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From the Department of Anesthesiology, Veterans General Hospital-Taipei, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
Address correspondence to: Dr. Shih-Tai Hsin, Department of Anesthesiology, Veterans General Hospital-Taipei, 201, sec 2, Shih-pai Road, Taipei, Taiwan, ROC. Phone: 886-2-28757549; Fax: 886-2-28751597; E-mail: sthsin{at}vghtpe.gov.tw
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Clinical features: A 45-yr-old man with protein S deficiency complicated by repeated attacks of deep vein thrombosis and pulmonary thromboembolism was scheduled for insertion of an IVC filter. He had history of chronic renal insufficiency, heart failure, and cerebral infarction with mild left hemiparesis. Current medication included diltiazem (30 mg, 1 tab tid ), prednisolone (5 mg , 2 tabs qd ), and warfarin (2.5 mg daily).
Preoperative transthoracic echocardiography demonstrated bilateral pleural effusions, moderate mitral regurgitation and tricuspid regurgitation, left atrial appendage thrombus and severe generalized hypokinesia of left ventricle. Nuclear medicine examination by 99Tc showed ejection fractions of left ventricle and right ventricle as 20% and 22%, respectively. Under the impression of protein S deficiency with multiple attacks of thromboembolism and failure of anticoagulant therapy, he was arranged for the procedure of vena caval filter insertion. Unfortunately, iatrogenic cardiac tamponade occurred during the course of the procedure with rapid hemodynamic deterioration. Because of the expedient of routine monitoring of cardiac condition with TEE, a prompt diagnosis was made. We successfully improved the patient's hemodynamic status after transthoracic echo-guided pericardiocentesis.
Conclusion: Intraoperative TEE is recommended to be used routinely in patients undergoing vena cava filter procedures. The availability of echocardiographic monitoring in the operation room allows the confirmation of the diagnosis and facilitation pericardiocentesis.
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Case report |
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Preoperative transthoracic two-dimensional echocardiography demonstrated bilateral pleural effusions, moderate mitral regurgitation and tricuspid regurgitation, left atrial appendage thrombus and severe generalized hypokinesia of the left ventricle. Nuclear medicine examination by 99Tc shows ejection fractions of left ventricle and right ventricle of 20% and 22%, respectively. Poor wall motion with severe generalized hypokinesia of the left ventricle was also noted. In the presence of protein S deficiency with multiple attacks of thromboembolism and failure of anticoagulant therapy, vena cava filter insertion was arranged.
Intra-operative monitoring items, including electrocardiogram, pulse oximetry, end-tidal capnography and continuous arterial blood pressure measurement, were applied. Anesthesia was induced with 1.5 mg•kg–1 lidocaine, 5.7 µg•kg–1 fentanyl, 0.27 mg•kg–1 etomidate, and 0.54 mg•kg–1 atracurium iv and maintained with isoflurane 1–1.5 % in O2 100% . The hemodynamic status during induction of general anesthesia was stable and agreeable. After stable anesthesia, a double lumen central venous catheter was placed via the internal jugular vein. Transesophageal echocardiography (TEE, Hewlett-Packard, model 5500, USA) with a multiplane probe was applied as a perioperative monitor.
The surgical procedure started by attempting to introduce the filter guide wire into the inferior vena cava(IVC) via the right external jugular vein. However, it could not be passed through the SVC and the guide wire coiled in the right atrium. At this juncture, atrial fibrillation was noted in the ECG tracing and blood pressure decreased from 105/65 mmHg to 60/35 mmHg with tachycardia (HR: 150/min) despite an intravenous fluid challenge. Repeated doses of ephedrine (40 mg total), continuous intravenous infusion of epinephrine and dopamine were then administrated, but of no avail. Central venous pressure was elevated from 11 cmH2O to 30 cmH2O and engorgement of jugular veins was also noted. At this time, the TEE demonstrated compression of right atrium, right ventricular diastolic collapse and pericardial accumulation of fluid, all of which were typical of cardiac tamponade (Figure 1
). Emergency pericardiocentesis, guided by TEE and confirmed by transthoracic echocardiography (TTE, Figure 2), was performed immediately. In total, 700 ml blood were drained and the drainage tube was left for continuous but slow drainage. The patient's hemodynamic improved soon after pericardiocentesis and central venous pressure decreased to within normal range. The vena caval filter insertion procedure was called off. Patient was transferred to ICU for further care.
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). Both thrombi were removed after sternotomy and atriotomy under cardiopulmonary bypass. The IVC filter was also successfully inserted thereafter via RA to IVC at the level of L2–3. The perioperative status of the patient was stable and whole procedure was done smoothly.
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Discussion |
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Deficiency of C or S protein, usually an autosomal dominant disorder, causes identical disease entities characterized by recurrent venous thromboembolism and pulmonary embolism. In addition, few patients with homozygous protein C deficiency have fulminant neonatal intravascular coagulation and require prompt diagnosis and treatment. All these patients had suffered manifest similar clinical symptoms by their early twenties. Heterozygous patients with protein C or S deficiency who develop acute thrombosis should be initially heparinized and then placed on oral anticoagulants.4 However, there are two potential problems with the use of coumarin anticoagulants in these patients. First, it lowers the level of the precoagulant factors II, VII, IX, and X, also may reduce the concentration of protein C and S sufficiently to nullify the desired antithrombotic effect. In addition, there are patients with coumarin-induced skin necrosis who are protein C deficient, suggesting that this defect may predispose patients to a rare but serious complication of oral anticoagulants.
The placement of vena caval filter is generally a contemplation for prophylaxis against pulmonary embolism in patients with deep-vein thrombosis or those at high risk for venous thromboembolism, in whom anticoagulant therapy failed or was contraindicated.5–7 An IVC filter may be placed immediately after an episode of large pulmonary embolism in order to forestall a subsequent fatal one. Many complications may also be associated with this procedure. Nevertheless, insertion of the filter is a safe, easy, and effective form of prophylaxis for pulmonary embolism in high-risk patients, although no significant differences in mortality between those who had or had not received vana caval filter.
Cardiac tamponade leads to impaired venous return, insufficient cardiac filling and reduction in stroke volume and cardiac output. Clinical manifestations include narrow pulse pressure, neck vein distention, markedly elevated central venous pressure, which equalizes the ventricular end-diastolic pressures and atrial pressures. Echocardiography is the most effective diagnostic tool due to its sensitive, specific, simple, innocuous and non-invasive nature. A classic transthoracic echocardiographic feature of cardiac tamponade is diastolic collapse of the RA or RV.8 In many cases, however, transthoracic imaging is difficult because of hindrance by mechanical ventilation or competition with the surgical field. TEE can provide adequate visualization, especially of the posterior part of the heart because of the proximity of the transducer to the cardiac structures.9 Once the diagnosis of cardiac tamponade is ascertained, emergency pericardiocentesis is not only a simple procedure but also provides a rapid hemodynamic relief. This life-saving procedure could be guided either by TTE or TEE. In this case, intra-operative TEE appears to be superior. Continuous aspiration may help avoid the need of immediate surgical intervention, but definite or radical treatment of pericardial tamponade due to bleeding may require thoracotomy for evacuation of hematoma.10
In conclusion, this report emphasizes the usefulness of intra-operative transesophageal echocardiography for early detection of pericardial tamponade in patients undergoing vena caval filter insertion procedure and the facilitation of guiding pericardiocentesis.
Accepted for publication March 9, 2000.
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2 Burke PE, Michna BA, Harvey CF, Crute SL, Sobel M, Greenfield LJ. Experimental comparison of percutaneous vena cava devices: titanium Greenfield filter versus bird's nest filter. J Vasc Surg 1987; 6: 66–70.[Medline]
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Haire WD. Vena cava filters for the prevention of pulmonary embolism (Editorial). N Engl J Med 1998; 338: 463–4.
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Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. N Engl J Med 1998; 338: 409–15.
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Martin JG, Marsh JL, Kresowik T. Phlegmasia Cerulea Dolens: a complication of use of a filter in the vena cava. A case report. J Bone Joint Surg 1995; 77: 452–4.
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Schoebrechts B, Herregods M-C, Van de Werf F, De Geest H. Usefulness of transesophageal echocardiography in patients with hemodynamic deterioration late after cardiac surgery. Chest 1993; 104: 1631–2.
9 Berge KH, Lanier WL, Reeder GS. Occult cardiac tamponade detected by transesophageal echocardiography. Mayo Clin Proc 1992; 67: 667–70.[Medline]
10 Callahan JA, Seward JB, Tajik AJ. Cardiac tamponade : pericardiocentesis directed by two-dimensional echocardiography. Mayo Clin Proc 1985; 60: 344–7.[Medline]
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