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.