Background: Transesophageal echocardiography (TEE) was developed in the 1960s with its potential applications that found its way into cardiac anesthesiology for intraoperative surveillance during cardiopulmonary bypass, heart valve management, and other cardiac procedures. To our knowledge, TEE is uncommonly used in obstetric anesthesia, and has never been used for surveillance of a tumor thrombus that was at risk of embolizing during cesarean section. We present a parturient whose intraoperative management benefitted from the use of transesophageal echocardiography.
Case Description: A 16 year old G1P0 parturient at 37 weeks of pregnancy presented to us from an outside hospital for higher level of care due a recently diagnosed renal mass. She endorsed a five month history of left upper quadrant discomfort that was routinely dismissed as pregnancy-related problem. Eventually, an MRI from an outside hospital performed at 27 weeks of gestation revealed a large mass arising from her left kidney. Further imaging with ultrasound measured it to be 21cm by 15cm in size. Her management was further complicated by the discovery of a large IVC thrombus in the suprahepatic region that was not amenable to IVC filter placement. Given the concern for potential embolization of this thrombus during labor, a multidisciplinary meeting deemed a cesarean section was a safer option given the better control of hemodynamics. However, the autotransfusion that normally follows delivery presented a concerning complication given this additional volume may allow for the thrombus to migrate towards the heart and cause a catastrophic cardiovascular collapse. Additionally, the team agreed it would be safer to manage the renal mass several weeks after delivery when her cardiovascular status had returned to the baseline of a nonparturient.
General anesthesia with invasive blood pressure monitoring was performed in anticipation of possible cardiopulmonary bypass in the event of thrombus migration. We performed a spinal anesthetic prior to induction for postoperative analgesia. A baseline TEE revealed the thrombus size to be 33mm by 37mm which occupied over 95% of the IVC. It extended proximally 2.5cm distal to the IVC/hepatic vein junction. We visualized small slit-like blood flow on color Doppler flowing around the tumor thrombus and up towards the IVC. Her vitals were kept stable with the goal of avoiding wide hemodynamic changes. She quickly delivered a neonate with APGAR scores of 2, 5, and 8 at 1 minute, 5 minutes, and 10 minutes respectively. A second evaluation with TEE at the end of the surgery noted the tumor thrombus to be unchanged in position and morphology.
Discussion: This particular case provided a challenge to the anesthesiology team because of the anticipated hemodynamic shifts that could potentially allow the tumor thrombus to embolize to the heart. We focused on an anesthetic technique with minimal hemodynamic perturbation, and with judicious use of intravenous medications to maintain her vitals within 20% of her baseline. Intraoperative TEE surveillance was also a powerful tool to assess the status of the thrombus and to predict the need for the vascular surgery team in the patient’s management.
