Anesth Analg 2000;91:1137-1138
© 2000 International Anesthesia Research Society
CARDIOVASCULAR ANESTHESIA
Reversible Tricuspid Valve Obstruction During Removal of Renal Cell Carcinoma with Intracardiac Tumor Extension
Kenji Takeda, MD,
Shigehito Sawamura, MD,
Hisayoshi Tamai, MD,
Reiko Hagihara, MD, and
Kazuo Hanaoka, MD
Department of Anesthesiology, Tokyo University School of Medicine, Tokyo, Japan
Address correspondence and reprint requests to Shigehito Sawamura, MD, Department of Anesthesiology, Tokyo University Hospital, 7-3-1, Hongo, Bunkyo, Tokyo, Japan 113-8655. Address e-mail to sawamura-ane{at}h.u-tokyo.ac.jp
 |
Abstract
|
|---|
Implications: Transesophageal echocardiography was used to identify and guide management of reversible tricuspid valve obstruction by a tumor mass during surgical removal of a renal cell carcinoma.
|
Introduction
|
|---|
We report a case of reversible tricuspid valve (TV) obstruction during resection of renal cell carcinoma (RCC) with intracardiac tumor extension. Intraoperative transesophageal echocardiography (TEE) was useful in diagnosing this rare cause of hypotension and guiding surgical manipulation.
|
Case Report
|
|---|
A 70-yr-old man with a right RCC was scheduled for radical nephrectomy. Preoperative transthoracic echocardiography had revealed that the tumor thrombus extended into the inferior vena cava (IVC) and reached the cardiac cavities (Figure 1). During systole, the tumor thrombus was located within the right atrium (Figure 2A). At end-diastole, however, it extended approximately 24 mm beyond the tricuspid orifice into the right ventricle (Figure 2B). The intracaval thrombus did not appear adherent to the IVC wall. Anesthesia was induced with 200 µg fentanyl, 2 mg midazolam, 6 mg pancuronium bromide, and 3% sevoflurane. After tracheal intubation, anesthesia was maintained with sevoflurane (0.5%–1.5%) and additional fentanyl, midazolam, and vecuronium. A TEE probe was placed in the esophagus to continuously observe the intracardiac tumor thrombus.
View larger version (40K):
[in this window]
[in a new window]
|
Figure 1. Schematic illustration of the renal cell carcinoma with intracaval and intracardiac tumor thrombus. Cephalad surgical retraction of the renal tumor (arrow A) can result in movement of the intracardiac thrombus into the right ventricle (arrow B). RCC = renal cell carcinoma, IVC = inferior vena cava, TV = tricuspid valve.
|
|
View larger version (106K):
[in this window]
[in a new window]
|
Figure 2. Transesophageal echocardiographic images of the intracardiac tumor thrombus. A, The tumor thrombus was located within the right atrium during systole. B, The tumor thrombus extended beyond the tricuspid orifice into the right ventricle at end-diastole. Tumor thrombus remaining at this location can obstruct the right ventricular inflow through the tricuspid valve. RA = right atrium, RV = right ventricle, TV = tricuspid valve.
|
|
As the surgical mobilization of the right renal tumor proceeded, there were several episodes of sudden decrease in the systemic arterial pressure (SAP; from 110 to 60 mm Hg) and increase in the central venous pressure (CVP; from 7 to 15 mm Hg mean pressure). This hemodynamic deterioration occurred when the renal tumor was retracted in the cephalad direction. As visualized with TEE, the intracardiac tumor thrombus extended far beyond the TV orifice throughout the cardiac cycle instead of withdrawing into the right atrium during systole. The thrombus appeared to be persistently obstructing the right ventricular inflow. The right atrium was dilated, and the right ventricular end-diastolic volume was remarkably small although the tricuspid orifice was widened because of the impinging thrombus. By anesthesiologist’s request, the surgeons retracted the renal tumor in the caudad direction. Subsequently, the tumor thrombus moved back into the right atrium and the right ventricular filling recovered. SAP and CVP immediately returned to the previous levels. After recognizing the cause of abrupt hypotension, surgeons were informed of the permissible extent of cephalad tumor retraction assessed with TEE and further episodes of hemodynamic deterioration were prevented.
The superior vena cava, the femoral vein, and the ascending aorta were cannulated and deep hypothermic (17°C) circulatory arrest was instituted. After atriotomy and venacavotomy, the intracardiac thrombus was pushed back into the IVC and was successfully extracted with the RCC tumor as one large mass. The patient was rewarmed and weaned from cardiopulmonary bypass (CPB). He was tracheally extubated on the next day and discharged 3 wk later without any neurological complications.
|
Discussion
|
|---|
Aggressive surgical treatment has been advocated for RCC with intracaval tumor thrombus because recent reports indicate that reasonable long-time survival can be obtained by surgery unless there is evidence of distant metastases (1–3). Techniques of CPB and deep hypothermic circulatory arrest have contributed to the improved safety and efficacy of caval thrombectomy (4).
TV obstruction by renal tumor thromboembolism often leads to circulatory arrest and needs immediate embolectomy under CPB (5,6). Sasaoka et al. (6) reported acute TV obstruction and pulmonary embolism during RCC thrombectomy. The thrombus separated into parts and migrated into the right ventricle and pulmonary artery. In our case, in contrast, TV obstruction was reversed by caudad retraction of the renal tumor because the renal tumor and intracardiac tumor thrombus remained one large mass. Although the intracardic tumor was not producing any symptoms preoperatively, it presumably obtained more mobility as the surgical isolation of the renal tumor proceeded because the vena caval tumor thrombus was not adherent to the IVC wall. This is the first report of reversible TV obstruction caused by intracardiac tumor extension of RCC.
Suggested advantages of the intraoperative use of TEE during resection of renal tumors extending into the IVC are quick detection of the tumor thrombus migration or air embolism and monitoring of ventricular function or volume status, especially when insertion of a pulmonary artery catheter is contraindicated because of a large intraatrial tumor (6–9). With the intraoperative use of TEE, we could immediately diagnose the cause of abrupt hypotension; that is, acute TV obstruction induced by a mobilized intracardiac tumor. Moreover, the information provided by TEE was essential for dictating the surgical management in an effort to minimize hemodynamic compromise.
In summary, we describe a case of RCC with intracardiac tumor extension. There were several intraoperative episodes of hemodynamic deterioration caused by acute TV obstruction by intracardiac tumor. This phenomenon was induced by cephalad retraction of the renal tumor and was easily reversed by caudad retraction. Intraoperative TEE was useful in diagnosing this phenomenon and in guiding surgical manipulation.
|
Acknowledgments
|
|---|
Support was provided solely from institutional and/or departmental sources.
|
References
|
|---|
-
Kuczyk MA, Bokemeyer C, Kohn G, et al. Prognostic relevance of intracaval neoplastic extension for patients with renal cell cancer. Br J Urol 1997; 80: 18–24.[Medline]
-
Giberti C, Oneto F, Martorana G, et al. Radical nephrectomy for renal cell carcinoma: long-term results and prognostic factors on a series of 328 cases. Eur Urol 1997; 31: 40–8.[Medline]
-
Glazer AA, Novick AC. Long-term followup after surgical treatment for renal cell carcinoma extending into the right atrium. J Urol 1996; 155: 448–50.[Medline]
-
Rodriguez-Rubio FI, Abad JI, Sanz G, et al. Surgical management of retroperitoneal tumors with vena caval thrombus in the inferior cava using cardiopulmonary bypass, arrested circulation and profound hypothermia. Eur Urol 1997; 32: 194–7.[Medline]
-
Utley JR, Mobin-Uddin K, Segnitz RH, et al. Acute obstruction of tricuspid valve by Wilms’ tumor. J Thorac Cardiovasc Surg 1973; 66: 626–8.[Medline]
-
Sasaoka N, Kawaguchi M, Sha K, et al. Intraoperative immediate diagnosis of acute obstruction of tricuspid valve and pulmonary embolism due to renal cell carcinoma with transesophageal echocardiography. Anesthesiology 1997; 87: 998–1001.[Medline]
-
Allen G, Klingman R, Ferraris VA, et al. Transesophageal echocardiography in the surgical management of renal cell carcinoma with intracardiac extension. J Cardiovasc Surg (Torino) 1991;32:833–6.
-
Koide Y, Mizoguchi T, Ishii K, Okumura F. Intraoperative management for removal of tumor thrombus in the inferior vena cava or the right atrium with multiplane transesophageal echocardiography. Cardiovasc Surg (Torino) 1998;39:641–7.
-
Sigman DB, Hasnain JU, Del Pizzo JJ, Sklar GN. Real-time transesophageal echocardiography for intraoperative surveillance of patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy. J Urol 1999; 161: 36–8.[Medline]
Accepted for publication July 11, 2000.
|
Top
Abstract
Introduction
