Case Presentation
A 65 year old man with a history of chronic renal insufficiency, dual chamber AICD, non-ischemic cardiomyopathy, and end-stage heart failure received a non-pulsatile LVAD (HeartMate 3®, Abbott, Boston, MA) as a bridge to heart transplantation.
The patient did well while under LVAD support. After two years he was re-evaluated and subsequently listed for heart transplantation. He received an appropriately matched donor heart which was implanted using the bicaval anastomosis technique. Unfortunately his orthotopic heart transplantation was complicated by severe primary graft failure requiring the placement of bilateral centrifugal pumps (Centrimags®, Abbott, Pleasanton, CA). His donor heart did not recover and therefore he received an implantation of a 70 cc TAH (CardioWest temporary Total Artificial Heart System; SynCardia Systems®, Inc, Tucson, AZ). He had a prolonged hospitalization during which he required the placement of a temporary dialysis catheter for continuous renal replacement therapy. This procedure was done under continuous fluoroscopy to avoid any life-threatening complications such as entrapment of the guide wire and/or line into the right sided mechanical valve of his TAH. In the following time, his renal function eventually recovered but he chronically required high dosages of diuretics. At that time he also experienced episodes of confusion, agitation, emotional lability, and short episodes of expressive aphasia. The computed tomography of his head only noted a small subarachnoid hemorrhage in the left frontal lobe. The patient recovered and was discharged home.
Three months after TAH implantation he was admitted with shortness of breath, weight gain, low fill volumes and low cardiac output readings on his TAH. Facial and upper extremity swelling was noted. A central line was placed under continuous imaging with projection of its tip just on the upper part of the SVC. The readings of his central venous pressure were exceeding values of 20 cm of H2O. Due to significant hypertension he was treated with multiple antihypertensive medications and diuretics.
Subsequently he was readmitted monthly to bimonthly with various problems such as epistaxis and labile mood swings. During all these admissions edema of his upper extremities, primarily left sided edema, and facial swelling had been noted. During his entire post TAH implantation course, he did receive multiple fluoroscopy guided central lines, as well as temporary dialysis catheter placements for volume removal due to diuretic resistance. The tips of the guide wires and lines were, intentionally, never inserted deeper than just into the upper part of the SVC to avoid the possibility of a wire and or a line entrapment into the TAH. A subclavian access was considered as contraindicated due to the risk that lifting his arm may generate the possibility that the tip of the line could advance deep enough getting entrapped in the right sided valve. The central venous pressures were always noted to be significantly elevated and considered to be caused by renal insufficiency in a patient with questionable compliance and intermittent need for intravenous diuretics and/or renal replacement therapy.
Due to the patient’s recurrent clinical presentations, an additional component such as SVCS was suspected, although venous ultrasound studies of his upper extremities did not reveal any deep venous thrombosis or occlusion. During one of his admissions for volume retention, a temporary dialysis catheter placement was performed by interventional radiology with findings consistent of severe stenosis of the SVC. The major concern for a possible venoplasty was that the treatment option carried the possibility for the guide wire not to pass immediately through the stenosis and curve above the stenosis without passing through the opening, which could eventually build up kinetic energy during the attempt to correct its position and unintentionally suddenly flip through the stenosis vested with additional kinetic energy and length when straightened. This uncontrolled move may hypothetically deviate the wire into the right sided valve of the TAH rather than to stay in the patient’s SVC or inferior vena cava. Under risk benefit analysis and informed consent by the patient and his proxies, the decision was made for venoplasty of the SVC stenosis by interventional radiology under fluoroscopy guidance. The pressure gradient within the SVC was measured above the stenosis at 30 mmHg and below the stenosis at 18 mmHg (Figure 1, 2). The patient’s SVC was serially dilated with 10 mm, 14 mm, and 18 mm diameter angioplasty balloons (Figures 3, 4). The 12 mmHg gradient was decreased finally down to 3 mmHg after angioplasty (Figure 5). The patient’s symptoms including the swelling of his upper extremities, shortness of breath, and hoarseness all improved post procedure. He has been discharged and will be evaluated for combined heart/kidney transplantation.