Asian Cardiovasc Thorac Ann 2007;15:e28-e29
© 2007 Asia Publishing EXchange Ltd
Partial Obstruction of the Inferior Vena Cava after Surgery for Left Atrial Myxoma
Gino Di Manici, MD,
Davide Di Lazzaro, MD,
Giuliana Bardelli, MD,
Francesco Grasselli, MD,
Uberto Da Col, MD,
Temistocle Ragni, MD
Department of Cardiac Surgery, Silvestrini Hospital, Perugia, Italy
For reprint information contact: Davide Di Lazzaro, MD Tel: 39 075 578 22139 Fax: 39 075 578 2214 Email: davide.dilazzaro{at}ospedale.perugia.it, Azienda Ospedaliera di Perugia, Ospedale "R. Silvestrini", S. Andrea delle Fratte Perugia, 06100 Italy.
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ABSTRACT
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We present a case of iatrogenic partial obstruction of the inferior vena cava after removal of a left atrial myxoma. The closure occurred subsequent to repair of a discontinuity between the right atrium and inferior vena cava caused by excessive traction on frail tissues.
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INTRODUCTION
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We present a case of obstruction of inferior vena cava, following a surgical operation for left atrial myxoma, focusing on the peculiar way it happened, and on the diagnostic path we had to follow to diagnose it.
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CASE REPORT
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A 58-year-old woman with a history of systemic hypertension and chronic obstructive pulmonary disease (COPD) was referred to our hospital. She had a recent, incidental diagnosis of left atrial myxoma. Surgery was performed through a standard right atrial approach, and incision of the atrial septum at the level of the fossa ovalis. During the procedure a laceration of the inferior vena cava (IVC) was noted, due to excessive traction on the right atrium. The laceration was easily and apparently safely repaired by means of a 4/0 Prolene running suture. The repair was accomplished with the venous cannula in situ, thus preventing accidental stenosis of the IVC. The rest of the operation was uneventful, as was the immediate postoperative course. The patient was discharged from the ICU on the 2nd postoperative day.
The only discrepancy noted was an immediate raise of serum levels of liver enzymes (ALT and AST), ascribed to the venous cannula penetrating too deeply into the IVC. Over the following days, the values slowly descended, but failed to reach normal levels.
On the 5th postoperative day the liver enzymes started to rise again, and the patient failed to show clear signs of complete recovery as expected. There were no signs of cardiac tamponade, or of low output syndrome. Surface echocardiography showed the presence of thrombotic material located in correspondence with the free wall of the right atrium and of the IVC, causing its partial compression. This fi nding was confi rmed by transesophageal echocardiography (TEE) (Figure 1
). As the patient’s general condition was acceptable, we decided to wait before considering a surgical option. However over the following days despite the clinical condition being stabilized, the patient failed to show any signs of clear improvement. A CT scan of the thorax and abdomen (Figure 2) confi rmed the hypothesis of external compression of the IVC, and a cavography (Figure 3) showed occlusion of the IVC extending up to the suprahepatic veins. Based on these fi ndings, we decided to re-operate on the patient.
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Figure 1 Echocardiography showing partial obstruction of the IVC (arrow). IVC = inferior vena cava, RA = right atrium.
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A careful examination of the right atrium and IVC showed no thrombus. The ascending aorta was cannulated, and venous drainage from the upper body was achieved by direct cannulation of the superior vena cava, while drainage from the lower body was achieved by cannulation of the femoral vein. In deep hypothermic arrest1 the right atrium was opened and the IVC inspected. At the site of the previous repair an almost complete occlusion of the lumen was found, due to a stitch pinching the caudal part of the interatrial septum. The stitch was one of the running sutures used to repair the laceration during the fi rst operation. Enlargement of the atriocaval junction was performed using a pericardial patch. The postoperative course was uneventful, and the patient was discharged after 15 days.
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DISCUSSION
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The peculiarities of this case involve the etiology of the IVC obstruction, and the long process needed to make a decision about management of a patient whose clinical condition was not poor enough to warrant urgent surgical consideration. Initially, a mechanism of IVC partial closure was not considered due to the false belief that the IVC could not be stenosed during repair, as it was accomplished with the venous cannula in situ. Secondly, the combination of subtle clinical signs could have been caused by external compression of the IVC as well as by partial obstruction. A succession of investigations suggested the former, which was thought would resolve spontaneously.
On revision of the echocardiography "a posteriori", it is apparent that the wedge-shaped IVC could suggest internal obstruction, as compared to an externally compressed IVC, which has a more rounded profi le.
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COMMENT
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The obstruction of the IVC is a rare iatrogenic complication which can happen during surgical procedures involving the right atrium. It can happen due to the need to repair injuries of the IVC caused by excessive traction during the surgical procedure. Weaning from extracorporeal circulation, as well as early postoperative course, can appear normal. This complication could happen more frequently in patients with small right atria, such as during surgery for myxomas of atrial septal defects. It could be determined not by a direct stenosis of the IVC but by stich pinching of the interatrial septum. In this case, performing the reparation with the IVC cannula in situ does not preserve from such complication. The clinical scenario may not be so clear and, in absence of a bright and complete recovery of the patient, the diagnostic attitude should be prompt and exhaustive. The surgical reparation should be accomplished during a short period of deep hypothermic arrest, after atrial and venous femoral cannulation. A prompt diagnosis and treatment are fundamental prerequisites for a good outcome.
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REFERENCES
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- Hartman AR, Yunis J, Frei LW, Pinard BE. Profound hypothermic circulatory arrest for the management of a penetrating retrohepatic venous injury: case report. J Trauma 1991;31:1310–1.[Medline]
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ABSTRACT
INTRODUCTION
