Unusual Presentation Of Right-To-Left Shunt

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Medically Challenging Case Report Poster 


Muhammad Shabsigh  
Westchester Medical Center


Paolo Trubiano  
Westchester Medical Center


A 56 year old female s/p liver and two renal transplantations complained of worsening dyspnea, severe desaturation on minimal exertion, and upper extremity easy fatigability. Cardiac workup revealed a persistent cardinal vein (vein of Marshall) extending from the innominate to the left superior pulmonary vein. Ten years prior, she received a Hemodialysis ReliableOutflow® (HeRO) device, used in patients whose AV fistula/graft failed, or to bypass an occlusion within the central veins. Over time, the venous outflow of the catheter occluded, causing obstruction of the SVC and innominate veins and SVC syndrome. The SVC stenosis increased the shunt through the vein of Marshall, worsening the right to left shunt, causing dyspnea and upper extremity claudication. During sternotomy for removal of impacted HeRO graft, patch angioplasty of the stenosed veins, and ligation of vein of Marshall, TEE confirmed the anomaly and ruled out atrial septal defect. Anesthetic management is described.

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Enter up to two references.

1. Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine. 2006 Jan 1;85(1):37-42