Ann Thorac Surg 1998;65:403-406
© 1998 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Echocardiography Allows Safer Venous Cannulation During Excision of Large Right Atrial Masses
John A. Rousou, MD,
Dennis A. Tighe, MD,
Robert D. Rifkin, MD,
Richard M. Engelman, MD,
Joseph E. Flack, Jr, ,
David W. Deaton, MD,
Charles A. Anene, MD,
Eugene A. Fernandes, MD
Division of Cardiac Surgery, Baystate Medical Center, Springfield, Massachusetts, USA
Division of Cardiology, Baystate Medical Center, Springfield, Massachusetts, USA
Accepted for publication July 27, 1997.
Dr Rousou, Division of Cardiac Surgery, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01107.
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Abstract
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Background. Excision of large right atrial masses requires bicaval cannulation and cardiopulmonary bypass. Safe venous cannulation can be accomplished only by knowing the exact intracavitary location and extension of the mass to avoid fragmentation. Transthoracic echocardiography and intraoperative transesophageal echocardiography, although helpful, cannot always define the exact intracavitary relationships of the tumor.
Methods. We have used both intraoperative transesophageal and epicardial echocardiography to guide venous cannulation in 4 patients with large right atrial masses. Both echo images are used by the surgeon to select the exact site and method of cannulation to avoid fragmentation of the mass. Epicardial echocardiography complemented the images obtained by transesophageal echocardiography.
Results. The technique of combined transesophageal and epicardial echocardiography allowed safe venous cannulation in all 4 patients. Each of the right atrial masses was safely excised using case-specific cannulation techniques guided by the echocardiographic images.
Conclusions. We propose the routine use of both intraoperative transesophageal and epicardial echocardiography in guiding venous cannulation for safe excision of large right atrial masses.
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Introduction
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Right atrial (RA) masses, although rare and less common than left atrial masses [1], can present problems during venous cannulation for cardiopulmonary bypass (CPB) [2]. Whether they are myxomas, thrombi, or vegetations, they can be pedunculated, sessile, or fragile and are subject to fragmentation and embolization during venous cannulation. It is difficult to know by external visual examination of the heart or by palpation (which could also be hazardous) what part of the right atrium, the superior vena cava (SVC), and the inferior vena cava (IVC) is free from abnormal masses, thrombi, or vegetations. Routine blind cannulation of the SVC and IVC can lead to disastrous complications from fragmentation of the mass.
Fragmentation and embolization from RA masses have been reported even without manipulation [3] [4]. The use of intraoperative transesophageal echocardiography (TEE) has been advocated by several investigators [5] [6] as superior or complementary to transthoracic echocardiography for total removal of intracardiac tumors. We used intraoperative epicardial echocardiography (EEC), with transducers operating at 7.5 MHz, in addition to TEE (SONOS 1500 echocardiograph and biplane echoscope; Hewlett-Packard Company, Andover, MA) for safe cannulation of the right side of the heart in 4 patients with large RA masses. The utility of this method is illustrated by the fact that venous cannulation was accomplished safely by altering (or not) routine cannulation techniques on the basis of the complementary intraoperative TEE and EEC findings.
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Material and Methods
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The case reports of the 4 patients follow.
Patient 1
A 42-year-old woman was found to have a large RA tumor by transthoracic echocardiography after she complained of episodes of shortness of breath and fatigue. Intraoperative TEE and EEC showed the tumor occupying most of the right atrium and the orifice of the IVC (Fig 1). The RA appendage and the SVC were free from tumor. Right-sided cannulation was accomplished by initially placing only one cannula through the RA appendage and advancing the cannula into the SVC. Cardiopulmonary bypass was then initiated with this single cannula, and during a brief period of total circulatory arrest (less than 30 seconds), the right atrium was opened. Under direct vision, the tumor was gently retracted enough to cannulate the IVC safely, with resumption of full CPB once bicaval cannulation was established. The tumor was a giant, multilobulated myxoma prolapsing into the right ventricle and the IVC (Fig 2). It was safely excised intact with a portion of the interatrial septum, which was repaired using a pericardial patch. The patient had an uneventful recovery and left the hospital in 4 days.
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(A) (Patient 1.) Transesophageal view in vertical plane showing large, multilobulated mass (MYX) in the right atrium. The mass partially obstructs inflow from the inferior vena cava (IVC), which is dilated. The orifice of the superior vena cava (SVC) and the right atrial appendage (RAA) are not compromised. (B) Epicardial view with transducer placed over most inferior portion of IVC possible and directed slightly superiorly showing the mass (MYX) extending into the IVC from the right atrium (RA). (LA = left atrium.)
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(Patient 1.) Large, multilobulated mass removed intact with a portion of the interatrial septum on which it was based. (The ruler is marked in inches.)
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Patient 2
A 69-year-old woman had had a transvenous pacemaker inserted several years previously for complete heart block. The patient presented with shortness of breath, palpitations, fever, and chills. Transthoracic echocardiography revealed a large RA mass attached to the pacemaker lead. Intraoperative TEE and EEC confirmed a large mass attached to the transvenous pacemaker lead within the right atrium and demonstrated extension superiorly into the SVC (Fig 3). Right-sided cannulation for CPB was safely accomplished by cannulating only the IVC, which was shown by EEC to be free from involvement with the mass. During a brief period of total circulatory arrest (about 30 seconds), the thrombus and lead were extracted under direct vision, and CPB was resumed. In addition, a single coronary bypass graft using vein to the right coronary artery was placed. The mass was found to be a large, infected thrombus occupying most of the right atrium and a portion of the SVC and was attached to the transvenous lead, thus precluding blind SVC cannulation. After operation, the patient had a new transvenous pacemaker inserted and left the hospital on a regimen of anticoagulation with Coumadin (crystalline warfarin sodium).
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(Patient 2.) Transesophageal view in vertical plane showing a complex mass (arrow) filling the visualized portion of the superior vena cava (SVC) and extending into the right atrium (RA). (B) Epicardial long-axis view of RA showing the mass (arrow) protruding from SVC. The orifice of the inferior vena cava (IVC) is demonstrated to be free from involvement by the mass. (LA = left atrium.)
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Patient 3
A 59-year-old woman was found by transthoracic echocardiography to have an RA mass attached to the interatrial septum after she complained of nonspecific chest symptoms. Intraoperative TEE and EEC showed the mass to have a broad base on the interatrial septum but no extension to either the SVC or the IVC (Fig 4). Routine bicaval cannulation was safely accomplished without resorting to transient circulatory arrest as in the previous 2 patients. The tumor and part of the septum were excised, and the resulting septal defect was closed using a pericardial patch. The tumor was a nonlobulated and well-rounded myxoma. The patient had an uneventful postoperative course and left the hospital within 5 days after the operation.
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(Patient 3.) Transesophageal view in vertical plane showing multilobulated mass (MYX) attached with a broad base on right atrial aspect of interatrial septum. The mass does not obstruct inflow from the superior vena cava (SVC) and does not extend near the right atrial appendage (RAA). (B) Epicardial view with transducer placed over inferior vena cava (IVC). The orifice of the IVC is shown to be free from involvement by the mass. (LA = left atrium; RA = right atrium.)
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Patient 4
A 59-year-old man was found to have a large RA mass by transthoracic echocardiography. Intraoperative TEE and EEC showed a giant, multilobulated RA mass with portions prolapsing into the orifices of the SVC, coronary sinus, and IVC. Venous cannulation was accomplished by direct high cannulation of the SVC and the IVC using right-angled venous cannulas, to avoid surgical fragmentation of the tumor. The right atrium could thus be opened safely, and the tumor, a myxoma, was excised intact. The patient’s recovery was uneventful, and he was discharged from the hospital within 5 days.
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Comment
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With current methods of myocardial protection, surgical removal of most right-sided cardiac masses is relatively simple and safe once CPB is accomplished. In experienced hands, mortality is less than half a percent, and complications are rare. However, in the presence of very large or fragile right-sided masses, cannulation of the venous side of the heart can be hazardous because of surgically induced fragmentation and possible embolization of the tumor or other mass. Cardiac tumors have been reported to grow from the free wall of the right atrium [7] or the IVC itself [8], thus necessitating careful selection of the exact site and method of venous cannulation. Knowledge of the exact intracavitary location, origin, and extension of portions of the RA mass before opening the cardiac chambers is virtually impossible without echocardiographic visualization of the RA and venous cavities.
Before the initiation of CPB, TEE or EEC or both can be extremely useful in clearly showing the exact location, origin, and possible prolapse of the mass from the atrium into the venae cavae. As illustrated in the four case reports, routine cannulation techniques can be altered and guided by the echocardiographic findings by taking into consideration the intracavitary spacial relationships of these masses. In patient 1, only the SVC was shown by echocardiography to be free from tumor; it was safely cannulated, and CPB was started with only one venous cannula. Similarly, in patient 2, CPB was initiated safely with only an IVC cannula. In patient 4, both caval cannulas were placed directly in the IVC and SVC, as both orifices were shown to have tumor by TEE and EEC. Routine bicaval cannulation was safely accomplished in patient 3 after TEE and EEC placed the tumor in the middle of the RA cavity without prolapse into the SVC or IVC.
We propose the routine combined use of intraoperative TEE and EEC in all patients with large right-sided cardiac masses as a tool to achieve safe cannulation of the SVC and IVC for CPB. We consider preoperative transthoracic echocardiography inadequate in this respect, and the use of intraoperative TEE, although indispensable, is sometimes inadequate if used alone, especially for defining the IVC–RA junction. The addition of intraoperative EEC, with separate direct examination of the SVC, IVC, and right atrium, effectively complements the findings of TEE in these patients and makes surgical removal of the mass safer and complete.
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References
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Abstract
Introduction
