Download External compression of superior vena cava after the replacement of

European Journal of Echocardiography (2008) 9, 589–590
doi:10.1093/ejechocard/jen116
External compression of superior vena cava after
the replacement of ascending aorta
Johannes Wacker, George Djaiani, Rita Katznelson*, and Jacek Karski
Received 17 September 2007; accepted after revision 9 February 2008; online publish-ahead-of-print 1 May 2008
KEYWORDS
SVC obstruction;
HOCM
We present a rare complication after open-heart surgery resulting in compression of the superior vena
cava (SVC) with the concurrent findings of the hypertrophic obstructive cardiomyopathy physiology.
A 59-year-old woman developed a low cardiac output syndrome, persistent hypotension, and increasing
filling pressures after emergency replacement of the ascending aorta and resuspension of the aortic
valve due to a type A aortic dissection. Transesophageal echocardiography (TEE) evaluation revealed
partial SVC obstruction, under-filled left ventricle (LV), and a persistent mitral systolic anterior
motion with increasing pressure gradient in the left ventricular outflow tract (LVOT). Surgical exposure
uncovered an intrapericardial thrombus around the aortic graft compressing the SVC. Removal of the
thrombus resulted in immediate haemodynamic improvement and elimination of both SVC and LVOT
obstructions. A comprehensive TEE exam should always be performed, and all the structures should
be visualized for the proper diagnosis and management of patients after cardiac surgery.
Clinical course
A 59-year-old woman was admitted to the hospital with
hypotension, chest pain, and shortness of breath. The transesophageal echocardiographic examination (TEE) revealed
pericardial effusion, a sigmoid basal ventricular septum,
severe posteriorly directed mitral regurgitation (MR),
mitral systolic anterior motion (SAM), turbulent flow in the
left ventricular outflow tract (LVOT), and a type A aortic dissection with an intimal flap extending from the aortic root to
the mid-arch. Emergency surgery consisted of replacement
of the ascending aorta and resuspension of the aortic
valve. Postoperative transesophageal echocardiography
(TEE) showed mild MR. After surgery, patient was transferred to the intensive care unit for elective postoperative
ventilation and haemodynamic monitoring.
In the first 6 postoperative hours, patient’s condition was
complicated by a low cardiac output syndrome necessitating
inotropic and vasopressor support. Over a period of 3 h, the
central venous pressure increased from 8 to 22 mmHg, and
the pulmonary artery diastolic pressure increased from 10
to 15 mmHg. Furthermore, persistent hypotension despite
fluid administration and increasing filling pressures led to
the clinical impression of cardiac tamponade. A TEE
* Corresponding author. Tel: þ1 416 439 4800, ext 2840; fax: þ1 416 340 3698.
E-mail address: [email protected]
demonstrated an under-filled, thickened hyperdynamic LV.
Basal intraventricular septal thickness was 22 mm. The distance from the right coronary cusp of the aortic valve to
the contact point of the anterior mitral valve leaflet
with the ventricular septum was 17 mm. A persistent SAM
(Supplementary data online, Video-clip S1) with the LVOT
pressure gradient of 120 mmHg was noted. Narrowing of
the superior vena cava (SVC) on 2D imaging (Figure 1) and
a turbulent flow from the SVC to right atrium (RA) were also
noted (Supplementary data online, Video-clip S2). The SVC
diameter was 5.3 mm and looked narrowed. This finding
was suggestive of external compression of the SVC consistent with either thrombus or haematoma. There was no evidence of external compression of RA or right ventricle (RV).
Right ventricle appeared mildly hypokinetic. Moderate
eccentric MR and moderate central tricuspid regurgitation
(TR) were also identified. The patient was taken back to
the operating room for chest exploration.
Surgical exposure uncovered an intrapericardial thrombus
around the aortic graft compressing the SVC. Removal of the
clot resulted in widening of the SVC measured at 13 mm
(Figure 2) and a laminar SVC flow. The LVOT pressure gradient dropped to 27 mmHg, and right ventricular function
improved. Cardiac function continued to improve and the
patient was discharged 12 days after surgery. A transthoracic
echocardiogram before discharge showed mild centrally
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008.
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Department of Anesthesia, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth
Street, Toronto, Ontario, Canada M5G 2C4
590
J. Wacker et al.
Figure 2 A 2D view of superior vena cava (SVC) after chest
exploration and removal of haematoma compressing the SVC.
directed MR and TR and trivial circumferential pericardial
effusion.
pressure, and equalization of central pressures, and is a
clinical diagnosis, which can be supported and/or confirmed
by echocardiography.
Although a few case reports have described localized
haematoma post cardiac surgery resulting in compression
of the RA and SVC, they commonly describe a clinical presentation of the SVC syndrome.3,4 We present a rare complication after open heart surgery resulting in compression of
the SVC with the concurrent findings of the HOCM physiology
in a patient with sigmoid basal septum. Without a comprehensive TEE examination, this diagnosis could not have
been established in a timely manner.
In conclusion, the current case report supports our
contention that TEE offers a comprehensive evaluation of
the cardiac tissues and helps delineate the causes of haemodynamic instability. Furthermore, a comprehensive TEE
exam should always be performed, and all the structures
should be visualized for the proper diagnosis and management of the patient. This, in turn, helps to determine
whether medical or surgical therapy is warranted.
Discussion
Prompt TEE evaluation is of critical importance in haemodynamically unstable patients after cardiac surgery leading
to significant changes in patient management.1 In the
reported case, TEE evaluation revealed partial SVC obstruction, under-filled LV, and a persistent SAM with increasing
pressure gradient in the LVOT. Patients with a sigmoid
basal ventricular septum may develop hypertrophic obstructive cardiomyopathy (HOCM) physiology which is particularly
accentuated in the presence of under-filled or hyperdynamic
LV due to the ongoing bleeding (hypovolaemia), and inotropic support. This type of response is related to the pressure
gradient between the apical and basal parts of the LV during
the ejection phase creating the obstruction of LVOT with SAM
followed by MR.
Expeditious surgical chest exploration led to the identification of an intrapericardial thrombus around the aortic
graft compressing the SVC. Removal of the thrombus
resulted in immediate haemodynamic improvement and
elimination of both SVC and LVOT obstructions. The SVC
obstruction may explain the patient’s delayed responsiveness to the initial fluid resuscitation and emphasizes the
importance of early TEE evaluation. Utilization of the
inferior vena cava access (e.g. femoral vein) rather than
SVC could have potentially facilitated the effectiveness of
early fluid resuscitation. Although the SAM with LVOT
obstruction was present during the initial procedure, it
was likely aggravated by the SVC obstruction.
Haemodynamic compromise due to extracardial effusions
after cardiac surgery is a rare but potentially livethreatening complication. While pericardial effusions are
as common as 85% after open heart surgery, progression to
cardiac tamponade ranges from 0.15 to 6%.2 Tamponade is
suspected by reduced cardiac output, decreased blood
Supplementary data
Supplementary data are available at European Journal of
Echocardiography online.
References
1. Wake PG, Ali M, Carroll J, Siu SC, Cheng DC. Clinical and echocardiographic diagnoses disagree in patients with unexplained hemodynamic
instability after cardiac surgery. Can J Anaesth 2001;48:778–83.
2. Kuvin JT, Harati NA, Pandian NG, Pandian NG, Bojar RM, Khabbaz KR. Postoperative cardiac tamponade in the modern surgical era. Ann Thorac Surg
2002;74:1148–53.
3. Aebischer N, Shurman AJ, Sharma S. Late localized tamponade causing
superior vena cava syndrome: an unusual complication of aortic valve
replacement. Am Heart J 1988;115:1130–2.
4. Pierli C, Iadanza A, Del Pasqua A, Fineschi M. Acute superior vena cava and
right atrial tamponade in an infant after open heart surgery. Int J Cardiol
2002;83:195–7.
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Figure 1 A black and white print of a colour flow Doppler view
reflecting the narrowing of superior vena cava.