Fatal cardiac tamponade due to coronary sinus thrombosis in acute lymphoblastic leukaemia: a case report
© Kitazawa et al; licensee BioMed Central Ltd. 2009
Received: 19 September 2009
Accepted: 27 November 2009
Published: 27 November 2009
We report a rare case of fatal cardiac tamponade attributed to coronary sinus thrombosis. An 83-year-old man was admitted to the hospital complaining of general fatigue. Laboratory examination revealed marked increase of atypical lymphoblastic cells in peripheral blood. CHOP therapy was started under the diagnosis of acute lymphoblastic leukemia. The patient died, however, of sudden cardiac arrest in the initial course of the chemotherapy. Autopsy revealed cardiac tamponade with markedly dilated and congested coronary vein induced by coronary sinus thrombosis. A condition similar to leukemia-related venous thromboembolic disease, combined with endothelial damage induced by leukemic infiltration, may cause this rare complication.
Coronary sinus thrombosis (CST) is an unusual but serious complication of central venous catheter devices . Direct trauma of the catheter to the coronary sinus endothelium is the most common cause of the thrombosis [1, 2]. The clinical outcome of CST is often unpredictable, however, and sometimes even asymptomatic  due to the rapid recovery of blood flow by collateral circulation. Although not so common as rupture of the aneurysm of sinus of Valsalva, CST can cause pericardial tamponade leading to sudden death [4, 5]. Here, a rare case of fatal cardiac tamponade attributed to coronary sinus thrombosis in an 83-year-old man with acute lymphoblastic leukemia is described.
Except for a very rare and spontaneous primary case , CST is usually initiated by endothelial damage after access to the right atrium through invasive cardiac procedures such as insertion of central venous lines, pacing wire, or coronary sinus catheterization [1, 2]. It has also been documented as a complication of heart transplants, mitral valve replacement and infectious endocarditis . Similar to venous thromboses, other than vessel wall injury leading to endothelial damage, factors such as stasis and alteration of the coagulation status all contribute to the formation of CST.
Thromboembolic complications in malignancies include clinically silent hemostatic abnormalities, venous thromboembolism, pulmonary embolism, disseminated intravascular coagulation and life-threatening thrombohemorrhagic syndrome . While cerebral venous and sinus thromboses are well documented as relatively rare but often fatal forms of venous thromboembolic complications of hematological malignancies , CST with sudden cardiac arrest after acute pericardial tamponade in leukaemic patients has not been reported. Because both endothelial damage by leukaemic cell infiltration to the venous vessel wall and the hyperviscosity and hypercoagulation status by leukaemic cells are common in leukaemia, especially in acute lymphoblastic leukaemia, clinically silent CST or sudden death by CST, as seen in this case, may be either missed or clinically not recognized as such. Furthermore, this sudden thrombotic risk could be increased by antiblastic drugs affecting the procoagulant activity of cells and the production of coagulation inhibitors from the liver .
Written informed consent was obtained from the patient for publication of this case report with accompanying images. A copy of the written consent is available for viewing by the Editor-in-Chief of the journal.
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