Left Atrial Dissection Associated with Pulmonary Vein Cannulation

• DOI: 10.1213/ane.0b013e3181b7c508
• Publication Date: 2009-10-15T07:21:17Z
• Authors: Daniel A. Tolpin; Charles D. Collard; Zachariah Thomas; Wei Pan
• Keywords: Male; Reoperation; Hematoma; Cardiopulmonary Bypass; Thrombosis; Middle Aged; Echocardiography, Doppler, Color; Aortic Dissection; 03 medical and health sciences; Treatment Outcome; 0302 clinical medicine; Pulmonary Veins; Catheterization, Peripheral; Humans; Heart Atria; Heart-Assist Devices; Cardiac Surgical Procedures; Heart Aneurysm; Echocardiography, Transesophageal; Thrombectomy

A 46-yr-old man underwent bioprosthetic aortic valve replacement, ascending arch aneurysm repair, and graft repair of the left main coronary artery. The surgery was complicated by postbypass ventricular failure requiring intraoperative Levitronix (Levitronix GMBH, Waltham, MA) assist device (LVAD) placement subsequent implantation a HeartMate II LVAD (Thoratec, Pleasanton, CA). Two days after 9 original surgery, patient returned to operating room for sternal closure transesophageal echocardiography (TEE) examination revealing multiple thrombi in outflow tract, root, right atrium. surgical plan altered include initiation cardiopulmonary bypass allow valve, revision graft, removal all visualized clots. Post–cardiopulmonary imaging revealed new hypoechoic mass between endocardium epicardium along posterior wall atrium (LA) extending into lateral (Fig. 1) (Video 1; please see video clips available at www.anesthesia-analgesia.org; Supplemental Digital Content 1, https://links.lww.com/AA/A22, midesophageal, 4-chamber view demonstrating initial atrial during weaning from [LVAD] flow [with Color Doppler]; this video, following can be seen: severely depressed function space wall; no communication [LA] is with color Doppler; RA = atrium; RV ventricle; LV ventricle). After protamine administration, became more hyperechoic. Intramural dissection diagnosed. Continued expansion intramural hematoma threatened impede blood LA ventricle reduce performance 2). Direct inspection large thrombus, which excised 2; 2, https://links.lww.com/AA/A23, an thrombus; normalization size thrombectomy; inflow cannula apex [LV], dilated [RV]; atrium). Postoperatively, patient’s clinical condition improved, he discharged home await heart transplantation.Figure 1.: Midesophageal, flow. In view, note (LA). MV mitral valve; ventricle.Figure 2.: thrombus formation wall. organized appearance as well obstruction (LV). device; ventricle.DISCUSSION rare complication cardiac that typically occurs surgery.1,2 It has also been reported artery blunt trauma or myocardial infarction, may occur spontaneously.2–4 case presented above, resulted cannulation superior pulmonary vein (RSPV) placement. Cardiac manipulation, heparinization, “sucking” effect propagated described above. appears mitral/tricuspid origin interatrial septum wall.2 However, pericardial impinging on mimic these findings.5 Manual exploration eliminated any trapped fluid behind excluded cause mass. Further TEE luminal border pulsated cycle. This type analysis ideally done continuous electrocardiographic recording display monitor. Similar what seen dissections, false cavity compressed systole being filled https://links.lww.com/AA/A22). M-mode useful tool often used dissections help identify true lumen. excellent distinguishing subtle movement intima or, case, relation Doppler examine tear point chamber. Pulsed wave across reveal if source high low pressure source. Other entities should considered when are thrombi, myxomas, cysts, aneurysms, other tumors.6 most frequently masses usually originate appendage, mobile free floating, intraluminal opposed case. clearly assisted making correct diagnosis An myxoma tumor would present examination. not likely fully heparinized patient. Using monitoring we were able temporal relationship reversal heparin changing mostly fluid-filled hyperechoic clotted 1 versus Fig. finding helped confirm our constant supply blood. To possible extension veins, it necessary 4 veins their junctions LA. accomplished starting midesophageal view. By rotating probe withdrawing slightly, RSPV visualized. expanding followed toward RSPV, had previous sump site 3) 3; 3, https://links.lww.com/AA/A24, rotated withdrawn [RSPV]; RSPV; Advancing further brings lower helpful adjunct. left-sided using same technique but left. particularly identifying anatomy cases congenital anomalous venous return. Another method visualize rotate bicaval view; entering bottom screen.Figure 3.: (RSPV). reduction chamber size. atrium.Postdecannulation well-described associated high-pressure arterial sites. theoretically low-pressure site, knowledge, there reports literature describing occurring cannula. underscores importance diagnosing complications vascular cannulation.