Annals of Pediatric Cardiology
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Table of Contents   
LETTER TO EDITOR  
Year : 2019  |  Volume : 12  |  Issue : 2  |  Page : 188-189
Late presentation of iatrogenic diversion of inferior vena cava to the left atrium


1 Department of Cardiothoracic and Vascular Surgery, Advanced Cardiac Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cardiothoracic and Vascular Anesthesiology, Advanced Cardiac Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication30-Apr-2019
 

How to cite this article:
Kumar R, Munirathinam GK, Raja J, Srivastava A, Mishra AK, Singh RS, Thingnam SK. Late presentation of iatrogenic diversion of inferior vena cava to the left atrium. Ann Pediatr Card 2019;12:188-9

How to cite this URL:
Kumar R, Munirathinam GK, Raja J, Srivastava A, Mishra AK, Singh RS, Thingnam SK. Late presentation of iatrogenic diversion of inferior vena cava to the left atrium. Ann Pediatr Card [serial online] 2019 [cited 2019 Jul 19];12:188-9. Available from: http://www.annalspc.com/text.asp?2019/12/2/188/257410




Sir,

Inferior vena cava (IVC) committed to the left atrium (LA) following surgical closure of atrial septal defect (ASD) is very rare. We describe an unusual case of cyanosis with exertional dyspnea in late adulthood after surgical repair of the defect in childhood in a patient with chronic myeloid leukemia. An 18-year-old girl presented to us with symptoms of breathlessness since childhood that severely compromised her daily activities. She was a known case of chronic myeloid leukemia for which she was on medication since 10 years of age. She attended a local physician, but the above symptoms were cited as sequelae of leukemia which led to further delay in consulting a cardiac surgeon or a cardiologist. She had undergone a surgical closure of ASD under fibrillatory arrest at 4 years of age. On examination, she had a pulse rate of 98 beats/min, blood pressure of 86/64 mmHg, bluish discoloration of lips and nail beds, and room air saturation of 86%. Chest examination revealed normal bronchovesicular breath sounds. Cardiovascular system examinations were essentially normal. A transthoracic echocardiogram (TTE) revealed small ostium secundum ASD of size 6 mm × 6 mm and IVC committed to LA instead of draining into the right atrium (RA) [Figure 1]. The patient was taken for surgery next day after preoperative workup. The procedure was conducted under normothermic cardiopulmonary bypass with bicaval cannulation and cardioplegic arrest. The operative findings were a 5 mm × 5 mm ostium secundum ASD, normal pulmonary venous drainage, IVC draining into LA, and a thick membrane separating IVC from RA likely a previous synthetic patch [Figure 2]. This patch was excised, and the ostium secundum defect was enlarged. The defect was closed with polytetrafluoroethylene patch, so that the opening of IVC drained into the RA. The postoperative recovery was uneventful. She was discharged on the 5th postoperative day and is doing fine after 1 year of follow-up.
Figure 1: Transthoracic subcostal view showing IVC directed toward the LA with shunting from LA to RA through ASD. LA: Left atrium, RA: Right atrium, IVC: Inferior vena cava, ASD: Atrial septal defect, IAS: Interatrial septum

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Figure 2: Intraoperative findings showing inferior vena cava diverted to the left atrium and a small atrial septal defect. (1) Superior vena cave cannula, (2) right atrial floor, (3) previous atrial septal defect patch, (4) atrial septal defect, (5) inferior vena cave cannula, (6) right atrial free wall

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Diversion of IVC blood into the LA during surgical repair of low-lying secundum type ASDs is an uncommon but recognized complication of surgical closure of ostium secundum ASDs.[1] The incidence of such complications was more frequent before the routine use of cardiopulmonary bypass when hypothermia had been used along with inflow occlusion to RA.[1],[2] This complication may occur if there is a surgical incorporation of the  Eustachian valve More Details of the IVC in the repair of a low-lying ASD.[2],[3] Most of these patients have an apparently uneventful postoperative course with satisfactory reduction in heart size, and pulmonary vascularity, only to be followed by the insidious onset of cyanosis, effort dyspnea, and eventually finger clubbing and polycythemia.[2] Sometimes, cyanosis may be appreciated when the subject undergoes evaluation of the symptoms many years after closure of the ASD.[4] The delayed presentation of symptoms due to this complication may be due to the formation of collaterals from IVC, azygos vein draining from IVC to superior vena cava.[4] Early diagnosis of this condition may prevent complications related to hypoxia, cyanosis, and other potentially life-threatening complications such as cerebrovascular accidents due to paradoxical embolism.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Bedford DE, Sellors TH, Somerville W, Belcher JR, Besterman EM. Atrial septal defect and its surgical treatment. Lancet 1957;272:1255-61.  Back to cited text no. 1
    
2.
Mustard WT. Diversion of the venae cavae into the left atrium during closure of atrial septal defects. J Thorac Cardiovasc Surg 1964;47:317-24.  Back to cited text no. 2
    
3.
Shuntoh K, Wada Y, Kawai T, Oka T. Diversion of the inferior vena cava into the left atrium after repair of atrial septal defect with partial anomalous pulmonary venous drainage. Kyobu Geka 1997;50:740-2.  Back to cited text no. 3
    
4.
Alanbaei M, Jutras L, Therrien J, Marelli A. Iatrogenic cyanosis and clubbing: 25 years of chronic hypoxia after the repair of an atrial septal defect. Can J Cardiol 2007;23:901-3.  Back to cited text no. 4
    

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Correspondence Address:
Dr. Rupesh Kumar
Department of Cardiothoracic and Vascular Surgery, Advanced Cardiac Center, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/apc.APC_98_18

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