Discussion:
Anaesthetic management of an intrapericardial tumor can present a serious challenge for the anaesthesiologist. Our current anaesthetic experience is predominately based on case reports. Teratomas can be associated with mass effect and pericardial effusions resulting in cardiac compression and respiratory distress after birth. After diagnosis, the typical treatment of choice is surgical resection.
For preoperative planning, it is important to obtain two-dimensional echocardiography as well as magnetic resonance imaging for larger tumors to elucidate the tumor’s involvement with adjacent structures. Determining the ability to separate the mass from vital structures, such as the great vessels and airway, is essential for anaesthetic and surgical planning. In our patient’s case, MRI/MRA as well as 2-Dimensional echo were all obtained during preoperative planning.
In patients with mass effect on the respiratory tree, the goal of preventing respiratory collapse is achieved by performing intubation while the patient is ventilating spontaneously. Depending on location of tumor, airway obstruction and hemodynamic collapse may still occur, which may need to be alleviated by immediate removal/lifting up of tumor by the surgeon after sternotomy. Cardiopulmonary bypass is often on standby, either as a rescue measure or to facilitate resection. In patients with critical positional symptoms of cardiopulmonary compression, induction of anaesthesia with maintenance of spontaneous ventilation may still be unsafe. Alternatives such as extracorporeal membrane oxygenation may need to be established prior to surgical resection 7, 8. In our patient’s case, mass effect on the cardiorespiratory system was somewhat mitigated after drainage of pericardial effusion. There was only a mild compression of distal trachea and we had the knowledge that she was previously uneventfully intubated during neonatal resuscitation. In our patient’s case, tumor resection occurred > 34 weeks gestational age and weight > 2000 grams to allow for cardiopulmonary bypass rescue or ECMO 9, 10, which may be precluded in smaller patients.
Intraoperatively, hemodynamic disturbances should be anticipated with tumor manipulation and surgical blood loss. Adequate IV access is essential as hemodynamic instability is expected and significant blood loss, while rare, can occur. In our patient, an infusion of dopamine and liberal fluid resuscitation including blood products were required to maintain hemodynamic stability. In addition, epinephrine and vasopressin infusions were immediately available. Despite these precautions, permissive hypotension was still required to facilitate surgical resection.
Postoperatively, most patients experience smooth recovery. Our patient was uneventfully discharged on POD 4. Histological examination showed a predominately mature teratoma with immature components, with elements from all three primitive germ cell layers. Patient returned on POD 36 for a repeat cardiac MRI, which showed no residual tumor.