An Interesting Case: Resection of an RV Mass
By Javier Joglar, MD and Stuart Hall, MD
Texas Children’s Hospital
The pt is a 16-yr-old male who presented to his PCP complaining of fever one day prior to surgery. He had a 6-month history of intermittent chills and “fingers and toes turning blue.” He also suffered intermittent fevers and chills, with his school RN noting 103.2°F (39.6°C) orally the prior day. He has had frequent night sweats for 6 months. He plays varsity tennis at school, but now complains of generalized fatigue, SOB, and his heart “pounding” with physical activity. He had had at least 2 episodes of hemoptysis and has suffered coughing paroxysms. The PCP sent the pt for an echocardiogram which demonstrated a large RV mass. Other PMHx included cystic acne, for which he had been on Accutane for 8 months, and several episodes of acute sinusitis for which he had received several courses of oral and IM antibiotics.
Echocardiogram at our institution revealed a large, well-defined mass in the RV which appeared adherent to the tricuspid valve apparatus. Its largest dimensions appeared to be ca. 30x21mm. There was flow around the mass out the RV outflow tract. CXR showed a normal cardiomediastinal silhouette but some questionable for tracheal deviation; a chest CT revealed an RV mass with extension into the PA and a R lower pulmonary artery embolus. Admission labs were within normal limits and his admission weight was 46.4 kg. He was scheduled for an urgent resection of this RV mass.
In the operating room, after the placement of routine monitors, the patient was induced with incremental doses of midazolam (6mg), fentanyl (250mcg) and vecuronium 5mg. The patient tolerated induction well and never gave indications that his lesion was hemodynamically significant despite its size and location. A right radial 20g arterial line and right internal jugular 7fr 16cm central line were placed percutaneously. In anticipation of a prolong cardiopulmonary bypass period and a possible septic process, the patient received 1G of methlyprednisolone in addition to cefotaxime 2G, vancomycin 1G, and gentamycin 115mg prior to surgical incision. The maintenance of anesthesia consisted of fentanyl, midazolam and 0.5-1.0 MAC of isoflurane.
Direct aortobicaval cannulation was achieved, and his temperature was decreased to 32° C. After right atriotomy was created there was a massive vegetation measuring approximately 6 x 2 x 2 cm filling the inlet and outlet portions of the right ventricle. The mass originated from the septal papillary muscle and involved the entire suspension mechanism of both the septal and inferior leaflets of the tricuspid valve; the heart was otherwise structurally normal. There was also a 2 x 2 cm abscess in the posterior basilar segment of the right lower lobe of the lung. Otherwise the heart appeared structurally normal.
With the noted intraoperative findings it was clear that an extensive tricuspid valvuloplasty versus tricuspid valve replacement would be needed and the temperature was further decreased to 28° C. Unfortunately, the entire suspension mechanism for the septal and inferior leaflets had to be resected; however, the leaflets themselves were uninvolved. A De Vega annuloplasty was performed and the valve appeared to be relatively competent. In addition, the abscessed area within the right lower lobe of the lung was resected.
Separation from CPB was uneventful on vasopressin 0.02 units/kg/hr. TEE evaluation demonstrated no residual intracardiac mass, no left or right ventricular outflow tract obstruction, mild tricuspid regurgitation and no significant pulmonary regurgitation.
Mild dyskinesis of the right ventricular free wall and normal left ventricular systolic function. Protamine was administered and the heart was decannulated with complications.
The patient recovered in the Cardiovascular Intensive Care Unit for several days, he was successfully extubated on post operative day 2, and eventually discharged home to complete 6 weeks of IV antibiotics. The final pathology report on the removed vegetation documented a large organizing fibrofibrinous vegetation with focal dystrophic calcifications, no organisms identified. The wedge resection of the RLL demonstrated organizing fibrofibrinous pleural adhesions with multiple thrombi in the small arteries of the lung tissue.
