. Ankle oedema, rales, or hepatomegaly were absent. Thyroid function test showed the following values FT3 1.2 pg/ml FT4 0.5 ng/dl TSH 10 micro IU/ml and patient was started on T. Thyroxine 50 mcg/day Chest Xray showed an expanded cardiac silhouette on the right side at the junction of diaphragm and heart (Fig. 1). At the time, differential diagnosis made were myocarditis, pericarditis, or pericardial cyst. The ECG showed no abnormalities. HRCT scan visualized a radiolucent border around a centrally located, normal-sized heart shadow measuring several centimetres in thickness. This radiolucency was indicative of a significant fat build-up in the tissues surrounding the heart. 2dEcho showed pericardial fat deposition with EF 62% and NRWM. Pulmonary Function Test (PFT) was done it showed restrictive pattern. Ultimately, the clinical impression was made that hypothyroidism was the cause of the patient's symptoms. It was suggested that the dyspnea was brought on by weakened muscle tone occurring as sequelae to hypothyroidism and the rapid increase in weight gain could have contributed to the increase in pericardial fat.

Cardiac tamponade in severe dengue: A case report

Dengue infection is characterized by a wide spectrum of clinical manifestations. Cardiac involvement may include arrhythmias, myocarditis, or pericardial effusion, which in some cases may be asymptomatic, but can also be fatal. We describe the case of a 45-year-old woman with severe dengue infection. She presented with hypotension refractory to fluid therapy requiring vasopressor support without improvement in vital signs. Decreased voltage on electrocardiographic tracing, enlarge cardiac silhouette in chest radiograph, and point-of-care ultrasound confirmed the presence of cardiac tamponade. Ultrasound-guided pericardiocentesis was performed with subsequent correction of clinical parameters. High clinical suspicion and early recognition of this infrequent but important presentation allowed a good outcome in our case.

The effects of alfaxalone on cardiac and pulmonary vascular size in cats evaluated by thoracic radiography and echocardiography.

Alfaxalone is a neuroactive steroid that modulates the GABAA receptor, which has shown recent widespread use as a sedative and anesthetic agent in cats, especially in patients being screened for cardiovascular disease. This prospective, partially blinded, randomized experimental study aimed to determine if sedation with alfaxalone would alter the appearance of the cardiac silhouette or pulmonary vasculature on thoracic radiographs or echocardiographic indices of cardiac or pulmonary vascular size. Eleven apparently healthy adult cats were recruited from a research colony. Four-view thoracic radiographs and an echocardiogram were performed at baseline and following a 5mg/kg intramuscular dose of alfaxalone. Vertebral heart score (VHS) and cranial and caudal lobar pulmonary vascular measurements were obtained at both time points by two independent blinded observers, and these were analyzed using two-way ANOVA. The nonblinded echocardiographer obtained echocardiographic measurements at both time points, which were analyzed using a paired t-test or Wilcoxon signed rank test. No significant differences were identified in VHS measurements or echocardiographic parameters between baseline and sedated cats. In healthy cats, alfaxalone does not appear to significantly affect the cardiovascular structures evaluated via thoracic radiography or echocardiography.

Reference values for Vertebral Heart Size and Manubrium Heart Score for Healthy Border Collies

This study aimed to establish reference values for vertebral heart size (VHS) and manubrium heart score (MHS) in healthy adult Border Collies. The study utilized 12 dogs, both male and female, aged between 1 and 9 years. All dogs exhibited normal results on B- and M-mode echocardiography. Thoracic radiographs were taken in left lateral (LL), right lateral (RL), and ventrodorsal (VD) recumbency. Both subjective and objective analyses were conducted by two evaluators. The reproducibility of the objective radiographic measurements was excellent (P < 0.001), with the following mean values and standard deviations: VHS LL = 9.95 ± 0.47; VHS RL = 10.10 ± 0.51; VHS VD = 10.84 ± 0.61; Short-MHS RL = 2.10 ± 0.17; Long-MHS RL = 2.57 ± 0.19; Overall MHS RL = 4.65 ± 0.33; Short-MHS VD = 2.13 ± 0.22; Long-MHS VD = 2.94 ± 0.26, and Overall MHS VD = 5.03 ± 0.42. This study contributes to the standardization of VHS and MHS measurements, thereby aiding in the evaluation of the cardiac silhouette of Border Collies.

Early Detection of Heart Failure with Autonomous AI-Based Model Using Chest Radiographs: A Multicenter Study.

The opportunistic use of radiological examinations for disease detection can potentially enable timely management. We assessed if an index created by an AI software to quantify chest radiography (CXR) findings associated with heart failure (HF) could distinguish between patients who would develop HF or not within a year of the examination. Our multicenter retrospective study included patients who underwent CXR without an HF diagnosis. We included 1117 patients (age 67.6 ± 13 years; m:f 487:630) that underwent CXR. A total of 413 patients had the CXR image taken within one year of their HF diagnosis. The rest (n = 704) were patients without an HF diagnosis after the examination date. All CXR images were processed with the model (qXR-HF, Qure.AI) to obtain information on cardiac silhouette, pleural effusion, and the index. We calculated the accuracy, sensitivity, specificity, and area under the curve (AUC) of the index to distinguish patients who developed HF within a year of the CXR and those who did not. We report an AUC of 0.798 (95%CI 0.77-0.82), accuracy of 0.73, sensitivity of 0.81, and specificity of 0.68 for the overall AI performance. AI AUCs by lead time to diagnosis (<3 months: 0.85; 4-6 months: 0.82; 7-9 months: 0.75; 10-12 months: 0.71), accuracy (0.68-0.72), and specificity (0.68) remained stable. Our results support the ongoing investigation efforts for opportunistic screening in radiology.

Effect of body condition score on the interobserver variability of vertebral heart scale assessment in dogs.

The vertebral heart scale (VHS) is widely known and used as an objective standard for the evaluation of cardiomegaly on thoracic radiographs. It, therefore, plays an important role in assessing the severity of canine heart disease. The body condition score (BCS) is a nine-scale body condition scoring system used to objectively document the body condition in dogs. Obese animals have widened precardiac and postcardiac mediastinum, fat deposits between the sternum and lungs or heart, as well as increased pericardial fat. These conditions could complicate cardiac silhouette evaluation and could, therefore, result in higher interobserver variability in the assessment of VHS. The purpose of this study was to investigate whether overweight dogs (BCS 6/9, 7/9, 8/9, and 9/9) have more variability in the interobserver VHS measurement compared with dogs with a normal BCS (BCS 4/9 and 5/9). The dogs were admitted to a private referral center for different medical reasons. The VHS was measured by three trained observers in right lateral radiographs of 18 overweight dogs and 33 dogs with a normal BCS. Bland-Altmann plots were constructed, and limits of agreement were calculated to show the variability of VHS measurements. No statistically significant differences in VHS variability were found between BCS categories, observers, sex, or age categories. In conclusion, BCS does not affect the reliability of VHS assessment among trained veterinarians.

Hérnia diafragmática peritônio-pericárdica em gato

Peritoneal-pericardial diaphragmatic hernia (PPHD) is a rare condition in dogs and cats, being more prevalent in felines. Studies show that the Persian breed is particularly predisposed to this condition, suggesting a genetic predisposition. HDPP is generally a congenital anomaly and is not associated with trauma in small animals. The most commonly herniated organs include the liver and loops of intestine, due to their proximity to the diaphragm. Diagnosis of HDPP usually involves a combination of imaging methods such as radiography, echocardiography, and abdominal ultrasound. Surgical correction is recommended in cases of evident clinical manifestations, as well as in herniations of vital organs, such as intestinal loops or stomach. However, in cases where the hernia is an incidental finding and the patient is clinically stable, surgery may be avoided due to the risks associated with the procedure. The objective of this work is to report the case of a five-year-old Persian cat, which had no clinical manifestations and was diagnosed with peritoneal-cardiac diaphragmatic hernia. During the treatment, the animal presented dyspnea, which was an episode that had previously occurred according to the owner. An x-ray, Doppler echocardiogram and abdominal ultrasound were requested. A significant increase in the cardiac silhouette and the presence of liver tissue within the pericardial sac were noted, confirming the diagnosis of HDPP. Due to the animal's age, the herniated organ and the presence of only one sporadic clinical sign, surgical treatment was not initially recommended. The owner chose not to perform the surgery and was prescribed a specific diet to assist in the weight loss process and avoid episodes of dyspnea. The animal lived until it was nine years old, when it died due to chronic kidney disease unrelated to HDPP.

Right versus left lateral recumbent radiographs for assessment of the cardiac silhouette in dogs.

Right versus left lateral recumbent radiographs for assessment of the cardiac silhouette in dogs.

Periaortic paraganglioma and pericardial effusion in a Golden Retriever dog: Case report

The case of a 10-year-old Golden Retriever dog treated at the ASMEVET veterinary hospital in the city of Tunja, Colombia is presented. The owner reported that the patient had an intermittent cough for 2 months. The physical examination revealed the patient to be hyperactive, body condition 4/5, and faint heart sounds. Echocardiography, chest x-ray, and electrocardiogram were performed, revealing pericardial effusion, increased size of the cardiac silhouette, and deviation of the S-T segment. Initially, treatment was attempted with antibiotics, diuretics and anti-inflammatory agents, without a favourable response. Two months later, it was necessary to perform emergency pericardiocentesis due to cardiac tamponade, and partial subphrenic pericardiectomy. Histopathological analysis revealed a paraganglioma. The patient survived 673 days after surgical treatment.

Transcatheter closure of a coronary artery to pulmonary artery fistula with two sequential giant aneurysms.

A 73-year-old female presented with exertional dyspnea and was found to have a coronary artery to pulmonary artery fistula with 2 sequential giant aneurysms. Her chest radiograph showed a mass above the cardiac silhouette.

AI-derived epicardial fat measurements improve cardiovascular risk prediction from myocardial perfusion imaging

Epicardial adipose tissue (EAT) volume and attenuation are associated with cardiovascular risk, but manual annotation is time-consuming. We evaluated whether automated deep learning-based EAT measurements from ungated computed tomography (CT) are associated with death or myocardial infarction (MI). We included 8781 patients from 4 sites without known coronary artery disease who underwent hybrid myocardial perfusion imaging. Of those, 500 patients from one site were used for model training and validation, with the remaining patients held out for testing (n = 3511 internal testing, n = 4770 external testing). We modified an existing deep learning model to first identify the cardiac silhouette, then automatically segment EAT based on attenuation thresholds. Deep learning EAT measurements were obtained in <2 s compared to 15 min for expert annotations. There was excellent agreement between EAT attenuation (Spearman correlation 0.90 internal, 0.82 external) and volume (Spearman correlation 0.90 internal, 0.91 external) by deep learning and expert segmentation in all 3 sites (Spearman correlation 0.90–0.98). During median follow-up of 2.7 years (IQR 1.6–4.9), 565 patients experienced death or MI. Elevated EAT volume and attenuation were independently associated with an increased risk of death or MI after adjustment for relevant confounders. Deep learning can automatically measure EAT volume and attenuation from low-dose, ungated CT with excellent correlation with expert annotations, but in a fraction of the time. EAT measurements offer additional prognostic insights within the context of hybrid perfusion imaging.

Radiographic Left Atrial Size Measurement of Dogs in Different Mitral Valve Disease Stages with Four Different Methods.

The left atrial size increases (LAS) in patients with mitral valve disease (MVD) as the disease progresses. The vertebral left atrial size (VLAS), the modified-vertebral left atrial size (M-VLAS), and the radiographic left atrial dimension (RLAD) are methods reported to assess LAS on dogs' radiographs. All these methods transform the LAS into vertebral units. The thoracic inlet (TI) has been used as a reliable reference point to measure the cardiac silhouette of dogs with MVD in different stages. The objective of this study was to assess the clinical utility of measuring a dog LAS on right thoracic X-rays using the TI as a reference and determine whether it could differentiate dogs in different MVD stages. LAS was divided by the TI to obtain the thoracic inlet left atrial score (TILAS). This was a retrospective observational study including 135 apparently healthy dogs performed to assess their LAS with four different methods: VLAS, M-VLAS, RLAD, and TILAS. Thirty-six dogs from the general population were selected and compared to 100 dogs in different MVD stages. The TILAS was significantly different between the control dogs and MVD dogs, increasing with the disease stage: control dogs 0.51 ± 0.08, B1 0.57 ± 0.14, B2 0.75 ± 0.13, and C 0.84 ± 0.18. VLAS, M-VLAS, and RLAD also increased as the disease progressed, as shown in previous studies. The TILAS accuracy to distinguish MVD dogs with cardiac enlargement was comparable to VLAS, M-VLAS, and RLAD (AUC 0.91 vs. 0.93, 0.90, and 0.94 respectively). A TILAS > 0.8 can identify dogs with cardiac enlargement secondary to MVD.

Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum.

Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.

A rare case of cardiac calcified amorphous tumor in a 34-year-old woman diagnosed at autopsy

Abstract Introduction/Objective Cardiac calcified amorphous tumor (CAT) is an uncommon, non-neoplastic heart lesion with an unknown incidence due to its rarity. Some authors have reported a female predominance of 62.5%. Many cases are associated with end-stage renal disease, diabetes mellitus and coronary artery disease. Dysfunction of calcium- phosphorus metabolism and hypercoagulability are thought to contribute to its pathogenesis. This is the first case reported from our institution. Methods/Case Report We present the case of a 34-year-old woman with a remote history of ulcerative colitis, type 1 diabetes mellitus, hypertension, Hashimoto thyroiditis, cardiomegaly, and end-stage renal disease on continuous hemodialysis. She had multiple hospitalizations for mesenteric ischemia and small bowel resections. She was admitted multiple times in 2021 for complaints of pain in bilateral thighs, shortness of breath, frequent loose stools, and abdominal pain. She was poorly compliant with hemodialysis. A chest x-ray showed severe enlargement of the cardiac silhouette. A CT angiogram of the abdomen and pelvis showed arteriosclerosis of the superior mesenteric, inferior mesenteric and celiac arteries. The patient presented to the hospital in February 2022 with continuous abdominal pain, gluteal pain, and diarrhea. Her creatinine was consistently elevated at 3.52 mg/dL. On the sixth day of admission, she was found unresponsive and was pronounced dead. Autopsy showed cardiomegaly (600 grams) with left ventricular hypertrophy, recent myocardial infarction of the posterolateral left ventricle and moderate to severe coronary artery atherosclerosis. There were lesions composed of calcified amorphous material involving the mitral valve, the endocardium and subendocardial portions of the left and right ventricles, consistent with multifocal cardiac calcified amorphous tumor. The largest lesion measured 4.0 cm. The cause of death was myocardial infarction complicating type 1 diabetes mellitus and end-stage renal disease. Results (if a Case Study enter NA) NA Conclusion CATs are usually asymptomatic but possible symptoms include dyspnea and syncope. As a result, they are often incidental findings. The calcified deposits may embolize, causing pulmonary embolism and cerebral infarction. CAT is most frequently observed in the left heart, especially on the mitral annulus; however, the right side of the heart can also be affected. End-stage renal disease is a predisposing condition, as seen in this patient.

Abstract 17593: Betel Quid Addiction Causing Monomorphic Ventricular Tachycardia

A 44-year-old woman presented to the emergency room due to worsening shortness of breath over the past few days with accompanying dizziness, cough, and fever. Her history was significant for asthma, obstructive sleep apnea, and hypertension. Upon arrival, she was noted to be hypoxic on room air and required supplemental oxygen. Physical exam showed extensive pitting edema in the lower extremities and crackles in bilateral lung fields. Chest radiograph revealed an enlarged cardiac silhouette and increased interstitial infiltrates consistent with pulmonary edema. While in the emergency department she was noted to have frequent episodes of asymptomatic non-sustained monomorphic ventricular tachycardia. Further questioning revealed the patient had been using betel quid daily for over 20 years to improve her mood and energy levels. She had attempted to quit in the past but was unable to do so. Echocardiogram was performed which showed preserved left ventricular function and severely dilated right ventricle. BNP was elevated at 1930 pg/mL. Due to her ventricular arrhythmias and cardiomyopathy, coronary angiography was performed; this was negative for epicardial coronary artery obstruction. Case was discussed with electrophysiology who determined the arrhythmias were likely caused by the extensive betel quid consumption. She was placed on beta-blockers and betel quid cessation was strongly recommended. Betel quid is a chewing product made from of areca nut, betel leaf, slaked lime, with or without tobacco. It is commonly used in the tropical Pacific, Asia, and parts of East Africa, and is the fourth most widely consumed addictive substances in the world due to its ability to increase alertness and produce mild euphoria. Adverse effects of betel quid include tachycardia, hyperlipidemia, metabolic syndrome, hepatotoxicity, and it is a known carcinogen. The active compound is arecoline, which acts as a parasympathomimetic on muscarinic and cholinergic receptors, increasing the central sympathetic response and producing tachycardia. Betel quid has been shown to produce ventricular arrhythmias in patients with underlying cardiomyopathy, which is likely what occurred in our patient. Betel quid cessation therefore advised in these patients.

Abstract 12877: Giant Pericardial Cyst Causing Syncope

A 30 year old male presented with episodes of near syncope with dizziness, palpitations, chest tightness, and left arm paresthesias. Upon presentation, his vitals were normal. Initial imaging of a chest radiograph showed an enlarged cardiac silhouette and a follow-up chest CT demonstrated a 10 cm cystic mass in the anterior mediastinum concerning for a giant pericardial cyst. Echocardiogram was performed which showed a normal ejection fraction, no valvular abnormalities, and a trivial pericardial effusion. A CT-guided drainage was performed with 440mL of fluid removed and shrinkage of the cyst to 27x63mm. The aspirate was loaded with leukocytes without organisms identified. The following day, the cyst recollected to 85x69mm. Repeat CT-guided drainage was attempted however was unsuccessful due to right pneumothorax. After resolution of the pneumothorax, he was asymptomatic prompting discharge with close outpatient follow-up. Outpatient imaging demonstrated increased size of the pericardial cyst to 11 cm in diameter. A third drainage via CT-guidance was attempted however only minimal fluid was able to be drained. As the patient remained asymptomatic, it was recommended the patient have repeat imaging in 6 months and monitor for symptoms. Pericardial cysts are relatively rare and comprise 7% of mediastinal masses. They originate from failed fusion of the mesenchymal lacunae that form the pericardial coelom. Pericardial cysts typically range from 1 to 5 cm in diameter, with those over 10cm being termed 'giant pericardial cysts'. Most cysts are asymptomatic, although if symptoms do occur they are generally in response to mass effect and compression of local structures, such as shortness of breath and chest discomfort. If a patient remains asymptomatic, conservative management with serial imaging is recommended. However, if a patient becomes symptomatic or develops complications, surgical management via a pericardectomy or percutaneous aspiration is recommended.

Abstract 12450: Mystifying Masquerade: Renal Cell Carcinoma Associated Arteriovenous Fistula Presenting as High-Output Heart Failure

Case Presentation: 59 year-old woman with CKD stage 3b and hypertension presented with 3 months of progressive dyspnea, abdominal distension, bilateral lower extremity edema, and a 60-pound weight gain. Physical exam noted diffuse anasarca, with stable hemodynamics on room air. EKG revealed low voltage leads and chest X-ray demonstrated an enlarged cardiac silhouette. CT abdomen was remarkable for significant ascites, body wall edema, and a suspicious large right renal mass. Diagnostic paracentesis indicated cardiac ascites. Echocardiogram showed preserved ejection fraction, moderate pericardial effusion and an enlarged right side of the heart. Right heart catheterization confirmed high-output heart failure (HOHF). A suspected renal mass-related arteriovenous fistula (AVF) was confirmed through inferior vena caval and renal venogram blood gas sampling, indicating arteriovenous shunting within the renal mass. Hepatic venogram excluded portal hypertension. MRI abdomen confirmed a large necrotic right renal mass consistent with renal cell carcinoma (RCC). Symptoms significantly improved after nephrectomy, with aggressive diuresis, and therapeutic paracenteses leading to an 80-pound weight loss. Postoperative echocardiography illustrated decrease in pericardial effusion and right ventricular size. Cardiac MRI and stress test were unremarkable prior to planned immunotherapy for stage III RCC. Discussion: AVF and HOHF associated with malignancy are unusual presentations. RCC is the most prevalent underlying malignancy linked with AVF and is hypothesized to be a result of hypervascularity caused by a VHL gene mutation. The most often utilized imaging modalities for detecting a tumor-related AVF are contrast enhanced CT or MRI. When imaging is inconclusive, a venogram with blood gas sample, as observed in our case, may be considered to establish an RCC-associated AVF.

THU601 Massive Pericardial Effusion As Sole Symptom For Uncontrolled Hypothyroidism.

Abstract Disclosure: D.A. Lopez: None. M. Caban: None. C. Camacho: None. Y. Fuentes: None. M. Sanchez: None. K. Velez: None. Hypothyroidism is a common endocrine disorder with worldwide prevalence resulting from deficiency of thyroid hormone that can affect multiple organs. It can be asymptomatic and subclinical or symptomatic with fatal complications. Hypothyroidism can present with symptoms such as fatigue, slow movement and slow speech, cold intolerance, constipation, weight gain, and bradycardia. Hypothyroidism can be the cause of pericardial effusion due to increase membrane permeability. Massive pericardial effusion or pericardial tamponade is rare. Pericardial effusion can also be caused by autoimmune conditions, infections, uremia, medications, iatrogenic, and trauma. This is a case of 68-year-old Hispanic female with past medical history of hypothyroidism that was admitted to the hospital due to large pericardial effusion. These findings were found incidentally by her primary care physician during a preoperative evaluation for cataract surgery. Chest X-ray showed massive enlargement of the cardiac silhouette. Echocardiogram was ordered presenting large circumferential pericardial effusion with moderate diastolic right atrial collapse reason why patient was sent to the hospital. Physical examination showed distant heart sounds but absent jugular venous distention. Vital signs were within normal limits. Beck's triad was absent. Electrocardiogram showed a sinus rhythm with low QRS voltage. Patient denied any recent procedure, trauma, myocardial infarction, malignancy, or fever. Complete blood count was without leukocytosis, normal hemoglobin levels and platelet count. Basic metabolic panel presented without electrolyte disturbances and preserved renal function. Evaluation for causes of pericardial effusion was made including autoimmune conditions. Results showed negative ANA, Rheumatoid factor, Anti-dsDNA antibody, Anti-Scl-70 antibody, anti-U1-ribonucleoprotein, anti-Ro, and anti-La. Inflammatory markers were within normal limits. TSH level were in 22.5μIU/mL (0.03-5.0μIU/mL) with undetectable Free T4 pointing towards uncontrolled hypothyroidism as the cause of her large pericardial effusion. Patient denied other symptoms of hypothyroidism. She agreed not being compliant with levothyroxine. Pericardiocentesis was done and 750ml of pericardial fluid was removed. A catheter was placed and 200ml of fluid was drained on the second day. Catheter was removed and Echocardiogram showed immediate resolution of the diastolic right atrial collapse. She was sent home with adequate medical therapy and intense education of hypothyroidism. As a take home message, this unique case presents the importance of being compliant to medical therapy since the initial presentation of uncontrolled hypothyroidism could be a fatal complication as pericardial effusion. This could’ve been prevented if compliance with medications was encourage since the beginning of this disorder. Presentation: Thursday, June 15, 2023