• Asploro Journal of Biomedical and Clinical Case Reports
• ISSN: 2582-0370
• Article Type: Clinical Image
• DOI: 10.36502/2020/ASJBCCR.6178
• Asp Biomed Clin Case Rep. 2020 Jan 2;3(1):15-17

Intraoperative Cardiogenic Shock Caused by Intracardiac Tumor Thrombi Obstruction

Yu KP¹, Lin YC^1,2,3*, Chang JY^1,2,3
1Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
²Mackay Medicine, Nursing and Management College, Taipei, Taiwan
³Mackay Medical College, Taipei, Taiwan

Corresponding Author: Ying-Chun Lin, MD
Address: Department of Anesthesiology, Mackay Memorial Hospital , No. 92, Sec. 2, Zhongshan N. Rd., Taipei City 10449, Taiwan.
Received date: 09 December 2019; Accepted date: 17 December 2019; Published date: 2 January 2020

Citation: Yu KP, Lin YC, Chang JY. Intraoperative Cardiogenic Shock Caused by Intracardiac Tumor Thrombi Obstruction. Asp Biomed Clin Case Rep. 2020 Jan 2;3(1):15-17.

Copyright © 2020 Yu KP, Lin YC, Chang JY. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Cardiogenic Shock, Tumor Thrombus, Inferior Vena Cava, Renal Cell Carcinoma

A 60-year-old man presented with left flank pain, a palpable abdominal mass, and hematuria for months. Computed tomography revealed a large tumor in the left kidney (approximately 17.7 cm in diameter) with evidence of left adrenal, left renal vein, and inferior vena cava (IVC) invasion. He underwent left nephrectomy with IVC thrombectomy. Transesophageal echocardiography (TEE) was used during the whole procedure and the tumor was found in the IVC (Fig-1) before resection.

After resection of the main tumor, pulseless electrical activity (PEA) following the sudden onset of hypotension was noticed during the snaring of the IVC. Cardiopulmonary resuscitation was performed and emergent cardiopulmonary bypass (CPB) was established. Newly discovered thrombi appeared in the right atrium (Fig-2), right ventricle, main pulmonary artery, and descending aorta; consequently, these were resected to remove the thrombi.

Weaning from CPB was difficult, with poor left ventricle wall motion noted on TEE. Since the left coronary artery was not seen, coronary obstruction by tumor thrombi was suspected. Therefore, coronary artery bypass graft operation was performed from the ascending aorta to the left anterior descending artery using a harvested autologous saphenous vein.

After the operation, the patient was transferred to the intensive care unit on extracorporeal membrane oxygenation (ECMO) support. Unfortunately, he died six days later because of cardiac failure complicated by multiple organ failure. The final pathological examination revealed renal cell carcinoma with tumor thrombus formation and venous migration.

Renal cell carcinoma (RCC) is characterized by its association with hypercoagulability, venous migration, and tumor thrombus formation [1,2]. Intraoperative TEE allows for monitoring cardiac function, determining thrombus extension, and guiding the level for cross-clamping IVC [3]. For complete removal of advanced tumor thrombi, TEE guidance was indispensable in our patient. For RCC with advanced IVC invasion, a temporary IVC filter may be considered to prevent dangerous tumor thrombus migration [4].

Declaration

This manuscript has not been published elsewhere and is not under consideration by another journal. There are neither conflicts of interest nor funding to declare. Since inform consent from the patient was not possible to get, an IRB approval (18MMHIS213e) for medical publication was received instead.

Acknowledgment

We thank Enago for their expertise and assistance in refining the language and grammar of our study.

References

[1] Tsimafeyeu IV, Demidov LV, Madzhuga AV, Somonova OV, Yelizarova AL. Hypercoagulability as a prognostic factor for survival in patients with metastatic renal cell carcinoma. J Exp Clin Cancer Res. 2009 Mar 2;28:30. [PMID: 19254383]

[2] Ciancio G, Soloway M. Resection of the abdominal inferior vena cava for complicated renal cell carcinoma with tumour thrombus. BJU Int. 2005 Oct;96(6):815-18. [PMID: 16153208]

[3] Pani S, Kelsh-Lasher R, Barlin J, Darling RC 3rd, Torosoff M, Kaufman RP Jr. Use of Transesophageal Echocardiogram and Interdisciplinary Approach to Intraoperative Management of Renal Cell Carcinoma With Inferior Vena Cava Invasion. J Cardiothorac Vasc Anesth. 2019 Oct 10. pii: S1053-0770(19)31039-0. [PMID: 31780356]

[4] Zhang JP, Zhu Y, Liu YJ, Zhang L, Sun LA, Guo JM, Lin ZM. Temporary filters and liver mobilization technique improve the safety and prognosis of radical nephrectomy and inferior vena cava thrombectomy in renal cell carcinoma with subdiaphragmatic thrombosis. Urol Int. 2013;91(3):279-84. [PMID: 23921190]