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DISCUSSION
This case adds to the body of literature advocating complete
TEE evaluation of the entire right-sided circulation throughout surgical extraction of IVC-occupying tumors. Complete
intraoperative TEE imaging depends on adequate and
timely views. The entire potential course of the tumor
should be imaged, from the IVC through the atrium (ME
bicaval view with examination of intrahepatic IVC and
evaluation for interatrial shunt), RV (4-chamber and RV
inflow-outflow view), and PAs (ME ascending aortic shortaxis view). These images should be obtained throughout
surgery: before, during, and after resection. Initial examination reveals the extent of the mass, its points of attachment, and the presence of an intracardiac shunt. Ongoing
examination during surgical manipulation of the tumor can
detect embolism.1,2 Postexcisional examination is critical
for surveillance for residual tumor.3
In our case, the RV inflow-outflow images obtained
pre-excision raised the suspicion of tumor involvement of
the TV and RV. By obtaining the RV inflow-outflow view
again after transcaval tumor excision but while the patient
was still on CPB, we were able to confirm the presence of
residual tumor and guide the surgeons to complete resection of the tumor. To obtain this view while the patient was
still on CPB, we used the previously described approach,
but this time found the optimal image at a greater degree of
rotation. We also requested that the surgeon and perfusionist allow some ventricular filling. The blood volume filling
the heart helped to elucidate the intracardiac structures.
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ECHO ROUNDS
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In a patient with an inferior vena cava (IVC) mass, a systematic intraoperative transesophageal echocardiographic
(TEE) examination is important for patient management (mass effect or potential for paradoxical embolization via
interatrial communications) and surgical planning (need for cardiopulmonary bypass). This should include imaging of
the intrahepatic IVC, the right cardiac chambers (midesophageal [ME] 4-chamber, right ventricular [RV] inflow/outflow
and bicaval views), the pulmonary artery (ME ascending aorta short-axis view), tricuspid valve, and interatrial septum.
The IVC can be imaged by advancing the probe slightly from the ME 4-chamber view while turning it rightward; the IVC
appears in short axis at its confluence with the right atrium. Increasing the multiplane angle gradually to between 30
and 90 degrees facilitates long-axis imaging of the IVC, while progressive advancement of the probe displays the
intrahepatic portion of the IVC and its confluence with hepatic veins.
In this case, TEE displayed extension of the tumor from the IVC into the RV through the tricuspid annulus in diastole.
A repeat TEE examination after initial resection demonstrated the presence of residual tumor within the RV and
prompted further surgical exploration.
Leiomyomatosis is a large IVC tumor with cavitary lesions, which may give rise to satellite lesions; complete resection
is critical. A methodical intraoperative TEE examination of all intra- and extracardiac structures along the potential
route of tumor extension, before and after surgical manipulation, helps document tumor extent and complete removal.
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