Misdiagnosed acute coronary syndrome masking a giant mediastinal mass causing obstructive shock: A case report

Abstrak

Background: Mediastinal tumors with intracardiac extension are exceedingly rare. Nevertheless, when both occur simultaneously, the most severe consequence is obstructive shock from mechanical inflow tract occlusion. This case illustrates the therapeutic paradox between emergency hemodynamic surgical rescue and the perioperative bleeding risk of prior antithrombotic therapy. Case Presentations: We report a 50-year-old man who was initially misdiagnosed with non-ST-elevation acute coronary syndrome (NSTE-ACS) and then received dual antiplatelet therapy (DAPT) and anticoagulant from the previous hospital. He then developed superior vena cava (SVC) syndrome with progressive hypoxemia and obstructive shock, prompting referral to our tertiary hospital. Bedside echocardiography revealed a large mass in the right atrium that originated from the superior vena cava and intermittently occluded the tricuspid valve. A patent foramen ovale (PFO) with right-to-left shunting was also identified. The multidisciplinary Heart Team recommended emergency open heart surgery for tumour evacuation and PFO repair, despite the substantial bleeding risk. Subsequent histopathology revealed thymic lymphoepithelial carcinoma. The patient succumbed to hemorrhagic shock despite aggressive damage-control resuscitation. Conclusions: This case highlights the critical utility of early point-of-care echocardiography in differentiating structural, mechanical causes of obstructive shock from acute coronary syndrome. It further underscores the therapeutic paradox faced by multidisciplinary Heart Teams when mandatory, emergency surgical decompression carries an extreme risk of catastrophic hemorrhage due to recent aggressive antithrombotic therapy.

Kata kunci

• Giant mediastinal mass
• obstructive shock
• management
• case report