Restoring the Flow! Superior Vena Cava (SVC) Obstruction Following ProtekDuo(TM) Insertion

Abstract

<h3>Introduction</h3> Right heart failure (RHF) following heart transplant (HT) is associated with poor postoperative outcomes. Percutaneous insertion of a right ventricular assist device (RVAD) has been used in post-HT RHF but it is not without its pitfalls. We describe the troubleshooting and management of a complication associated with the ProtekDuo^(TM) cannula. <h3>Case Report</h3> A 65-year-old lady was bridged to HT from a left ventricular assist device. Post-operatively she developed RHF refractory to escalating inotrope and vasopressor support. A 29Fr ProtekDuo^(TM) cannula (with Centrimag^(TM) pump) was inserted to provide RVAD support. Following placement, the patient deteriorated further with facial swelling, hypotension unresponsive to fluids and increasing support requirements. Echocardiogram showed normal right ventricular size with no effusion and chest radiograph confirmed that the ProtekDuo cannula was appropriately positioned.(1) SVC obstruction was subsequently demonstrated on venogram (2), SVC pressures were 36mmHg with no pulsatility, in comparison right atrial pressures were 12mmHg with a normal venous waveform. To relieve the obstruction the ProtekDuo^(TM) was exchanged for a dual cannula configuration with a 25Fr multistage cannula draining via the femoral vein and a 19Fr single-stage return to the pulmonary artery. Pressure measurement showed a persistent gradient of 10mmHg across the SVC despite the smaller cannula (3). To resolve this a single-stage 17Fr cannula was inserted into the innominate vein (via the axillary vein) for upper body venous drainage. This was connected to the femoral drainage with a Y-connector (4). The patient returned to theatre for an SVC repair and was weaned off support. She is now moving forward with her recovery. <h3>Summary</h3> We have described the troubleshooting and management of hemodynamic deterioration secondary to SVC obstruction following ProtekDuo^(TM) cannula insertion.