Page 33 - Journal of Structural Heart Disease Volume 5, Issue 2

Case Report
46
Figure 4. Transesophageal echocardiogram of the Cardioform device with color Doppler..
Figure 5. Radiographic image of Cardioform with transesopha- geal probe.
Discussion
Given the poor prognosis of patients with extend- ed tumor thrombus from a renal cell carcinoma into the IVC, with rare yet potentially fatal risks of distal embolism particularly intraoperative, the diagnosis of RCC with IVC thrombus necessitates prompt eval-
uation and preoperative optimization [7]. Patients in that category with a PFO further warrant rapid coor- dination of a multidisciplinary team including struc- tural interventional cardiologists to prepare appropri- ately selected patients for PFO closure before surgical resection of the RCC. Radical nephrectomy with IVC thrombectomy is considered to be the most effective therapeutic option in these patients [7].
The presence of severe AS in patients undergoing non-cardiac surgery (NCS) is often under-recognized and most available preoperative risk calculators do not account for it. The current American [6] and Eu- ropean [10] guidelines recommend AVR for patients with symptomatic severe AS; hence such patients’ NCS should ideally be delayed. In our patient, given the time sensitivity of her RCC with an IVC throm- bus, along with a very high risk of distal emboliza- tion with surgery, we decided to proceed with TAVR to better optimize her cardiovascular risk profile for higher chances of a cardiovascular event free radical nephrectomy.
In our case, decision had to be made with regards to her PFO and severe symptomatic AS in a patient with RCC and an extensive IVC thrombus as a means of optimization for her potentially curative radical nephrectomy. Due to thrombosis of the IVC, and successful case reports of using the R-IJ as the ap- proach for PFO closure, we committed to using that approach. We chose the COD due to a lower erosion risk and ease of its delivery system manipulation giv- en the curved anatomy through the internal jugular vein.
Furthermore, the use of multidisciplinary in-hospi- tal teams has been shown to improve outcomes and improve patient satisfaction [11]. Our extensive dis- cussions and detailed planning with the patient and her family, the team of oncologists, urologists, ne- phrologists, general surgeons, intensivists and nurses led to successful PFO closure and TAVR that optimized our patient for her curative radical nephrectomy and IVC thrombectomy.
Conclusion
To the best of our knowledge, this is the first case report of a successful transcatheter PFO closure with a COD through the R-IJ vein. It was also performed
Journal of Structural Heart Disease, April 2019
Volume 5, Issue 2:43-47