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ECHO ROUNDS

Complete Intraoperative Transesophageal


Echocardiogram Imaging of the Extent of an Inferior
Vena Cava Mass Guides Surgical Management
Sarah J. Little, MD, Frank Van der Heusen, MD, and Kevin C. Thornton, MD

52-year-old woman presented to our institution


with progressive dyspnea and palpitations. Her
medical history was limited to a hysterectomy for
uterine fibroids 3 years before admission. A computed
tomographic scan revealed a large mass arising from the
left pelvis extending up the inferior vena cava (IVC) to the
right atrium (RA). The patient was scheduled for surgical
extraction of this mass. She gave consent for publication of
this report.
After induction of anesthesia, a transesophageal echocardiogram (TEE) with emphasis on the entire potential
course of the tumor was performed. Imaging of the intrahepatic IVC revealed a large, smooth walled, polycystic
mass. In the midesophageal (ME) bicaval view, the freely
mobile intracardiac portion of the mass nearly filled the
RA. In this view, color flow Doppler at a low Nyquist limit
suggested no patent foramen ovale, lessening concern
for systemic embolism. In the 4-chamber view, the
tumor protruded into the right ventricle (RV) during
diastole (Video 1, see Supplemental Digital Content 1,
http://links.lww.com/AA/A179; see Appendix for video
legends). The ME RV inflow-outflow view showed the bulky
mass traversing the tricuspid annulus (Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A180;
see Appendix for video legends). The view was obtained as
described by the American Society of Echocardiography/
Society of Cardiovascular Anesthesiologists guidelines, by
turning the probe right from the ME 4-chamber view to
center the tricuspid valve (TV) and then rotating the
multiplane angle to 60 to 90 degrees while keeping the TV
visible. During this rotation, the RV outflow tract opened
and the pulmonic valve and pulmonary artery (PA) came
into view, somehow distorted by the bulk and mobility of
the mass. In this view, the tricuspid subvalvular apparatus
appeared hyperechoic but was obscured by the mass.
Tumor involvement of the TV could not be excluded.
Finally, in the ME ascending aortic short-axis view, a linear
echodensity was noted in the right PA, but was believed to
be more consistent with near field artifact. The left ventricular ejection fraction was estimated at 65%. There were no
wall motion abnormalities noted.

From the Department of Anesthesia and Perioperative Care, University of


California, San Francisco, San Francisco, California.
Accepted for publication June 25, 2010.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.anesthesia-analgesia.org).
Written informed consent to publish the study was received.
Reprints will not be available from the author.
Address correspondence to Frank Van der Heusen, MD, University of
California, San Francisco, 521 Parnassus Ave., Room C-455, Box 0648, San
Francisco, CA 94143. Address e-mail to vanderheusen@anesthesia.ucsf.edu.
Copyright 2010 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181f1f919

November 2010 Volume 111 Number 5

The initial surgical approach for excision of the tumor


involved a midline sternotomy and bilateral subcostal
incisions. After cannulation of the aorta and RA appendage
and the institution of cardiopulmonary bypass (CPB), deep
hypothermic circulatory arrest was initiated and the intraabdominal vena cava opened. A long rubbery rope of
tumor was easily extracted and removed from its point of
attachment to the left iliac vein. The tumor appeared
grossly intact and was sent to pathology (Fig. 1).
After closure of the IVC, during the rewarming phase
before weaning from CPB, ongoing TEE of the RV inflowoutflow view revealed a thin sliver of residual tumor
entangled in the chordae of the septal leaflet of the TV and
fluttering in the RV outflow tract (Video 3, see Supplemental Digital Content 3, http://links.lww.com/AA/A181; see
Appendix for video legends). The surgeons were notified of
these findings. They elected to recool the patient and
perform an atriotomy to extract the residual sliver of tumor
from the RV (Fig. 1). No further evidence of tumor was
noted during the subsequent termination of CPB. The
patient had an uneventful postoperative course. Pathologic
examination of the specimens confirmed the diagnosis of
intravascular leiomyomatosis.

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

Figure 1. The large tumor after extraction, labeled


as it originally related to the left (L) and right (R) iliac
veins and the heart (H). Inset: The second thinner
tumor, twisted and knotted from turbulent blood
flow. (Courtesy of Dr. Michael Cascio, MD, of the
UCSF Pathology Department.)

Communication between the anesthesia and surgical teams


allowed optimization of the TEE examination and the
diagnosis of residual tumor.
Our case involves IV leiomyomatosis, a tumor that
shares occupancy of the IVC with the more familiar renal
cell carcinoma, but has unique characteristics important to
the anesthesiologist and echocardiographer. It is a rare type
of tumor that, although benign, can be fatal because of
mechanical interference with cardiac function. These
tumors occur primarily in middle-aged women with
prior hysterectomy. They frequently arise from uterine,
ovarian, or hypogastric veins, and extend via the IVC to
the RA, remaining in the intravascular space. These
tumors can have multiple endovascular points of attachment. Rubbery and smooth, they have little thrombogenic potential, in contrast with renal cell carcinomas.
They can, however, give rise to similar satellite lesions.
Treatment depends on complete resection of the tumor.
The surgical approach is variable and can involve staged
abdominal and thoracic procedures or 1-step procedures
with or without CPB and circulatory arrest.4 Intraoperative TEE is a powerful tool to guide the surgical approach by defining the extent of the tumor and its points
of attachment.5

APPENDIX: ONLINE ECHOCARDIOGRAPHIC VIDEO


IMAGES LEGENDS
Video 1: The 4-chamber view demonstrates a large polycystic mass
in the right atrium (RA), protruding through the tricuspid valve (TV)
into the right ventricle (RV) during diastole. LA left atrium; MV
mitral valve; LV left ventricle.

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Video 2: In this prebypass right ventricular inflow-outflow view, the


aortic valve (Ao) is central with the right heart inflow on the right of
the screen and the outflow tract on the left. The mass is seen
protruding through the tricuspid valve (TV). A hyperechoic linear
density arising from the subvalvular apparatus and traversing the
right ventricle (RV) toward the pulmonic valve (PV) is suggested.
Tumor involvement of the RV and pulmonary artery cannot be
excluded.
Video 3: This right ventricular inflow-outflow image was obtained
during intravascular volume loading in preparation for discontinuing
cardiopulmonary bypass. Although the view is somewhat distorted,
the aortic valve (Ao) is still central. Clearly visible is a tumor fragment
tangled in the tricuspid subvalvular apparatus and fluttering in the
right ventricular outflow tract (RVOT). RA right atrium; TV
tricuspid valve; RV right ventricle.
REFERENCES
1. Chen H, Ng V, Kane CJ, Russell IA. The role of transesophageal
echocardiography in rapid diagnosis and treatment of migratory tumor embolus. Anesth Analg 2004;99:3579
2. Komanapalli CB, Tripathy U, Sokoloff M, Daneshmand S, Das
A, Slater M. Intraoperative renal cell carcinoma tumor embolization to the right atrium: incidental diagnosis by transesophageal echocardiography. Anesth Analg 2006;102:378 9
3. Martinelli SM, Mitchell JD, McCann RL, Podgoreanu MV,
Mathew JP, Swaminathan M. Intraoperative transesophageal
echocardiographic diagnosis of residual tumor fragment after
surgical removal of renal cell carcinoma. Anesth Analg
2008;106:16335
4. Harris LM, Karakousis CP. Intravenous leiomyomatosis with
cardiac extension: tumor thrombectomy through an abdominal
approach. J Vasc Surg 2000;31:1046 51
5. Subramaniam B, Pawlowski J, Gross BA, Kim YB, LoGerfo FW.
TEE-guided one-stage excision of intravenous leiomyomatosis
with cardiac extension through an abdominal approach. J Cardiothorac Vasc Anesth 2006;20:94 5

ANESTHESIA & ANALGESIA

Residual Intracardiac Mass on TEE

Clinicians Key Teaching Points

By Kent H. Rehfeldt, MD, Nikolaos J. Skubas, MD,


and Martin J. London, MD

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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