Visual Diagnosis in Emergency Medicine| Volume 47, ISSUE 6, e153-e155, December 2014

Skin Color Change with Circulatory Assist Devices: Superior Vena Cava Syndrome

      An 82-year-old man with hypertension was admitted to our hospital after loss of consciousness. Electrocardiogram showed complete atrioventricular block and ST-segment elevation in the inferior leads (Figure 1A). We diagnosed him with ST-segment elevation inferior myocardial infarction. He collapsed during transfer to the catheterization laboratory and was diagnosed with pulseless electrical activity. We performed cardiac massage, intubated him, and initiated venous-arterial extracorporeal membrane oxygenation (V-A ECMO) and intra-aortic balloon pumping (IABP). Coronary angiography showed severe stenosis in the right coronary artery and total occlusion in the left anterior descending artery (Figure 1B, C). We performed primary coronary intervention in the right coronary artery (Figure 1D). After moving him to the intensive care unit, we noticed a reddening of his skin (Figure 2A). Skin color changes were localized to the upper side of the body, including the face, both arms, and along the diaphragm. These changes were easily blanchable. His blood pressure was brought to 125/61 mm Hg by IABP, and his pulse rate was 104 beats/min. The ECMO flow was 2.5–3.0 L/min and could not be increased despite large amounts of saline infusion and transfusion. The edematous change impeded visual neck vein examination; however, redness of the upper part of body led to the suspicion of acute superior vena cava (SVC) syndrome, although we could not find the exact cause of SVC syndrome despite insertion of the ECMO venous cannula. Transthoracic echocardiography could not clearly visualize the heart and vessels due to a poor echocardiographic window, but transesophageal echocardiography showed pericardial effusion and collapse of the right ventricle and both left and right atria. We could not find any thrombus in the right atrium or clearly visualize the SVC (Figure 3A). We performed emergency pericardiocentesis, and the skin color returned to normal after 600 mL of blood was removed from the pericardial space, and echocardiography showed restoration of the right heart and left atrial cavities (Figure 2, Figure 3B).
      Figure thumbnail gr1
      Figure 1(A) A 12-lead electrocardiogram. Complete atrioventricular block and ST-segment elevation in the inferior lead, and significant ST-segment depression in the other lead. (B) Coronary angiography. Total occlusion of the left anterior descending artery (white arrow). (C) Right coronary artery shows significant stenosis (arrow heads), which was jeopardized collateral artery to left descending artery. (D) Right coronary artery after stenting, which improved collateral flow to left anterior descending artery.
      Figure thumbnail gr2
      Figure 2(A) Skin color changes involve broad erythema on the upper body prior to pericardiocentesis. Arrow indicates the border of the skin erythema, which clearly demarcates the upper body. (B) After pericardiocentesis, skin erythema improved immediately.
      Figure thumbnail gr3
      Figure 3Transesophageal echocardiography shows the four chambers of the heart. (A) A small amount of pericardial effusion that totally compresses the right atrium and ventricle. (B) After pericardiocentesis, there is no residual pericardial fluid and the right atrial and right ventricular cavities are restored. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
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