An Unusual Cause of Superior Vena Cava Stenosis

Abstract

<h3>Introduction</h3> An unusual cause of superior vena cava stenosis following heart transplantation. <h3>Case Report</h3> A sixty-five year old female underwent orthotopic heart transplantation for chemotherapy-induced cardiomyopathy after treatment for breast cancer in 2008. She required peripheral veno-arterial extracorporeal membrane oxygenation for primary graft dysfunction immediately post-transplantation. Venous access proved challenging due to a combination of implantable defibrillator therapy (extracted at transplant) and left sided mastectomy with lymph node clearance. Attempts at floating a pulmonary artery catheter were unsuccessful. Three days later she developed clinical signs of superior vena cava (SVC) obstruction, with head and upper limb oedema and elevated central venous pressure at 25mmHg. Echocardiography showed a moderate pericardial effusion but no tamponade and an underfilled right heart. Venography confirmed stenosis of the SVC during contrast injection, and measurement of central venous pressures demonstrated a pressure gradient of >4mmHg across the narrowing, with dampening of the pressure waveform distally (Figures). Surgical exploration of the SVC anastomosis site identified a haematoma causing external venous compression. Evacuation of the haematoma resulted in full resolution of symptoms. <h3>Summary</h3> Superior vena cava stenosis is an uncommon complication following heart transplantation, characterized by elevated central venous pressures and upper body oedema. Venography and direct intravenous pressure measurements are diagnostic. Surgical exploration or revision of the anastomosis may be indicated.