Early Detection of a Cavopulmonary Tumor Embolus with the Use of Transesophageal Echocardiography

Abstract

P ulmonary tumor embolization from renal cell carcinoma (RCC) is associated with severe cardiopulmonary morbidity and high perioperative mortality rates. In one study, 1 the direct extension of RCC into the inferior vena cava (IVC) was observed in 22 of 295 patients (7%). Massive pulmonary embolism (PE) can occur during surgical treatment for RCC, especially when the tumor extends into the IVC.2-6 Advantages of using transesophageal echocardiography (TEE) during RCC excision include evaluating the cephalic extension of tumor into the IVC, monitoring the tumor during surgical mobilization, and evaluating cardiac function. 7,8We report a case in which continuous TEE monitoring prevented a patient's death from PE, when RCC extended into the IVC. Case ReportIn January 2012, a 71-year-old woman presented with severe right-sided abdominal pain. The patient's medical history included hypertension, chronic obstructive pulmonary disease, osteoarthritis, peptic ulcer disease, glaucoma, aortic insufficiency, mitral regurgitation, and hyperlipidemia. Her surgical history was notable for a C-section and treatment of a perforated peptic ulcer. Her medications included amlodipine, digoxin, hydrochlorothiazide, lisinopril, omeprazole, pravastatin, spironolactone, and zolpidem. She had no known drug allergies. Until recently, she had smoked one pack of cigarettes per day for approximately 15 years. Magnetic resonance images of the patient's abdomen revealed a 9.5 × 6-cm mass in the right kidney with a 2-to 3-cm extension into the infrahepatic portion of the IVC (Figs. 1 and 2). Contrast computed tomograms (CT) of the chest revealed substantial mediastinal lymphadenopathy and multiple small lung nodules. Results of a bone scan were negative. We decided to perform radical nephrectomy and resection of the intracaval mass. The urology team informed the patient that, at worst, surgery would be palliative rather than curative and might extend her life only for months.The patient's preoperative blood pressure (BP) was 120/65 mmHg, and her heart rate was 80 beats/min. She was given 2 mg of midazolam, and general anesthesia was induced. The patient was monitored by means of electrocardiography (ECG), pulse oximetry, a radial arterial line, a central venous pressure line, end-tidal carbon dioxide measurement, and a rectal temperature probe. An iE33 xMATRIX Echocardiography System probe (Koninklijke Philips N.V.; Best, The Netherlands) was placed. Initially,

Transesophageal echocardiography experience in thepediatric age group in a tertiary cardiac center*

“…TEE is an option, apart from the perioperative period or interventional procedures, in visualization of thrombus or vegetation, in etiologic differentiation of syncope, or where TTE is inadequate for diagnosis. In the case of syncope or transient ischemic attack, the anatomically opened foramen ovale (PFO) might need to be closed (17,18). During TEE evaluation by colored Doppler or agitated serum injection, shunting of blood through the PFO can be definitely shown (14).…”

Transgastric Abdominal Ultrasonography in Anesthesia and Critical Care: Review and Proposed Approach

“…Diagnosis of right ventricular systolic and diastolic dysfunction, 22-30 pulmonary hypertension, 31-33 assessment for IVC stenosis in liver transplantation, heart transplantation, ECMO, and artificial heart, 9,24,[34][35][36][37][38][39][40][41][42] ruling-out abdominal IVC tumor [43][44][45][46][47][48][49][50][51][52][53][54][55][56][57] or thrombus 45,48,56,[58][59][60][61][62] as a cause of pulmonary embolism and right-to-left shunting through a PFO in hypoxic patients with right heart dilation, 45,48,56,[58][59][60][61] and abdominal compartment syndrome 24,34,63 ; intraoperative monitoring during renal cell carcinoma surgery involving the inferior vena cava 43,45,46,…”

“…Abdominal Transgastric Ultrasonography level of the left hepatic lobe, between the stomach and the heart (Supplemental Digital Contents 12 and 15, Figure 5E, Video View 3, http://links.lww.com/AA/ D479, http://links.lww.com/AA/D482). Several authors have also reported on the role of TGAUS in managing patients with renal tumor extending to the IVC, 43,[45][46][47][48][49][58][59][60][61]64 which is discussed in the following section. The hepatic venous velocity patterns can give insight into hepatic perfusion as well as right heart dynamics.…”

Nutrition Considerations in the Pediatric Cardiac Intensive Care Unit Patient

“…Studies show no consistent difference between the two modalities [41][42][43] Early identification of children at risk for tube feedings and subsequent early feeding tube placement will likely decrease hospital length of stay. 44 Risk-adjusted comparison of temporary versus surgical tubes is necessary to help determine which type of feeding tube, if any, is superior with regard to safety and/or improved outcomes after neonatal cardiac surgery.…”