Anesth Analg 2006;102:378-379
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000189254.92030.52
CARDIOVASCULAR ANESTHESIA
Intraoperative Renal Cell Carcinoma Tumor Embolization to the Right Atrium: Incidental Diagnosis by Transesophageal Echocardiography
Christopher B. Komanapalli, MD*,
Uttam Tripathy, MD*,
Mitchell Sokoloff, MD
,
Siamak Daneshmand, MD,
Asish Das, MD
, and
Matthew S. Slater, MD*
Department of *Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Division of Urology & Renal Transplant, Urologic Oncology, and Department of Anesthesiology, Division of Cardiac Anesthesia, Oregon Health and Science University, Portland, Oregon
Address correspondence and reprint requests to Matthew Slater, MD, OHSU Division of Cardiothoracic Surgery, Mail code: L353, 3181 SW Sam Jackson Park Road, Portland, Oregon 97239. Address e-mail to slaterm{at}ohsu.edu.
We present a case of a 55-yr-old female patient with a 13.5-cm right renal cell carcinoma with tumor thrombus in the right renal vein. Two weeks before surgery, the patient developed anasarca and dyspnea. The patient was taken to the operating room 6 weeks after her initial computed tomography (CT) scan for a left nephrectomy and renal vein thrombectomy. Intraoperatively, inferior vena cava (IVC) engorgement raised concern for caval involvement with tumor thrombus, but no tumor was palpated in the IVC. A transesophageal echocardiography (TEE) probe was placed and a standard TEE examination was performed as per Society of Cardiovascular Anesthesiologists/American Society of Echocardiography (SCA/ASE) guidelines. No intracardiac abnormality was identified and the examination did not reveal any evidence of a tumor thromboembolus. After IVC and renal vein mobilization, a large floating mass appeared in the right atrium (Fig. 1). The mass was clearly visible in midesophageal (ME) 4-chamber, ME bicaval, and ME right ventricular outflow tract (RVOT) views and was causing intermittent right ventricular inflow obstruction with hemodynamic embarrassment. Mobilization of the infrahepatic IVC was performed for vascular control before removal of the renal mass and renal vein thrombus. Simultaneously, the cardiothoracic surgery team was consulted, a median sternotomy was performed, and the patient was placed on cardiopulmonary bypass (CPB) via standard aortic cannulation and a single superior vena cava cannula so as to not disturb the embolus. A right atriotomy was made and the tumor thromboembolus removed (Fig. 2). An IVC cannula was placed and the atrium was carefully inspected for residual embolic material; none was found and the atriotomy was closed. TEE revealed no residual mass, and there was no evidence of thromboembolus in the central pulmonary arteries. The patient was weaned from CPB and transferred to the intensive care unit. She made an uneventful recovery and was discharged home on postoperative day 8.
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Figure 1. Intraoperative transesophageal echocardiography reveals intraatrial thrombus nearly obstructing the tricuspid valve in the modified mid-esophageal bicaval view. RA = right atrium; RV = right ventricle; TV = tricuspid valve; Embolus = renal cell carcinoma inferior vena cava (IVC) thromboembolus.
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Figure 2. 4.1 x 5.6 cm intraatrial thromboembolus. Video: The video consists of two separate clips. The first one is a midesophageal right ventricular outflow tract (RVOT)/inflow view and the second one is midesophageal/bicaval view. One can clearly visualize the mass in the right atrium intermittently obstructing the tricuspid valve.
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Renal cell carcinoma has a propensity for intravascular embolization and tumor migration. Intraoperative tumor embolization into the heart can be fatal if not diagnosed and treated immediately. Although most tumor thromboemboli are identified preoperatively by CT imaging, (with a sensitivity and specificity of 93% and 80% respectively), occasionally these masses are not seen (1). The size of a right-sided tumor embolus determines the clinicopathologic ramifications that will be incurred as it travels to or through the heart. If the mass is larger than the tricuspid annulus (approximately 30 mm) it will remain in the right atrium unless it fragments. Small masses will easily traverse the tricuspid and pulmonary valve orifices and travel distally in the pulmonary vasculature but, because of the small proportion of pulmonary arterial cross-sectional area involved, these masses rarely produce life-threatening hemodynamic or gas exchange problems. Intermediate-sized masses pose the most risk; masses that either lodge in the tricuspid annulus or the right ventricular outflow tract (RVOT) at the pulmonary valve level, pulmonary bifurcation (saddle embolus) or those that occlude the left or right mainstem pulmonary arteries can produce hemodynamic consequences, including right heart failure or dramatic ventilation/perfusion mismatches. Patients with previously normal right heart pressures (i.e., those with previously normal pulmonary vascular resistance [PVR]) are at risk to acutely decompensate when the right ventricle is acutely subjected to rapid increases in PVR. In this case, we hypothesize that a noncontiguous tumor thromboembolus migrated to the intrahepatic cava preoperatively and was dislodged intraoperatively during IVC mobilization. Intraoperative TEE identified a tumor thromboembolus in the case and guided treatment. Intraoperative TEE is a valuable tool to aid in the rapid diagnosis of intracardiac emboli and can direct treatment (2). TEE views, such as a ME RVOT/inflow and ME bicaval images, are helpful in visualizing thromboemboli/masses of the right atrium and RVOT (see video clip on www.anesthesia-analgesia.org).
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Footnotes
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Supplemental data available at www.anesthesia-analgesia.org.
Accepted for publication September 7, 2005.
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References
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- Hallscheidt PJ, Fink C, Haferkamp A, et al. Preoperative staging of renal cell carcinoma with inferior vena cava thrombus using multidetector CT and MRI: prospective study with histopathological correlation. J Comput Assist Tomogr 2005;29:64–8.[Medline]
- Katz ES, Rosenzweig BP, Rorman D, et al. Diagnosis of tumor embolus to the pulmonary artery by transesophageal echocardiography. J Am Soc Echocardiogr 1992;5:439–43.[Medline]
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