Post-operative refractory hypotension due to right heart compression by hepatic cysts in a patient with autosomal dominant polycystic kidney disease

Cardiac compression of a hepatic cyst in polycystic liver disease: A rare cause of hemodynamic instability

Polycystic liver disease (PLD) develops due to embryonic ductal plate malformation of intrahepatic bile ducts. Cysts in the liver can range from a simple compression effect to severe liver failure. The most common complication is rupture and inflammation of cyst. It can sometimes progress to the extent of pushing the heart to the left or compressing the inferior vena cava, thereby reducing the venous return. Here, we present a case with giant liver cyst-related symptoms that caused external compression of the right ventricle and atrium. A 71-year-old female patient was admitted to our emergency department with increasing dyspnea, chest pain, and abdominal distension. Her vital signs were as follows: temperature 38°C, pulse 140 beats/min, and blood pressure 70/40 mmHg. Her abdomen was distended, and there was minimal epigastric tenderness. Hepatomegaly was also present. Posteroanterior chest radiography revealed opacity that erased the right diaphragm contour at the right inferior hemithorax. In thoracoabdominal computed tomography, the heart was deviated toward the left due to the compression of a large cystic formation located in the hepatic right lobe, pushing the diaphragm to the superior. Piperacillin/tazobactam 3 g × 4.5 g treatment was initiated, and external drainage was performed by interventional radiology. Following this procedure, significant improvement was observed in the patient’s condition. Her symptoms significantly improved, and the drainage catheter was removed on the seventh day. Hepatic cysts in patients with PLD may compress adjacent structures, and cardiac compression can be life-threatening if hemodynamic instability occurs.

Hepatic Cyst Compressing The Right Atrial and Ventricular Inflow Tract: An Uncommon Cardiac Complication

Commonly reported complications of hepatic cysts are spontaneous hemorrhage, rupture into the peritoneal cavity, infection and compression of the biliary tree however cardiac complications are not commonly reported. We are presenting a case of a large liver cyst presenting with right atrial and ventricular inflow tract impingement resulting in cardiac symptoms. A 68 year-old Hispanic female presented with one month of fatigue and shortness of breath after household work and walking less than one block, right upper quadrant pain and weight loss. She had history of multiple hepatic cysts for more than 12 years, well-controlled diabetes and hypertension. Examination of the heart revealed tachycardia with regular heart sounds. There were no murmurs. She had tenderness in her right upper quadrant on palpation and an enlarged smooth liver. Rest of physical examination was unremarkable. CT scan of the abdomen showed multiple non-enhancing liver cysts in both lobes, with the largest measuring 12 x 15 x 17 cm which was significantly increased from her baseline of 7 x 8 x 10 cm in 2003. Echocardiogram showed normal left ventricular ejection fraction, grade 1 diastolic dysfunction and a hepatic cyst impinging RA and RV inflow tract. She had successful laparoscopic enucleation of liver cyst and subsequent relief from tachycardia, fatigue and shortness of breath. In conclusion, this case illustrates that hepatic cysts may become symptomatic after remaining quiescent for an extended period. They may present with unusual symptoms and clinicians should be mindful of rare complications, such as in this case.