A Rare Case of Stenosis at the Inferior Vena Cava to Right Atrium Anastomosis After Bicaval Orthotopic Heart Transplantation

Abstract

Stenosis at either the superior or inferior caval anastomosis is a rare complication of orthotopic heart transplantation (OHT) and is unique to the bicaval surgical technique. The severity of stenosis dictates the degree of clinical significance, varying from asymptomatic to congestive end-organ injury and hemodynamic instability from impaired preload. Due to differences in the anatomic location of organ congestion, the clinical presentation also depends on which of the 2 anastomoses is involved. In this article, the authors describe a case of stenosis at the inferior vena cava to right atrium anastomosis, which was diagnosed intraoperatively during OHT after weaning from cardiopulmonary bypass. Transesophageal echocardiography provided an accurate and timely diagnosis of this complication, which allowed for immediate surgical correction. Surprisingly, a large, native Eustachian valve was found to be obstructing the anastomosis. Resection of the valve relieved the previously significant narrowing across the anastomosis. This case highlights the importance of thorough intraoperative transesophageal echocardiographic evaluation of graft anastomoses during OHT, as well as an understanding on the part of the echocardiographer of the specific surgical techniques employed during OHT.

IVC Stent to Improve Ventricular Assist Device Filling Following Pediatric Cardiac Transplant

“…Caval stenosis, however, rarely complicates this approach and superior CS has been reported in up to 2.4% of patients, while the larger caliber IVC anastomosis is less frequently affected. 2,5 Donor-recipient size mismatch (11.6 kg recipient vs 30 kg donor in this case), hemostatic sutures, and prominent eustachian valves have been implicated in previous reports of IVC stenosis post-OHT 5,6 and may have contributed to the present case. It was, however, the negative pressure generated by the right atrial cannula that ultimately unmasked our patient's CS.…”

Driving Paradigms Shifts Is at the Core of Our Specialty

“…In a similar fashion, the second report by Abrams and colleagues describes the intraoperative diagnosis of an inferior vena cava to right atrial anastomotic site obstruction after orthotopic heart transplantation with bi-caval technique. 25 Although superior or inferior caval anastomosis stenosis is not a frequent complication, in this case the anastomotic obstruction was caused by the presence of a large Eustachian valve from the native heart. The significance of this case is the proactive use of a comprehensive TEE examination, leading to early detection of an unsuspected complication.…”

Balancing the tug of war: intraoperative and postoperative management of multiorgan transplantation

“…The latter technique demonstrated improved perioperative mortality and valvular function and decreased rates of arrythmias and pacemaker implant [23,24]. Superior and inferior vena cava anastomoses must be carefully evaluated for potential stenosis by TEE [25,26]. The transplanted heart is denervated and physiologic heart rate responses to hemodynamic changes will be absent requiring vigilant multimodal monitoring.…”