Removal of Massive Right Atrial Thrombus Guided by Transesophageal Echocardiography William L. Holman, MD, Cecil H. Coghlan, MD, Mary R. Dodson, MD, Raj Balal, MD, and Navin C. Nanda, MD Divisions of Cardiothoracic Surgery and Cardiovascular Disease, University of Alabama at Birmingham and Birmingham Veteran’s Administration Medical Center, Birmingham, Alabama
Formation of massive right atrial thrombi around a peritoneovenous shunt is a known complication of these devices. Removal of an obstructive right atrial thrombus requires cardiopulmonary bypass and has been associated with a high morbidity and mortality. Transesophageal echocardiography was used in this case to diagnose and guide the surgical removal of a massive right atrial thrombus. (Ann Tliorac Surg 1991;52:323-5)
T
he LeVeen and Denver peritoneovenous shunts are used to return ascitic fluid to the venous circulation. Peritoneovenous shunting often results in prompt and dramatic relief of persistent ascites; however, multiple complications including disseminated intravascular coagulation, congestive heart failure, myocardial ischemia, renal failure, hepatic failure, infection, and pulmonary edema may occur [l].Tissue thromboplastins in the ascitic fluid may also cause clotting of the shunt [2], superior vena caval occlusion [3], or the formation of right atrial and right ventricular thrombi originating from the tip of the shunt [4-81. Removal of thrombi from the right side of the heart requires cardiopulmonary bypass and is technically straightforward. However, this operation has been associated with a high morbidity and mortality related to hypotension and low cardiac output before initiation of cardiopulmonary bypass, and to the patient’s severe underlying hepatic disease. The mortality in reported cases is 40% [4-81. This report illustrates the use of preoperative and intraoperative transesophageal echocardiography for the diagnosis and expeditious surgical removal of a massive right atrial thrombus that formed around a Denver shunt. The patient is a 41-year-old man with Laennec‘s cirrhosis who required placement of a Denver peritoneovenous shunt 2 years before admission. The patient subsequently stopped consuming alcohol with a mild improvement in his hepatic disease. He still required spironolactone (Aldactone; G.D. Searle & Co, Chicago, IL), 50 mg orally twice per day, and furosemide (Lasix; Hoechst-Roussel Accepted for publication Jan 16, 1991 Address reprint requests to Dr Holman, Department of Surgery, University of Alabama at Birmingham, University Station, Birmingham, AL 35294.
0 1991 by The Society of Thoracic Surgeons
Pharmaceuticals, Somerville, NJ), 80 mg orally twice per day, together with the Denver shunt to control his ascites. Six months before admission, swelling of the upper extremities and head developed. Occlusion of the superior vena cava was diagnosed and the patient was begun on warfarin sodium (Coumadin; Du Pont Pharmaceuticals, Wilmington, DE) therapy. The shunt was examined by ultrasound and was considered patent. On the day of admission, episodes of syncope associated with tonicoclonic movements developed, and the patient was transferred emergently to the Birmingham VA Medical Center. He was admitted to the neurology service. His neurological examination was normal, and a computed tomographic scan of the head showed no mass lesions. An electroencephalogram was normal. During this evaluation it was noted that the patient had recurrent episodes of syncope whenever he sat up or stood. A transthoracic echocardiogram showed a large right atrial mass that intermittently occluded the tricuspid orifice. A transesophageal echocardiogram was then performed to provide better definition of this mass together with Doppler assessment of inferior and superior vena caval flow. The transesophageal echocardiogram and Doppler study demonstrated patency of the superior vena cava and inferior vena cava. There was a mass occupying almost the entire right atrial cavity with intermittent ball-valve occlusion of the tricuspid orifice (Fig 1).Blood flow was noted from the cavae around the right atrial mass and into the right ventricle, implying that the mass was free within the atrium. While on the medical service the patient underwent endoscopy. This showed no evidence of variceal hemorrhage. The patient was then heparinized to prevent further thrombus formation. While receiving heparin, he was carefully observed in several positions to determine which position would allow the safest induction of anesthesia and operation. The patient had the highest blood pressure while in Trendelenburg position and rolled onto his right side. When supine and in Trendelenburg position, the pressure was lower but still obtainable. The left lateral decubitus position caused loss of blood pressure and syncope. The patient was taken to operation for removal of the mass. Anesthesia was induced with the patient in the maximal Trendelenburg and rightward tilted position possible on the operating table. A transesophageal echocardiographic probe was in place. Despite severe hypo0003-4975/91/$3.50
314
Ann Thorac Surg 1991;52:31>5
CASE REPORT HOLMAN ET AL ECHOCARDIOGRAPHICALLY GUIDED OPERATION
lated for partial cardiopulmonary bypass. Flow data from the transesophageal probe together with palpation of the atrium while observing the two-dimensional echocardiogram were used to localize a portion of the lower right atrial wall where the atrial mass was clearly nonadherent. A pursestring was placed at this position for insertion of a second right-angle cannula and institution of total cardiopulmonary bypass. After bypass was established, the Denver shunt was removed along with a large adherent white thrombus mass that encased the distal portion of the shunt. The right ventricle was carefully examined for additional thrombus; however, none was found. Air was removed from the ventricle, it was closed, and then the patient was taken off cardiopulmonary bypass on lowdose dopamine support. Postoperatively the patient required multiple adjustments of diuretic therapy to treat recurrent ascites; however, the convalescence was otherwise uneventful. He was able to sit and stand without difficulty. A
B Fig I . Bip/ane traizsesophagcal echucardio,qraphir examination. This runs perfornied by using a 5-MHz Aloka 870 probe with the patient in the right lateral decubitus position. ( A ) Longitudinal plane exuriiination demonstrates a large right ntrinl m s s (maximum size, 5.5 x 4.5 cm) attached to the anterior u~allof the superior vena cava (SVC) nenr its entrance into the right atrium IRA). The arrow points to a portion of the Denver shunt that is seen embedded in the mass. The inferior vem cava was not involved. ( B ) Transverse plane exaniination also visualized the mass well and demonstrated a portion of it protruding into the right ventricle through the tricuspid orifice. However, the relationship of the m s s to the superior vena cava could not he visualized in this plane. There zuere prominent echo-@ spaces in the tumor niass. (LA left atrium; LV = left ventricle.)
tension after induction of anesthesia, continued flow of blood across the tricuspid orifice was confirmed by the transesophageal probe. After the chest was expeditiously entered, the aorta and superior vena cava were cannu-
Comment Thrombus formation within or around a peritoneovenous shunt can cause shunt occlusion, superior vena cava occlusion, or thrombus formation within the right heart. Thrombus formation within the atrium and ventricle is a particularly dangerous complication. The thrombus can severely impede blood flow through the right heart and may embolize to the lung. Safe and successful removal of the thrombus requires the use of extracorporeal circulation. Transthoracic echocardiography initially diagnosed this condition; however, the transesophageal echocardiogram provided data that were crucial to the planning of a successful and expeditious operation in this patient. Without the information provided by the transesophageal study another surgical option would have been to use femorofemoral bypass before incision. Although this method might have been used successfully, the requirement for a second incision in the groin would have lengthened the operation and could have resulted in persistent leakage of ascitic fluid from the groin if the peritoneum was injured during the dissection. The transesophageal echocardiogram was used after removing the thrombus to confirm that there was free flow of blood through the tricuspid valve, that tricuspid valve function was normal, and that there were no residual masses in the right ventricle or main pulmonary artery. We believe that preoperative and especially intraoperative transesophageal echocardiography was beneficial in the successful treatment of this rare condition.
References 1. Lund RH, Moritz MW. Complications of Denver peritoneovenous shunting. Arch Surg 1982;117:9248. 2. Shaw RB. Use of fibrinolytic agent to restore function in a clotted LeVeen shunt. South Med J 1982;75:1285-7. 3. Vujic I, Moore LB, LeVeen HH. Recanalization of occluded superior vena cava for replacement of LeVeen shunt catheter. Radiology 1987;164:270-2. 4. Goose P, Guez S, Roudaut R, Deville C, Dallocchio M. An
Ann Thorac Surg 1991;52:3155
unusual complication of the Le Veen shunt: a right atrial ventricular chamber pseudotumor. Clin Cardiol 1987;lO: 370-1. 5. Ugolini V, Norcross JF, Schreiber JF, Kuntz RE, Taylor AL. Intracardiac thrombus causing peritoneovenous shunt failure: detection by two-dimensional echocardiography. J Am Coll Cardiol 1986;7:11746. 6. Eugene J, Runyon BA, Conroy RM, Haiduc NJ, Juler GL. Right atrial thrombus secondary to peritoneovenous shunt:
CASE REPORT HOLMAN ET AL ECHOCARDIOGRAPHICALLY GUIDED OPERATION
315
successful removal with use of cardiopulmonary bypass. Surgery 1983;94:11&9. 7. Pietro DA, Bloomfield P, Joss M, Parisi AF. Multiple intracardiac masses complicating peritoneo-venous (LaVeen) shunt. Am Heart J 1984;108:60&8. 8. Mestres CA, de Lacy AM, Pomar JL. Massive right atrial and ventricular thrombosis after peritoneovenous shunting treating by thrombectomy and tricuspid valvectomy. Ann Thorac Surg 1987;44:205-6.
Notice From the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the operations they performed during the year prior to application for recertification. This practice review should consist of 1 year's consecutive major operative experiences. (If more than 100 cases occur in 1 year, only 100 need to be listed.) They should also keep a record of their attendance at approved postgraduate medical education activities for the 2 years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS IV syllabus (Self-Education/Self-Assessment in Thoracic Surgery). It is not necessary for candidates to purchase
SESATS IV booklets prior to applying for recertification. SESATS IV booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1994 may begin the recertification process in 1992. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications is May 1, 1992. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
Formation of massive right atrial thrombi around a peritoneovenous shunt is a known complication of these devices. Removal of an obstructive right atrial thrombus requires cardiopulmonary bypass and has been associated with a high morbidity and mortality. Transesophageal echocardiography was used in this case to diagnose and guide the surgical removal of a massive right atrial thrombus. (Ann Tliorac Surg 1991;52:323-5)
T
he LeVeen and Denver peritoneovenous shunts are used to return ascitic fluid to the venous circulation. Peritoneovenous shunting often results in prompt and dramatic relief of persistent ascites; however, multiple complications including disseminated intravascular coagulation, congestive heart failure, myocardial ischemia, renal failure, hepatic failure, infection, and pulmonary edema may occur [l].Tissue thromboplastins in the ascitic fluid may also cause clotting of the shunt [2], superior vena caval occlusion [3], or the formation of right atrial and right ventricular thrombi originating from the tip of the shunt [4-81. Removal of thrombi from the right side of the heart requires cardiopulmonary bypass and is technically straightforward. However, this operation has been associated with a high morbidity and mortality related to hypotension and low cardiac output before initiation of cardiopulmonary bypass, and to the patient’s severe underlying hepatic disease. The mortality in reported cases is 40% [4-81. This report illustrates the use of preoperative and intraoperative transesophageal echocardiography for the diagnosis and expeditious surgical removal of a massive right atrial thrombus that formed around a Denver shunt. The patient is a 41-year-old man with Laennec‘s cirrhosis who required placement of a Denver peritoneovenous shunt 2 years before admission. The patient subsequently stopped consuming alcohol with a mild improvement in his hepatic disease. He still required spironolactone (Aldactone; G.D. Searle & Co, Chicago, IL), 50 mg orally twice per day, and furosemide (Lasix; Hoechst-Roussel Accepted for publication Jan 16, 1991 Address reprint requests to Dr Holman, Department of Surgery, University of Alabama at Birmingham, University Station, Birmingham, AL 35294.
0 1991 by The Society of Thoracic Surgeons
Pharmaceuticals, Somerville, NJ), 80 mg orally twice per day, together with the Denver shunt to control his ascites. Six months before admission, swelling of the upper extremities and head developed. Occlusion of the superior vena cava was diagnosed and the patient was begun on warfarin sodium (Coumadin; Du Pont Pharmaceuticals, Wilmington, DE) therapy. The shunt was examined by ultrasound and was considered patent. On the day of admission, episodes of syncope associated with tonicoclonic movements developed, and the patient was transferred emergently to the Birmingham VA Medical Center. He was admitted to the neurology service. His neurological examination was normal, and a computed tomographic scan of the head showed no mass lesions. An electroencephalogram was normal. During this evaluation it was noted that the patient had recurrent episodes of syncope whenever he sat up or stood. A transthoracic echocardiogram showed a large right atrial mass that intermittently occluded the tricuspid orifice. A transesophageal echocardiogram was then performed to provide better definition of this mass together with Doppler assessment of inferior and superior vena caval flow. The transesophageal echocardiogram and Doppler study demonstrated patency of the superior vena cava and inferior vena cava. There was a mass occupying almost the entire right atrial cavity with intermittent ball-valve occlusion of the tricuspid orifice (Fig 1).Blood flow was noted from the cavae around the right atrial mass and into the right ventricle, implying that the mass was free within the atrium. While on the medical service the patient underwent endoscopy. This showed no evidence of variceal hemorrhage. The patient was then heparinized to prevent further thrombus formation. While receiving heparin, he was carefully observed in several positions to determine which position would allow the safest induction of anesthesia and operation. The patient had the highest blood pressure while in Trendelenburg position and rolled onto his right side. When supine and in Trendelenburg position, the pressure was lower but still obtainable. The left lateral decubitus position caused loss of blood pressure and syncope. The patient was taken to operation for removal of the mass. Anesthesia was induced with the patient in the maximal Trendelenburg and rightward tilted position possible on the operating table. A transesophageal echocardiographic probe was in place. Despite severe hypo0003-4975/91/$3.50
314
Ann Thorac Surg 1991;52:31>5
CASE REPORT HOLMAN ET AL ECHOCARDIOGRAPHICALLY GUIDED OPERATION
lated for partial cardiopulmonary bypass. Flow data from the transesophageal probe together with palpation of the atrium while observing the two-dimensional echocardiogram were used to localize a portion of the lower right atrial wall where the atrial mass was clearly nonadherent. A pursestring was placed at this position for insertion of a second right-angle cannula and institution of total cardiopulmonary bypass. After bypass was established, the Denver shunt was removed along with a large adherent white thrombus mass that encased the distal portion of the shunt. The right ventricle was carefully examined for additional thrombus; however, none was found. Air was removed from the ventricle, it was closed, and then the patient was taken off cardiopulmonary bypass on lowdose dopamine support. Postoperatively the patient required multiple adjustments of diuretic therapy to treat recurrent ascites; however, the convalescence was otherwise uneventful. He was able to sit and stand without difficulty. A
B Fig I . Bip/ane traizsesophagcal echucardio,qraphir examination. This runs perfornied by using a 5-MHz Aloka 870 probe with the patient in the right lateral decubitus position. ( A ) Longitudinal plane exuriiination demonstrates a large right ntrinl m s s (maximum size, 5.5 x 4.5 cm) attached to the anterior u~allof the superior vena cava (SVC) nenr its entrance into the right atrium IRA). The arrow points to a portion of the Denver shunt that is seen embedded in the mass. The inferior vem cava was not involved. ( B ) Transverse plane exaniination also visualized the mass well and demonstrated a portion of it protruding into the right ventricle through the tricuspid orifice. However, the relationship of the m s s to the superior vena cava could not he visualized in this plane. There zuere prominent echo-@ spaces in the tumor niass. (LA left atrium; LV = left ventricle.)
tension after induction of anesthesia, continued flow of blood across the tricuspid orifice was confirmed by the transesophageal probe. After the chest was expeditiously entered, the aorta and superior vena cava were cannu-
Comment Thrombus formation within or around a peritoneovenous shunt can cause shunt occlusion, superior vena cava occlusion, or thrombus formation within the right heart. Thrombus formation within the atrium and ventricle is a particularly dangerous complication. The thrombus can severely impede blood flow through the right heart and may embolize to the lung. Safe and successful removal of the thrombus requires the use of extracorporeal circulation. Transthoracic echocardiography initially diagnosed this condition; however, the transesophageal echocardiogram provided data that were crucial to the planning of a successful and expeditious operation in this patient. Without the information provided by the transesophageal study another surgical option would have been to use femorofemoral bypass before incision. Although this method might have been used successfully, the requirement for a second incision in the groin would have lengthened the operation and could have resulted in persistent leakage of ascitic fluid from the groin if the peritoneum was injured during the dissection. The transesophageal echocardiogram was used after removing the thrombus to confirm that there was free flow of blood through the tricuspid valve, that tricuspid valve function was normal, and that there were no residual masses in the right ventricle or main pulmonary artery. We believe that preoperative and especially intraoperative transesophageal echocardiography was beneficial in the successful treatment of this rare condition.
References 1. Lund RH, Moritz MW. Complications of Denver peritoneovenous shunting. Arch Surg 1982;117:9248. 2. Shaw RB. Use of fibrinolytic agent to restore function in a clotted LeVeen shunt. South Med J 1982;75:1285-7. 3. Vujic I, Moore LB, LeVeen HH. Recanalization of occluded superior vena cava for replacement of LeVeen shunt catheter. Radiology 1987;164:270-2. 4. Goose P, Guez S, Roudaut R, Deville C, Dallocchio M. An
Ann Thorac Surg 1991;52:3155
unusual complication of the Le Veen shunt: a right atrial ventricular chamber pseudotumor. Clin Cardiol 1987;lO: 370-1. 5. Ugolini V, Norcross JF, Schreiber JF, Kuntz RE, Taylor AL. Intracardiac thrombus causing peritoneovenous shunt failure: detection by two-dimensional echocardiography. J Am Coll Cardiol 1986;7:11746. 6. Eugene J, Runyon BA, Conroy RM, Haiduc NJ, Juler GL. Right atrial thrombus secondary to peritoneovenous shunt:
CASE REPORT HOLMAN ET AL ECHOCARDIOGRAPHICALLY GUIDED OPERATION
315
successful removal with use of cardiopulmonary bypass. Surgery 1983;94:11&9. 7. Pietro DA, Bloomfield P, Joss M, Parisi AF. Multiple intracardiac masses complicating peritoneo-venous (LaVeen) shunt. Am Heart J 1984;108:60&8. 8. Mestres CA, de Lacy AM, Pomar JL. Massive right atrial and ventricular thrombosis after peritoneovenous shunting treating by thrombectomy and tricuspid valvectomy. Ann Thorac Surg 1987;44:205-6.
Notice From the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the operations they performed during the year prior to application for recertification. This practice review should consist of 1 year's consecutive major operative experiences. (If more than 100 cases occur in 1 year, only 100 need to be listed.) They should also keep a record of their attendance at approved postgraduate medical education activities for the 2 years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS IV syllabus (Self-Education/Self-Assessment in Thoracic Surgery). It is not necessary for candidates to purchase
SESATS IV booklets prior to applying for recertification. SESATS IV booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1994 may begin the recertification process in 1992. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications is May 1, 1992. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
