Damage control: cavoatrial anastomosis during a catastrophic right intrapericardial pneumonectomy.
While undergoing an intrapericardial pneumonectomy for a massive right pulmonary inflammatory pseudotumor that had invaded the mediastinum, an 18-year-old woman experienced a nearly fatal iatrogenic complication. Dense scarring adjacent to the pseudotumor had drawn in the superior vena cava posterolaterally and fused the right main pulmonary artery to the right superior pulmonary vein within the pericardium. The failure of a linear stapler to secure the pulmonary vessels led to torrential hemorrhage. Attempts to control the bleeding resulted in inadvertent superior vena cava occlusion and central venous pressure elevation. Because cardiopulmonary bypass might not have been reliably established in time to avoid irreversible cerebral ischemia, we borrowed a technique from congenital heart surgery and rapidly fashioned a cavoatrial connection. The patient survived the operation without negative neurologic or cardiac sequelae, recovered fully, and had no recurrence of the pseudotumor. Herein, we describe the intraoperative decisions that were made under intense time pressure to avert catastrophe.
Van Natta
Timothy L
TL
Department of Cardiothoracic Surgery, University of Iowa Hospitals & Clinics, Iowa City, Iowa 52245, USA. tvannatta@dhs.lacounty.gov
Parekh
Kalpaj R
KR
Dearmond
Daniel T
DT
Iannettoni
Mark D
MD
D000293:Adolescent; D000714:Anastomosis, Surgical; D016063:Blood Loss, Surgical / Q000517:prevention & control*; D006348:Cardiac Surgical Procedures; D002388:Catastrophic Illness; D002496:Central Venous Pressure; D002560:Cerebrovascular Circulation; D005260:Female; D006325:Heart Atria / Q000601:surgery; D006488:Hemostasis, Surgical / Q000009:adverse effects*; D006801:Humans; D007049:Iatrogenic Disease; D016726:Plasma Cell Granuloma, Pulmonary / Q000473:pathology / Q000601:surgery*; D011013:Pneumonectomy / Q000009:adverse effects*; D013479:Superior Vena Cava Syndrome / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D017792:Surgical Stapling / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014683:Vena Cava, Superior / Q000293:injuries / Q000503:physiopathology / Q000601:surgery*