P016: TRANSESOPHAGEAL ECHOCARDIOGRAPHIC GUIDANCE FOR ASPIRATION THROMBECTOMY DEVICE ANGIOVAC FOR LARGE RIGHT ATRIAL THROMBUS
Mariah Gosling, MD; Miguel Abalo, MD
University of Miami/Jackson Health System
The incidence of right atrial masses is not well defined as typically only symptomatic patients are referred for workup. When a mobile mass is visualized in the right atrium, the differential diagnosis includes thrombus, primary cardiac tumor, metastatic tumor and tricuspid valve vegetation. Although there are no evidence-based guidelines for the treatment of right heart masses, the main treatment options include anticoagulation, systemic thrombolysis and surgical embolectomy. However, open surgical management of cardiac and large vessel thrombi are associated with increased morbidity and mortality. Percutaneous aspiration thrombectomy through the AngioVac system is the first less invasive surgical option that is successful in patients who are not surgical candidates or are hemodynamically compromised (1). In the Registry of AngioVac Procedures in Detail (RAPID) study, 70-100% of clot removal was achieved for right heart masses in a majority (58.5%) of patients (2).
A 32 year-old wheelchair bound female with morbid obesity (BMI 42), history of gastric bypass, and a recent DVT of the right axillary vein was found to have ischemic bowel on CT angiography. Patient was emergently taken to the OR for an ex-lap when the surgical team was notified of a right atrial mass extending from the IVC spanning 3 cm. The surgical team consulted cardiothoracic surgery and the decision was made to prioritize thrombus removal. In the meantime, the anesthesia team placed an arterial and central line. The patient was then taken back to the SICU while the cardiac team was called into the hospital. The patient was brought to the cath lab intubated and sedated. A transthoracic echocardiogram (TEE) confirmed a right atrial thrombus that extended from the IVC with no clear attachment. The right and left ventricular function were within normal limits. The patient was paralyzed with rocuronium and continued on a phenylephrine and norepinephrine drip. She underwent aspiration of the right atrial thrombus with AngioVac thrombectomy via a RIJ catheter under transesophageal echocardiographic guidance. Throughout the procedure, the heart function remained stable. No mass or embolism was left in the heart after the procedure.
The use of TEE was vital in this procedure to guide the AngioVac cannula and alert the anesthesiologist to caval rupture or impending right ventricular obstruction if the mass dislodged. The AngioVac system functions as a veno-venous ECMO circuit connected to a thrombus filter and centrifugal pump allowing the aspirated thrombus, tumor, and septic vegetation to pass through a filter that is trapped in a reservoir before returning blood back to the body (3). As definition management has shown to provide the greatest survival benefit, timely transport to the operating room is vital. The goals of anesthesia for an AngioVac procedure for removing a large right atrial thrombus include: anticipating rapid manipulation of hemodynamics in the event of cardiovascular compromise, providing optimal images with TEE, ensuring a motionless field for safe manipulation of the cannula, adequately oxygenate in the event of distal embolization to the pulmonary vascular and planning for rapid open surgical procedure in the event of major complications (3).