Clin Res Cardiol 95:54–56 (2006) DOI 10.1007/s00392-006-0316-8
C. Werner R. Rbah M. Böhm
Received: 11 April 2005 Accepted: 22 August 2005
Dr. Christian Werner ()) · Rania Rbah Prof. Dr. med. Michael Böhm Klinik für Innere Medizin III Universitätsklinikum des Saarlandes Direktor: Prof. Dr. med. Michael Böhm 66421 Homburg-Saar, Germany Tel.: 0 68 41 / 1 62 30 00 Fax: 0 68 41 / 1 62 33 69 E-Mail:
[email protected]
CASE REPORT
Cardiovascular dysphagia
n Summary A 72-year-old patient was admitted to our clinic following posterior wall myocardial infarction. Furthermore, he had suffered from dysphagia and intermittent regurgitation for a time period of two months. Radiological diagnostics revealed an esophageal impingement by the left atrium and the descending aorta due to severe thoracic scoliosis. This represents an infre-
quent form of cardiovascular esophageal compression. n Key words Extrinsic esophageal compression – dysphagia lusoria
Physical examination
Electrocardiography
72-year-old male patient (172 cm, 79 kg); Cardiovascular system: heart sounds rhythmic, 70 bpm, without murmurs, RR 163/80 mmHg, no peripheral pulse deficit; Thorax and lungs: hyperlordosis, dextral arcuate scoliosis, vesicular breath sound, normal percussion sounds; Gastrointestinal system: soft, no tenderness to pressure, no hepatosplenomegaly, normal peristaltic movements; Central nervous system: no neurological deficit.
Sinus rhythm, left axis deviation, q wave in lead III and aVF, negative T in lead II, III, aVF and V5–6.
Two-dimensional echocardiography Left ventricle within normal dimensions and preserved systolic function, no hypertrophy, inferior hypokinesia, signs of impaired diastolic relaxation. Color-coded duplex sonography: aortic insufficiency grade I, mitral insufficiency grade I–II.
Laboratory tests Creatine kinase 1000 U/l, CK-MB 79 U/l, ASAT 164 U/l, LDH 511 U/l, C-reactive protein 30 mg/l, hemoglobin 11.6 g/dl.
Cardiac catheterization Left ventricular angiography: ejection fraction 76%, inferior hypokinesia. Coronary angiography: 70% stenosis of the proximal circumflex artery, occlusion of a right coronary artery posterolateral branch as the infarct lesion.
C. Werner et al. Cardiovascular dysphagia
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Radiological findings Chest radiography (Fig. 1) showed a right-sided scoliosis of the thoracic spine and vertebral osteophytes. The main findings of the gastrografin swallow examination were a dorsal compression and kinking within the central part of the esophagus and stasis of contrast medium following the regular contraction at this point (Figs. 2 and 3). Computed tomography of the thorax revealed a sigmoid rotatory scoliosis of the lumbar and thoracic spine and multiple lateral supporting osteophytes. The elongated aorta displaces the trachea and forces the esophagus into sinistrolateral course. Further caudal the esophagus becomes impinged between the left atrium, descending aorta and the left main bronchus (Figs. 4 and 5), resulting in a compression and significant stenosis. This stricture is followed downwards by an atypical course of the esophagus left of the descending aorta to the esophageal hiatus of the diaphragm.
Clinical course and discussion The percutaneous coronary intervention was followed by an inconspicuous clinical course after the myocardial infarction. Radiological imaging revealed an extrinsic esophageal compression as the cause of the patient’s complaints, for example, due to a mediastinal tumor. However, computed tomography of the chest showed a rare case of cardiovascular com-
Fig. 1 Chest radiography
Fig. 2 Contrast swallow examination
Fig. 3 Contrast swallow examination
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Clinical Research in Cardiology, Volume 95, Number 1 (2006) © Steinkopff Verlag 2006
Fig. 4 Computed tomography of the thorax (1: Esophagus, 2: Thoracic aorta, 3: Left atrium, 4: Left ventricle, 5: Pulmonary veins, 6: Vertebral body, 7: Sternum)
Fig. 5 Computed tomography of the thorax (1: Esophagus, 2: Thoracic aorta, 3: Left atrium, 4: Left ventricle, 5: Pulmonary veins, 6: Vertebral body, 7: Sternum)
pression as the cause of dysphagia in this case. The patient turned down the option of endoscopic examination at the time. Examples for extrinsic esophageal compression are found in inflammatory, postoperative and neoplastic mediastinal diseases, but also in substernal strumae, cervical spondylitis and vertebral osteophytes. Vascular esophageal compression syndromes are typically caused by an aberrant origin of the right subclavian artery far left in the aortic branch
and course of this “A. lusoria” [1–4] anterior or posterior of the esophagus. In addition, similar forms of esophageal compression can result from a congenital right-sided aorta, aortic aneurysms and conditions of left atrial enlargement [2]. In contrast to the progressive nature and unfavorable prognosis of malignancy-induced dysphagia, vascular abnormalities are frequently associated with rather mild and intermittent symptoms and a benign clinical course [3].
References 1. Bayford D (1794) An account of a singular case of obstructed deglutition. Mem Med Soc London 2:275–280 2. Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper DL, Hauser SL, Longo DL (eds) (1998) Harrison’s principles of internal medicine, 14th edn. McGraw-Hill, New York
3. Janssen M, Baggen MG, Veen HF, Smout AJ, Bekkers JA, Jonkman JG, Ouwendijk RJ (2000) Dysphagia lusoria: clinical aspects, manometric findings, diagnosis and therapy. Am J Gastroenterol 95:1411–1416
4. Kent PD, Poterucha TH (2002) Aberrant right subclavian artery and dysphagia lusoria. N Engl J Med 346:1637
