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New Cardiac Mass During Cardiopulmonary Bypass
DIAGNOSTIC DILEMMAS Ronald A. Kahn, MD Paul S. Pagel, MD, PhD Section Editors
New Cardiac Mass During Cardiopulmonary Bypass Brenna A. Davis, MD,* Gerard R. Manecke, Jr, MD,* and Michael M. Madani, MD†
A
39-YEAR-OLD 80-kg man with chronic thromboembolic pulmonary hypertension presented for pulmonary thromboendarterectomy (PTE). The patient had suffered his first pulmonary embolism 11 years before surgery. His medical history was otherwise unremarkable. According to the referring physicians, the etiology of his hypercoagulability was protein S and antithrombin III deficiencies. Tests for antithrombin III deficiency at the authors’ institution, however, were negative. A preoperative transthoracic echocardiogram revealed normal left ventricular size and systolic function, mildly enlarged right atrium and ventricle, and an estimated pulmonary artery systolic pressure of 49 mmHg. Anesthesia was induced with midazolam, fentanyl, and rocuronium. A right internal jugular 9F introducer and pulmonary artery catheter were placed. A transesophageal echocardiogram (TEE) examination was performed, with findings similar to those of the preoperative transthoracic echocardiogram.
From the Departments of *Anesthesiology and †Surgery, University of California San Diego Medical Center, San Diego, CA. Address reprint requests to Brenna A. Davis, MD, Department of Anesthesiology, UCSD Medical Center, 200 W Arbor Dr 8770, San Diego, CA 92103. E-mail: [email protected] © 2008 Elsevier Inc. All rights reserved. 1053-0770/08/2205-0027$34.00/0 doi:10.1053/j.jvca.2008.05.004 Key words: transesophageal echocardiography, pulmonary thromboendarterectomy, pseudothrombus, echocardiographic mass
786
Fig 1. TEE image showing highly echoic mass in the left ventricle (arrow).
Surgery began with a median sternotomy incision. The patient was fully heparinized with 37,000 units, resulting in an activated coagulation time of 435 seconds. Aortic and bicaval venous cannulations were performed; the patient was placed on full cardiopulmonary bypass with a pulmonary artery vent in place. He was gradually cooled to 19°C. Once the heart fibrillated, an additional vent was placed in the left ventricle via the right superior pulmonary vein. Upon repeat examination during the cooling time, an abnormality was noted on TEE (Fig 1). What is the mass indicated by the arrow?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 22, No 5 (October), 2008: pp 786-787
NEW CARDIAC MASS
787
DIAGNOSIS: STAGNANT BLOOD IN THE LEFT VENTRICLE RESULTING FROM MALFUNCTION OF THE LEFT VENTRICULAR VENT
The surgeon was alerted to the authors’ finding. The surgeon shared that he had experienced some difficulty positioning the left ventricular vent. Therefore, he suspected that it may have come out and was not draining the left ventricle effectively. He then repositioned the vent, and, with echocardiographic guidance, the authors were able to confirm proper positioning with adequate drainage (Fig 2). The remainder of the procedure and hospitalization were uneventful. In the present case, the authors were primarily concerned for the development of a new thrombus. Although the activated coagulation time was in the “safe range” for cardiopulmonary bypass (⬎400 seconds), the patient’s history of hypercoagulability, possible antithrombin III deficiency, and the newness of the “mass” generated concern. Furthermore, at that point of the surgery, the aorta was not yet cross-clamped, raising the possibility of stroke or systemic embolization. Patients undergoing PTE are at risk for filling of the left heart during cardiopulmonary bypass via bronchial circulation with fistulas to the pulmonary venous system as well as drainage from the thebesian veins of the left ventricular myocardium directly into the left ventricle. Surgeons at the authors’ institution typically place a left-sided vent as described earlier to circumvent this problem.1 In this case, the left ventricular vent was malfunctioning, resulting in the accumulation of stagnant blood in the left ventricle. During most cardiac surgeries, the surgeon is observing and manipulating the heart manually and can thus quickly diagnose distention of the left ventricle. PTE is unique in that there are prolonged periods of cooling and warming; the operation is performed with deep hypothermic circulatory arrest. During these periods, the surgeon does not have reason to palpate or directly observe the heart continuously. Together with relative predominance of the bronchial circulation in chronic thromboembolic pulmonary hypertension, this increases the likelihood that blood accumulation in the left ventricle may occur. The accumulation of blood, which
Fig 2. TEE image after the cardiac surgeon’s intervention, showing an empty left ventricle.
can result in distention of the left ventricle, must be diagnosed early to prevent damage to the myocardium. An echocardiographic pseudothrombus during cardiac surgery has been described once previously in the literature.2 In that instance, a highly echoic mass was noted at the sinus of Valsalva, and the aorta was incised to explore the problem. In that case, involving the use of a left ventricular–assist device, no thrombus was found and the rest of the case proceeded uneventfully. The authors speculated that the mass was representative of stagnant blood flow at the sinus of Valsalva, similar to the finding in the present case.2 TEE is a clinically useful tool in pulmonary thromboendarterectomy. However, caution must be taken to avoid erroneous diagnosis or misinterpretation of findings. In this case, alerting the surgeons early avoided overdistention of the left heart, and communication resulted in proper diagnosis of this dilemma. The present case serves as an illustration of the importance of good communication between the anesthesiologist and surgeon to achieve optimal outcome and avoid complications.
REFERENCES 1. Jamieson SW, Kapelanski DP, Sakakibara N, et al: Pulmonary endarterectomy: Experience and lessons learned in 1,500 cases. Ann Thorac Surg 76:1457-1462, 2003
2. Fukumoto M, Arima H: Pseudothrombus in the aorta. Anesthesiology 105:860-861, 2006
New Cardiac Mass During Cardiopulmonary Bypass Brenna A. Davis, MD,* Gerard R. Manecke, Jr, MD,* and Michael M. Madani, MD†
A
39-YEAR-OLD 80-kg man with chronic thromboembolic pulmonary hypertension presented for pulmonary thromboendarterectomy (PTE). The patient had suffered his first pulmonary embolism 11 years before surgery. His medical history was otherwise unremarkable. According to the referring physicians, the etiology of his hypercoagulability was protein S and antithrombin III deficiencies. Tests for antithrombin III deficiency at the authors’ institution, however, were negative. A preoperative transthoracic echocardiogram revealed normal left ventricular size and systolic function, mildly enlarged right atrium and ventricle, and an estimated pulmonary artery systolic pressure of 49 mmHg. Anesthesia was induced with midazolam, fentanyl, and rocuronium. A right internal jugular 9F introducer and pulmonary artery catheter were placed. A transesophageal echocardiogram (TEE) examination was performed, with findings similar to those of the preoperative transthoracic echocardiogram.
From the Departments of *Anesthesiology and †Surgery, University of California San Diego Medical Center, San Diego, CA. Address reprint requests to Brenna A. Davis, MD, Department of Anesthesiology, UCSD Medical Center, 200 W Arbor Dr 8770, San Diego, CA 92103. E-mail: [email protected] © 2008 Elsevier Inc. All rights reserved. 1053-0770/08/2205-0027$34.00/0 doi:10.1053/j.jvca.2008.05.004 Key words: transesophageal echocardiography, pulmonary thromboendarterectomy, pseudothrombus, echocardiographic mass
786
Fig 1. TEE image showing highly echoic mass in the left ventricle (arrow).
Surgery began with a median sternotomy incision. The patient was fully heparinized with 37,000 units, resulting in an activated coagulation time of 435 seconds. Aortic and bicaval venous cannulations were performed; the patient was placed on full cardiopulmonary bypass with a pulmonary artery vent in place. He was gradually cooled to 19°C. Once the heart fibrillated, an additional vent was placed in the left ventricle via the right superior pulmonary vein. Upon repeat examination during the cooling time, an abnormality was noted on TEE (Fig 1). What is the mass indicated by the arrow?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 22, No 5 (October), 2008: pp 786-787
NEW CARDIAC MASS
787
DIAGNOSIS: STAGNANT BLOOD IN THE LEFT VENTRICLE RESULTING FROM MALFUNCTION OF THE LEFT VENTRICULAR VENT
The surgeon was alerted to the authors’ finding. The surgeon shared that he had experienced some difficulty positioning the left ventricular vent. Therefore, he suspected that it may have come out and was not draining the left ventricle effectively. He then repositioned the vent, and, with echocardiographic guidance, the authors were able to confirm proper positioning with adequate drainage (Fig 2). The remainder of the procedure and hospitalization were uneventful. In the present case, the authors were primarily concerned for the development of a new thrombus. Although the activated coagulation time was in the “safe range” for cardiopulmonary bypass (⬎400 seconds), the patient’s history of hypercoagulability, possible antithrombin III deficiency, and the newness of the “mass” generated concern. Furthermore, at that point of the surgery, the aorta was not yet cross-clamped, raising the possibility of stroke or systemic embolization. Patients undergoing PTE are at risk for filling of the left heart during cardiopulmonary bypass via bronchial circulation with fistulas to the pulmonary venous system as well as drainage from the thebesian veins of the left ventricular myocardium directly into the left ventricle. Surgeons at the authors’ institution typically place a left-sided vent as described earlier to circumvent this problem.1 In this case, the left ventricular vent was malfunctioning, resulting in the accumulation of stagnant blood in the left ventricle. During most cardiac surgeries, the surgeon is observing and manipulating the heart manually and can thus quickly diagnose distention of the left ventricle. PTE is unique in that there are prolonged periods of cooling and warming; the operation is performed with deep hypothermic circulatory arrest. During these periods, the surgeon does not have reason to palpate or directly observe the heart continuously. Together with relative predominance of the bronchial circulation in chronic thromboembolic pulmonary hypertension, this increases the likelihood that blood accumulation in the left ventricle may occur. The accumulation of blood, which
Fig 2. TEE image after the cardiac surgeon’s intervention, showing an empty left ventricle.
can result in distention of the left ventricle, must be diagnosed early to prevent damage to the myocardium. An echocardiographic pseudothrombus during cardiac surgery has been described once previously in the literature.2 In that instance, a highly echoic mass was noted at the sinus of Valsalva, and the aorta was incised to explore the problem. In that case, involving the use of a left ventricular–assist device, no thrombus was found and the rest of the case proceeded uneventfully. The authors speculated that the mass was representative of stagnant blood flow at the sinus of Valsalva, similar to the finding in the present case.2 TEE is a clinically useful tool in pulmonary thromboendarterectomy. However, caution must be taken to avoid erroneous diagnosis or misinterpretation of findings. In this case, alerting the surgeons early avoided overdistention of the left heart, and communication resulted in proper diagnosis of this dilemma. The present case serves as an illustration of the importance of good communication between the anesthesiologist and surgeon to achieve optimal outcome and avoid complications.
REFERENCES 1. Jamieson SW, Kapelanski DP, Sakakibara N, et al: Pulmonary endarterectomy: Experience and lessons learned in 1,500 cases. Ann Thorac Surg 76:1457-1462, 2003
2. Fukumoto M, Arima H: Pseudothrombus in the aorta. Anesthesiology 105:860-861, 2006