Off-pump right atrial surgery: Vena caval inflow occlusion in cardiac lesions

Vena caval inflow occlusion, despite its utility in pediatrics, is rarely used in adults. We report the use of inflow occlusion in adults when cardiopulmonary bypass is contraindicated.

Between January 1999 and July 2014, 35 patients in 3 hospitals presented with right-sided cardiac lesions; 27 had right-sided endocarditis with sepsis despite maximal medical therapy, the rest had organized sterile masses with embolic potential in the right side of the heart. Comorbidities included immunosuppression, malignancy, and dialysis-dependent renal failure. Twelve patients had heparin-induced thrombocytopenia. Using inflow occlusion on a beating heart, tricuspid valve vegetectomy was performed in 23 patients, vegetectomy and tricuspid valve repair in 3, removal of infected pacing leads in 7, and removal of a migrated inferior vena cava filter in 1. Eight patients had a single 2-min period of vena caval inflow occlusion, and 25 had additional periods of vena caval inflow occlusion after periods of reperfusion. The first 23 procedures were performed through a sternotomy. Nine patients underwent a right minithoracotomy (redo in 2).

There were no deaths. Infected patients had resolution of sepsis and improvement in respiratory status. Three patients had moderate tricuspid regurgitation, the rest had trivial to mild tricuspid regurgitation. One patient had a transient neurological deficit postoperatively, and one had late empyema.

Removal of infective material, sterile masses, and retained foreign bodies can safely be performed under vena caval inflow occlusion when cardiopulmonary bypass is contraindicated.