Giant Pseudoaneurysm of the Left Atrium after Pneumonectomy

A 68-year-old female with squamous cell carcinoma of the middle lobe and infiltration of the right lung veins (sT3G3N1) underwent pneumonectomy with lymphadenectomy and intrapericardial ligation of the lung veins (R0 resection). After prolonged weaning, she left the hospital with nocturnal invasive ventilation via tracheostomy. Nine months later, she developed clinical deterioration with nausea and vomiting, leading to a stay in another hospital, where a pyelonephritis was diagnosed and treated with antibiotics. Since that time, the patient had dyspnoea and tachypnoea, which resulted in increasing use of invasive ventilation also in the daytime. This led to readmission. The blood gas analysis showed a pH of 7.54, a pCO2 of 31.5 mm Hg and a pO2 of 94.9 mm Hg under invasive mechanical ventilation with additional oxygen flow of 2 L/min. The inspiratory pressures were reduced, leading to a better tolerance of the mechanical ventilation and a normalization of the blood gases. A chest X-ray showed an opacified right hemithorax (Fig. 1). The contrast-enhanced CT scan of the thorax with coronal (Fig. 2a), sagittal (Fig. 2b) and axial scans (Fig. 2c) revealed a giant (9.4 × 6.6 × 7.1 cm) hyperdense structure, which nearly filled the right hemithorax and communicated with the left atrium. The colour Doppler echocardiography (Fig. 2d) showed a giant aneurysm which originated from the left atrium at the point of the ligated lung veins. Surprisingly, the patient was asymptomatic haemodynamically. A relation between the pseudoaneurysm and the deteriorated respiratory situation could not be found. The patient received further palliative care because of hepatic and paravertebral metastatic disease.