Refractory Hypotension Following Heart Transplantation

Introduction Bicaval anastomosis is the most adopted surgical technique for OHT. We present a case of IVC stenosis following bicaval OHT; a rare but potentially catastrophic complication. Case Report A 59-year-old woman with ischemic cardiomyopathy presented for OHT. Her intraoperative course was unremarkable. She was on stable doses of inotropes/vasopressors postoperatively. Four hours later, she became tachycardic and hypotensive requiring escalating vasopressor support. Swan-Ganz catheterization revealed low cardiac indices and filling pressures. She was resuscitated with 5 L of crystalloid and albumin without improvement in hypotension. She notably developed progressive abdominal distention corresponding with fluid resuscitation. TEE showed a small hyperdynamic LV and a small underfilled RV (Figure 1A). Flow acceleration was noted at the IVC-RA junction with velocity of 2 m/s (Figure 1B). The gradient across the junction was 16 mmHg (Figure 1C). A femoral CVC was placed and transduced to measure pressure in the IVC. The transduced gradient across the SVC and IVC was 18 mmHg; consistent with that found on TEE. She was emergently taken to the operating room. Evidently, the IVC anastomosis was obstructed by presence of a thickened eustachian valve. The valve was completely excised. The IVC orifice and anastomosis were confirmed to be widely patent and the anterior wall of the anastomosis was closed. TEE following resection showed resolution of IVC-RA pressure gradient (Figure 1D). Her hemodynamics subsequently showed hypervolemia for which aggressive diuresis was started. She was slowly weaned off vasopressor support. Her cardiac index improved to >2.0. She later had an uncomplicated course and overall recovery. Summary IVC stenosis is an underrecognized cause of hypotension following bicaval OHT. Prompt recognition using TEE is crucial for immediate repair and prevention of multi-organ failure. A thickened donor eustachian valve can result in IVC stenosis and may require surgical resection if hemodynamically significant.