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Hemodynamic collapse during pulmonary embolectomy due to loss of venous return from acute occlusion of the cardiopulmonary venous cannula with thromboembolus

^a Cardiothoracic Section, Department of Anesthesiology and Critical Care, University of Pennsylvania Medical Center, Dulles 680, HUP, 3400 Spruce Street, Philadelphia, PA 19104-4283, USA
^b Quantitative Echocardiographic Laboratory, Division of Cardiology, Department of Medicine, University of Pennsylvania Medical Center, USA
^c Division of Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, USA

Received 17 January 2008; received in revised form 8 April 2008; accepted 10 April 2008

*Corresponding author. Tel.: +1-(215) 662-7631; fax: +1-(215) 349-8133.

E-mail address: yiandoc{at}hotmail.com (J.G.T. Augoustides).

	Abstract

Top Abstract 1. Introduction 2. Clinical scenario 3. Discussion References

 
We report a case of hemodynamic collapse during pulmonary embolectomy with cardiopulmonary bypass. The hemodynamic collapse was due to complete loss of venous return due to thromboembolic occlusion of the atrial cannula. The diagnosis was made during focused intraoperative transesophageal echocardiography.

Key Words: Cardiopulmonary bypass; Pulmonary embolism; Echocardiography

	1. Introduction

Top Abstract 1. Introduction 2. Clinical scenario 3. Discussion References

 
Emergent pulmonary embolectomy is indicated in the setting of large central clot burden and/or associated right ventricular dysfunction detected echocardiographically [1]. Furthermore, hemodynamic collapse is common with induction of general anesthesia in these clinical scenarios [2]. Although cardiopulmonary bypass (CPB) is recommended for hemodynamic salvage, the occurrence of hemodynamic deterioration after institution of CPB in this scenario has not been described [2]. We report such a case where hemodynamic collapse was due to thromboembolic occlusion of the CPB venous cannula. Immediate effective management of this mechanical complication was possible because of a prompt diagnosis by focused intraoperative transesophageal echocardiography.

	2. Clinical scenario

Top Abstract 1. Introduction 2. Clinical scenario 3. Discussion References

 
A 43-year-old lady was admitted to an intensive care unit for management of adult respiratory distress syndrome. During her admission, she developed acute severe hypotension that prompted urgent transthoracic echocardiography. The echocardiogram was consistent with massive acute pulmonary embolism: it showed serpentine thromboemboli in the right atrium, severe tricuspid regurgitation, and severe right ventricular dysfunction. She was referred to our university hospital for emergent pulmonary embolectomy.

In the operating room, the patient had an uneventful induction of general endotracheal anesthesia due to aggressive pharmacologic support of right ventricular function [1, 2]. Transesophageal echocardiography confirmed the previously reported findings. After systemic heparinization, aortoatrial cannulation for cardiopulmonary bypass was performed with a minimal touch technique. Full cardiopulmonary was instituted uneventfully.

Within minutes of full CPB, there was complete loss of venous return. Targeted transesophageal echocardiography revealed thromboembolic occlusion of the right atrial cannula (Fig. 1). Immediate visual inspection of the cannula confirmed this diagnosis. The cannula tip was manually cleared of thromboemboli and reinserted into the right atrium, with prompt resumption of complete venous return. After aortic cross-clamping, the atrial cannula was revised to bicaval cannulation with minimal cardiac manipulation. This conduct of CPB was deliberately chosen to minimize the risk of thromboembolism.

View larger version (42K): [in this window] [in a new window]   Fig. 1. Transesophageal echocardiographic midesophageal four-chamber view (RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle). The arrow depicts a right atrial cannula that is occluded by mobile serpentine thrombus in the right atrium. Note the dilated right ventricle and the bulging of the interatrial septum into the left atrium (reflecting the high right atrial pressure due to right ventricular failure).

View larger version (114K): [in this window] [in a new window]   Fig. 2. Intraoperative photograph of the operative specimens (RA, right atrium; LPA, left pulmonary artery; RPA, right pulmonary artery). There are multiple thromboemboli extracted from the right atrium, and the major branches of the pulmonary artery.

The remaining perioperative course was uneventful. The patient was transferred to the surgical floor on the second postoperative day. On the tenth postoperative day, the patient was transferred to a rehabilitation facility on therapeutic anticoagulation with coumadin.

	3. Discussion

Top Abstract 1. Introduction 2. Clinical scenario 3. Discussion References

 
To the best of our knowledge, this is the first report of mechanical obstruction of the CPB venous cannula during pulmonary embolectomy. The mobile serpentine thromboemboli in the right atrium made this complication a likely possibility upon initiation of full CPB when venous flow was now through the atrial cannula. Initial right atrial cannulation was chosen over bicaval cannulation to minimize cardiac manipulation and the risk of thromboembolism, as explained earlier.

The role of echocardiography in pulmonary embolectomy has traditionally included diagnosis and assessment of right heart function [4]. Our case adds the detection of mechanical venous obstruction to this echocardiographic menu. Although an inflow cannula for CPB may be obstructed by a heart structure such as an aneurysmal interatrial septum or a tricuspid valve leaflet, this was unlikely in this case [5]. The interatrial septum was bulging into the left atrium away from the right atrial cannula due to the severe acute pulmonary hypertension and associated right ventricular failure (Fig. 1). The tricuspid leaflets had limited excursion due to the severe dilation of the tricuspid annulus and right ventricle. As a result, they were tethered in the right ventricle, far away from a right atrial cannula.

In summary, the clinical observation from this case is that the complete loss of venous return during CPB for acute embolectomy may be due to thromboembolic occlusion of the venous cannula. This mechanical complication must be added to the intraoperative differential diagnosis of this scenario. Intraoperative transesophageal echocardiography can promptly diagnose the obstruction and guide its management, thus further expanding its utility in pulmonary embolectomy [6].

	References

Top Abstract 1. Introduction 2. Clinical scenario 3. Discussion References

 

1. Leacche M, Unic D, Goldhaber SZ, Rawn JD, Aranki SF, Couper GS, Mihaljevic T, Rizzo RJ, Cohn LH, Aklog L, Byrne JG. Modern surgical treatment of massive pulmonary embolism: results of 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005;129:1018–1023.[Abstract/Free Full Text]
2. Rosenberger P, Shernan SK, Shekar PS, Tuli JK, Weismuller T, Aranki SF, Eltzschig HK. Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy. Anesth Analg 2006;102:1311–1315.[Abstract/Free Full Text]
3. Augoustides JG, Ochroch EA. Inhaled selective pulmonary vasodilators. Int Anesthesiology Clin 2005;43:101–114.[CrossRef]
4. Rosenberger P, Shernan SK, Body SC, Eltzschig HK. Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism. Anesth Analg 2004;99:12–16.[Abstract/Free Full Text]
5. Augoustides J, Mancini DJ, Horak J, Pochettino A, Dupont F, Dowling RD. Case 1- 2003. The use of intraoperative echocardiography during insertion of ventricular assist devices. J Cardiothorac Vasc Anesth 2003;17:113–120.[CrossRef][Medline]
6. Rosenberger P, Shernan SK, Mihaljevic T, Eltzschig HK. Transesophageal echocardiography for detecting extrapulmonary thrombi during pulmonary embolectomy. Ann Thorac Surg 2004;78:862–866.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John G.T. Augoustides Joseph E. Bavaria Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Augoustides, J. G.T. Articles by Bavaria, J. E. PubMed PubMed Citation Articles by Augoustides, J. G.T. Articles by Bavaria, J. E. Related Collections Anesthesia Extracorporeal circulation Great vessels Related Article