Download Superior vena cava obstruction after heart transplantation

Case Study
Superior vena cava obstruction
after heart transplantation
Asian Cardiovascular & Thoracic Annals
2016, Vol. 24(1) 88–90
ß The Author(s) 2014
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DOI: 10.1177/0218492314532279
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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]
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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.
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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, González-Calle A, Adsuar-Gómez 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.
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Corrigendum
Corrigendum
Asian Cardiovascular & Thoracic Annals
2016, Vol. 24(1) 91
ß The Author(s) 2014
Reprints and permissions:
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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.