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Robotic Resection Of Intrapericardial Aortopulmonary Window Paraganglioma
John O. Barron, MD, Siva Raja, MD, PhD, Sudish C. Murthy, MD, PhD.
Cleveland Clinic, Cleveland, OH, USA.
BACKGROUND: A 56-year-old female with history of severe hypertension and episodes of headache, flushing, and diaphoresis was found to have a 2 cm hyper-enhancing mass abutting the intrapericardial left main pulmonary artery, concerning for paraganglioma. This was supported by dotatate PET/CT avidity, with laboratory studies revealing elevated plasma dopamine but otherwise normal plasma and urine metanephrines and catecholamines.
METHODS: She received 2 weeks of preoperative alpha blockade with doxazosin, followed by robotic assisted resection of the intrapericardial lesion via the left chest. Intrapericardial dissection was facilitated by incision of the pericardial reflection overlying the left superior pulmonary vein. Given its hypervascularity, the lesion was resected using a combination of bipolar cautery, clips, and the vessel sealer.
RESULTS: The patient was discharged on postoperative day 2 and recovered without complication. Plasma dopamine levels have since normalized. Pathology demonstrated a paraganglioma with negative level 5 and 6 lymph nodes. She was referred for genetic testing.
CONCLUSIONS: Resection of paraganglioma requires a preoperative plan for management of intraoperative hemodynamic lability, with nitroprusside available in the event of severe hypertension, and fluids in the event of hypotension following resection. Incision of the pericardial reflection overlying the proximal superior pulmonary vein facilitates safe access/control to the intrapericardial pulmonary artery, a vital skill with a wide range of applications.
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