Case Study

Superior vena cava obstruction after heart transplantation

Asian Cardiovascular & Thoracic Annals 2016, Vol. 24(1) 88–90 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314532279 aan.sagepub.com

Babak Sharif Kashani1, Zargham Hossein Ahmadi2, Seifollah Abdi3, Seyed Mohsen Mirhosseini4, Amir Abbas Kianfar5 and Shanay Niusha2

Abstract Superior vena cava obstruction can be a serious complication after heart transplantation. A 58-year-old man with ischemic cardiomyopathy underwent orthotopic bicaval heart transplantation. On the 12th postoperative day, one hour after removing the central venous line, he developed sudden onset of facial edema, cyanosis, and tachycardia. Emergency transesophageal echocardiography revealed superior vena caval thrombosis at the site of anastomosis. Considering the risks of surgical reexploration, the superior vena cava was recanalized by stent deployment. All of the patient’s symptoms were relieved a few hours after stent placement.

Keywords Central venous catheters, heart transplantation, stents, superior vena cava syndrome, thrombosis, vena cava, superior

Introduction Heart transplantation is the treatment of choice for patients with end-stage heart failure who do not respond to medical, interventional, or other surgical treatments.1 In the early 1960s, the classic technique for heart transplantation was developed, but another technique (bicaval anastomosis) was developed at nearly the same time.2 Currently, bicaval anastomosis is frequently used because of its hemodynamic benefits due to the fact that sinus node function seems to be better preserved.3 However, it can have some complications such as vena caval anastomotic stenosis or strictures, which may lead to superior vena cava (SVC) syndrome. If a central venous line (CVL) remains for a prolonged time, it may be one of the causes of secondary thrombosis. We describe the case of a patient with SVC obstruction 2 weeks after heart transplantation, who was treated successfully by endovascular stent placement.

Case report Our patient was a 58-year-old man who had suffered from ischemic cardiomyopathy in the terminal phase with functional class IV and myocardial volume

oxygen consumption of 13 cckg 1min 1. He had a history of hypertension, hyperlipidemia, and diabetes mellitus which was controlled with oral hypoglycemic agents. He underwent orthotopic bicaval heart transplantation. Anastomosis of the left atrial cuff, aorta, pulmonary artery and inferior vena cava were performed with 4/0 Prolene sutures, while the SVC 1

Tobacco Prevention and Control Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Lung Transplantation Research Center, National Research of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3 Department of Interventional Cardiology, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran 4 Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran Corresponding author: Zargham Hossein Ahmadi, Masih Daneshvari Medical Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Darabad, Niavaran, Tehran 1956944413, Iran. Email: [email protected]

Downloaded from aan.sagepub.com at DALHOUSIE UNIV on December 10, 2015

Kashani et al.

89

anastomosis was performed with 5/0 Prolene sutures. The technique for SVC anastomosis, like the other anastomoses, was running sutures. As the diameter of the anastomosis was small, the traction applied to the sutures was not very great, so that the pursestring effect and tightening of the anastomosis were minimal. The patient was weaned off cardiopulmonary bypass with adrenaline 0.1 mgkg 1min 1 for inotropic support. Intraoperative transesophageal echocardiography (IOTEE) showed no gradient across the anastomotic sites including the SVC anastomosis. As the IOTEE did not show any gradient across the SVC anastomois, and as the anastomosis seemed to be perfect, so the gradient across the SVC anastomosis did not measured directly. During the first 24 postoperative hours, the patient was extubated, and the inotrope dose was tapered and discontinued on the 5th postoperative day. Transesophageal echocardiography on the first postoperative day revealed a normal ejection fraction with mild to moderate right ventricular dysfunction and no evidence of any torsion or gradient in the SVC, inferior vena cava, aorta, or pulmonary artery anastomotic sites. On the 12th postoperative day, prior to discharge and one hour after removing the CVP line, the patient developed sudden onset of facial edema, cyanosis, and tachycardia. Emergency transesophageal echocardiography revealed SVC thrombosis at the site of anastomosis. Intravenous heparin 800 Uh 1 was started. Computed tomographic angiography revealed a thrombus in the SVC extending to the left jugular vein and left subclavian vein. Venography showed complete obstruction of the proximal SVC with an enlarged patent azygos vein (Figure 1). Considering the diagnosis of SVC syndrome and the risks of surgical reexploration, we decided to perform

Figure 1. Venography showing obstruction of the proximal superior vena cava (lower arrow) with an enlarged patent azygos vein (upper arrow).

stent placement. As the face and neck of the patient were very edematous and he was restless, any manipulation of that area was avoided, and a wire was passed via the right femoral vein through the inferior vena cava and right atrium to the site of obstruction, and a stent was deployed successfully (Figure 2). All of the patient’s symptoms were relieved a few hours after stent placement. Warfarin 5 mg daily was started, and the international normalized ratio was kept between 2 and 2.5 for 3 months. The patient was discharged home a few days after the endovascular procedure, and during 4 years of follow-up, he has been asymptomatic with no complaint.

Discussion The SVC is the second largest vein in the human body. Factors contributing to SVC obstruction can be malignant or benign in nature. Most cases arise from malignant and neoplastic conditions. SVC obstruction in benign conditions is rare and it can be caused by histoplasmosis infection, thrombophlebitis, tuberculosis, central venous catheters, pacemaker catheters, defibrillators and resynchronizations, mediastinal fibrosis because of granulomatous disease or radiation, intrathoracic goiter, ventriculoatrial shunts, and aortic aneurysms. Rarely, vena caval stenosis is a complication after heart transplantation using the bicaval anastomosis technique.3,4 The incidence of this complication seems to be greater in the pediatric heart transplant group.5 Mismatch of the SVC diameters of the recipient and donor may cause late stenosis of the SVC due to tightening of the suture line or intimal hyperplasia.6 Because there was no gradient in the SVC in the early postoperative course of this patient

Figure 2. The superior vena cava became patent after deployment of a stent.

Downloaded from aan.sagepub.com at DALHOUSIE UNIV on December 10, 2015

90

Asian Cardiovascular & Thoracic Annals 24(1)

and he was asymptomatic, a clot was the most likely cause of his subsequent symptoms. It is recommended that the duration of CVL placement should be based on the clinical condition of the patient,7 so it is not standard practice to leave a CVL in a patient until the time of discharge. The tip of the CVL may cause trauma to the endothelium, or it may be a primary nidus for thrombosis. Because the symptoms in our patient started after removing the CVL, the CVL catheter might have allowed minimal SVC patency for the passage of the blood. There was no evidence of any abnormality in venous drainage in the upper part of the body before removing the CVL. Therefore, the CVL might have played a role not only in SVC obstruction but also in delayed presentation of SVC syndrome. Considering that our patient was taking corticosteroids and immunosuppressive medications, surgical reexploration would have involved a higher risk than an endovascular procedure. The endovascular procedure avoided a second operation in this critically immunosuppressed patient. Furthermore, the follow-up results after stent placement in our patient confirmed the safety of this procedure, even early after transplantation. This case suggests that SVC obstruction following bicaval heart transplantation can be safely treated by endovascular procedures, and the CVL should be withdrawn as soon as the patient’s condition is suitable. Acknowledgement The authors gratefully thank Dr. Negar Salehi, Cardiologist and Interventionalist, Rajaie Heart Center, for assistance in deployment of the stent, and also Ms. Laila Salimi, RN, the coordinator of heart tansplant team for follow up of the patient and collection of data.

Conflict of interest statement None declared.

References 1. Antunes MJ, Biernat M, Sola E, et al. Cardiac allograft systolic function. Is the aetiology (ischaemic or idiopathic) a determinant of ventricular function in the heart transplant patient? Interact Cardiovasc Thorac Surg 2008; 7: 586–590. 2. Hosseinpour AR, Gonza´lez-Calle A, Adsuar-Go´mez A, et al. Surgical technique for heart transplantation: a strategy for congenital heart disease. Eur J Cardiothorac Surg 2013; 44: 598–604. 3. Jacob S and Sellke F. Is bicaval orthotopic heart transplantation superior to the biatrial technique [Review]? Interact Cardiovasc Thorac Surg 2009; 9: 333–342. 4. Sze DY, Robbins RC, Semba CP, Razavi MK and Dake MD. Superior vena cava syndrome after heart transplantation: percutaneous treatment of a complication of bicaval anastomosis. J Thorac Cardiovasc Surg 1998; 116: 253–261. 5. Tzifa A, Marshall AC, McElhinney DB, Lock JE and Geggel RL. Endovascular treatment for superior vena cava occlusion or obstruction in pediatric or young adult population: a 22-year experience. J Am Coll Cardiol 2007; 49: 1003–1009. 6. Shah M, Anderson AS, Jayakar D, Jeevanandam V and Feldman T. Balloon-expandable stent placement for superior vena cava-right atrial stenosis after heart transplantation. J Heart Lung Transplant 2000; 19: 705–709. 7. Rupp SM, Apfelbaum JL, Blitt C, et al. American Society of Anesthesiologists Task Force on Central Venous Access. Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012; 116: 539–573.

Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Downloaded from aan.sagepub.com at DALHOUSIE UNIV on December 10, 2015

Corrigendum

Corrigendum

Asian Cardiovascular & Thoracic Annals 2016, Vol. 24(1) 91 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314541599 aan.sagepub.com

Superior vena cava obstruction after heart transplantation by Babak Sharif Kashani, Zargham Hossein Ahmadi, Seifollah Abdi, Seyed Mohsen Mirhosseini, Amir Abbas Kianfar and Shanay Niusha. Asian Cardiovascular and Thoracic Annals, first published on April 14, 2014 as doi:10.1177/0218492314532279 (published in this issue 24: 88–90). For the above paper, the acknowledgment section was incomplete, the correct text is below: We would like to give our special thanks to Dr. Farshid Salehi, researcher at the Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, who has been a major contributor to the research and had a main role in writing the primary draft of the article, Dr. Negar Salehi, Cardiologist and Interventionalist, Rajaie Heart Center, for assistance in deployment of the stent, and also Ms. Laila Salimi, RN, the coordinator of the heart transplant team, for follow-up of the patient and collection of data.

Superior vena cava obstruction after heart transplantation.

Superior vena cava obstruction can be a serious complication after heart transplantation. A 58-year-old man with ischemic cardiomyopathy underwent ort...
173KB Sizes 2 Downloads 5 Views

Recommend Documents


Successful venous angioplasty of superior vena cava syndrome after heart transplantation.
Introduction. For patients with terminal heart failure, heart transplantation (HTX) has become an established therapy. Before transplantation there are many repeated measurements with a pulmonary artery catheter (PAC) via the superior vena cava (SVC)

Immediate postoperative percutaneous stenting of superior vena cava obstruction following heart transplantation in adult patients with pacemaker leads.
Vena cava superior syndrome is a serious complication after heart transplantation, leading to low cardiac output, cerebral edema, and multi-organ dysfunction. We report three adult patients who underwent heart and heart-lung transplantation and requi

Heart transplantation in a patient with persistent left superior vena cava.
A 56-year-old male presented with severe exertional dyspnea and pitting edema in the lower extremities. The pre-operative evaluation demonstrated biventricular dysfunction associated with severe tricuspid valve regurgitation and a persistent left sup

Orthotopic heart transplantation in patients with persistent left superior vena cava: bicaval and biatrial techniques.
Persistent left superior vena cava (LSVC) is the most common congenital venous abnormality. With the increasing number of children who survive into adulthood with congenital heart malformations, the recognition of persistent LSVC among patients with

Congenital Absence of Superior Vena Cava with no Manifestation of Superior Vena Cava Syndrome.
Total absence of superior vena cava (SVC) is a very rare anomaly, and the patient usually suffers from SVC syndrome or conduction disturbances. We report an asymptomatic 27 year-old male, with complete absence of SVC. Transthoracic echocardiography a