Development of Subneopulmonary Obstruction Early After Arterial ...

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CASEREPORT ALEXI-MESKISHVILIET AL ARTERIALSWITCH OPERATION IN AN ADULT

gested, b u t m a y actually worsen the clinical s y n d r o m e b y causing further p l a q u e h e m o r r h a g e [3] a n d a t h e r o e m b o l i [4]. Patients are also e x p o s e d to the complications associated with lifelong anticoagulation therapy. Operative d e b r i d e m e n t has b e e n s u g g e s t e d as a m e t h o d of preventing cerebral vascular accidents in patients who are undergoing open heart operations for reasons other than recurrent cerebral vascular accidents [5]. W e have ext e n d e d this p h i l o s o p h y to treating cerebral vascular accidents in patients who otherwise w o u l d not have req u i r e d o p e n heart operations. Several recent technical advances have facilitated this procedure. The use of axillary artery cannulation avoids retrograde embolization from the d e s c e n d i n g aorta [6], which is universally p r e s e n t in patients with substantial a s c e n d i n g aortic atherosclerosis [7]. W i t h axillary artery cannulation, the high-velocity flow is away from the d i s e a s e d a s c e n d i n g aorta a n d arch. Furthermore, there is little to no sandblasting effect. The use of circulatory arrest a n d r e t r o g r a d e cerebral perfusion provides excellent exposure of the a s c e n d i n g aorta a n d arch, as well as s u p e r i o r cerebral protection [8]. Furthermore, the constant efflux of b l o o d out of the h e a d vessels prevents the entry of atherosclerotic emboli, which m a y be d i s l o d g e d during operation [8]. W e believe that e n d a r t e r e c t o m y of the ascending aorta a n d transverse arch can safely prevent further systemic embolic events a n d avoid the complications associated with l o n g - t e r m medical m a n a g e m e n t . Patients with systemic emboli without a cardiac source or cerebral vascular disease b u t with diffuse atherosclerosis involving the ascending aorta, especially with mobile plaques, m a y be candidates for endarterectomy.

References 1. Karalis DG, Chandrasekaran IG Victor MF, Ross JJ, Mintz GS. Recognition and embolic potential of intraaortic atherosclerotic debris. J Am Coll Cardiol 1991;17:73-8. 2. Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J 1990;120:658-60. 3. Moldveen-Geronimus M, Merriam JC Jr. Cholesterol embolization: from pathologic curiosity to clinical entity. Circulation 1967;35:946-53. 4. Ridker PM, Michel T. Streptokinase therapy in cholesterol embolization. Am J Med 1989;87:357-8. 5. Ribakove GH, Katz ES, Galloway AC, et al. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 1992;53:758-63. 6. Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery! an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:885-91. 7. Blauth BI, Cosgrove DM, Webb BW, et al. Atheroembolism from the ascending aorta. J Thorac Cardiovasc Surg 1992;103: 1104-12. 8. Lytle BW, McCarthy PM, Meaney KM, Stewart RW, Cosgrove DM. Systemic hypothermia and circulatory arrest combined with arterial perfusion of the superior vena cava: effective intraoperative cerebral protection. J Thorac Cardiovasc Surg 1995;109:738-43. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc

Ann Thorac Surg 1996;61:1518-20

Development of Subneopulmonary Obstruction Early After Arterial Switch Operation in an Adult Vladimir Alexi-Meskishvili, MD, Frank U h l e m a n n , MD, Felix Berger, MD, Peter E. Lange, MD, PhD, a n d Roland Hetzer, MD, PhD Departments of Cardiothoracic and Vascular Surgery and Pediatric Cardiology, German Heart Institute Berlin, Berlin, Germany In a 19-year-old woman who had previously undergone pulmonary artery banding at the age of 1.5 years, a muscular right ventricular outflow tract obstruction developed 3 days after an arterial switch operation. Although conservative therapy proved successful, prophylactic surgical intervention on the conal septum may be beneficial in preventing the postoperative development of right ventricular outflow tract obstruction.

(Ann Thorac Surg 1996;61:1518-20) he arterial switch operation, a well-established procedure for treating a ventricular septal defect comb i n e d with o-transposition of the great arteries, is usually p e r f o r m e d in infants [1]. Very limited experience has b e e n m a d e with this operation in adults [2], in w h o m it can be followed b y u n u s u a l complications early after operation, as o b s e r v e d in the p r e s e n t case.

T

The female patient p r e s e n t e d to the G e r m a n Heart Institute Berlin for the first time w h e n she was 18 years old a n d d e e p l y cyanotic with arterial oxygen saturation at 76% a n d hematocrit at 0.70. W h e n she was 1.5 years old p u l m o n a r y artery b a n d i n g a n d a Blalock-Hanlon procedure were p e r f o r m e d at a n o t h e r hospital. Cardiac catheterization a n d a n g i o g r a p h y indicated a s u b p u l m o n a r y ventricular septal defect a n d transposition with a n t e r i o r / p o s t e r i o r relation of the great arteries. The distal p u l m o n a r y artery/systemic p r e s s u r e ratio was 0.46, with a 70-mm H g p r e s s u r e g r a d i e n t across the p u l m o n a r y artery band. N e i t h e r a right ventricular aortic p r e s s u r e gradient nor angiographic features of right ventricular outflow tract obstruction were o b s e r v e d (Fig 1A; Table 1). At the age of 19 years the patient u n d e r w e n t an arterial switch operation involving c a r d i o p u l m o n a r y bypass, core cooling to 25°C rectal t e m p e r a t u r e , a n d m y o c a r d i a l protection with a n t e g r a d e crystalloid cardioplegia, w h e r e b y ventricular a n d atrial septal defects were closed with Teflon patches. A f t e r w a r d the patient was w e a n e d from c a r d i o p u l m o n a r y b y p a s s w i t h o u t difficulty. Inotropic Accepted for publication Nov 2, 1995. Address reprint requests to Dr Alexi-Meskishvili,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin,Augustenburger Platz 1, D-13353 Berlin, Germany. 0003-4975/96/$15.00 SSDI 0003-4975(95)01162-5


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CASE REPORT ALEXI-MESKISHVILI ET AL ARTERIALSWITCHOPERATIONIN AN ADULT

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pressure and an 8-mm Hg systolic pressure gradient between the right ventricle and n e o p u l m o n a r y artery (see Table 1). Cardiac index increased over the next 2 days from 1.6 L • min 1. m 2 on the first postoperative day to 3.1 L- min 1. m - 2 o n the third. At the same time right ventricular systolic pressure increased significantly up to 180 m m Hg due to the development of dynamic s u b n e o p u l m o n a r y stenosis as documented by transesophageal echocardiography. Cardiac catheterization and angiography on the third postoperative day revealed no residual defects except a 128-mm Hg pressure gradient across the right ventricular outflow tract as a result of dynamic subpulmonary muscular stenosis occurring at the end of systole (see Table 1; Fig 1B). Because the patient's cardiac output and ventricular function were adequate, and considering that the infusion of epinephrine (0.08 to 0.15 mg • kg -1 • rain 1) during the postoperative period might have caused subpulmonary obstruction, the patient was weaned from catecholamine support, which resulted in a decrease in right ventricular pressure (see Table 1). The patient was extubated 7 days after operation and discharged from the hospital on the 27th postoperative day. Transthoracic echocardiography indicated a 20-mm Hg systolic pressure gradient across the right ventricular outflow tract.

Comment

Fig 1. Right ventriculography before and after arterial switch operation (end-systolic phase). (A) Six months before arterial switch operation. No right ventricular ou~qow tract obstruction or systolic pressure gradient was observed. (B) Three days after arterial switch operation, right ventriculography revealed a significant subpulmonary dynamic muscular obstruction. The systolic pressure gradient between the right ventricles and pulmonary artery was 128 mm Hg.

support was provided with epinephrine infusion (0.15 m g • kg -1 • min 1). Pressure measurement 30 minutes after bypass revealed a slight decrease in pulmonary arterial diastolic

Arterial switch operations in adults in w h o m pulmonary artery banding was performed in infancy are rare [2]. Although no right ventricular subaortic obstruction was found preoperatively or intraoperatively, significant right ventricular (subneopulmonary) dynamic outflow tract muscular stenosis developed during the early postoperative period with suprasystemic pressure in the right ventricle. Right ventricular (subaortic) outflow obstruction in patients with transposition of the great arteries and subpulmonary ventricular septal defect, or TaussigBing anomaly, observed in 40% to 50% of the cases, is the result of anterior displacement of the conal septum and hypertrophy of the ventricular infundibulum fold, which can be aggravated by pulmonary artery banding [3-8]. Vogel and associates [8] established the correlation between preoperative subaortic obstruction in cases in which the subaortic region was tubular and smaller than the aortic valve during the systolic and diastolic phases, even in the absence of a pressure gradient. If not recognized and treated properly, this complication can be lethal in the early postoperative period. Kanter and colleagues [7] intraoperatively observed the development of subvalvular right ventricular outflow tract obstructions in 5 patients with complex transposition, which manifested themselves as suprasystemic pressure in the right ventricle as well as the inability to be weaned from cardiopulmonary bypass. None of these patients had a right ventricular outflow tract gradient preoperatively. Despite a second period of cardiopulmonary bypass and transventricular infundibular resection, only 2 of the 5 patients survived. In the present case neither echocardiographic, angiographic, nor pressure parameters preoper-

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CASEREPORT ABE ET AL CORONARYARTERY~CORONARYSINUSFISTULA


Table 1. Pressure Dynamics in the Cardiac Chambers and Great Arteries Pressure (mm Hg) Chamber/Artery

6 mo Before ASO

30 min After ASO

Postoperative Day 3

Postoperative Day 5

Postoperative Day 8

Right ventricle Pulmonary artery Left ventricle Aorta

140/0-11 50/30 140/0-12 140/80

60/11 52/18 NM 120/80

170/0-17 42/23 120/0-17 120/60

70/15 32/28 NM 120/70

65/10 37/20 NM 115/60

ASO = arterial switch operation;

NM = not measured.

atively indicated a subaortic obstruction (see Fig 1A; Table 1). Postbypass pressure m e a s u r e m e n t s were not predictive. A n i m p r o v e m e n t in cardiac index a n d contractility during the first 3 postoperative days resulted in the d e v e l o p m e n t of a s u b n e o p u l m o n a r y right ventricular m u s c u l a r obstruction p r e s u m a b l y aggravated by circulatory support with e p i n e p h r i n e infusion. W e a n i n g the patient from vasopressor support resulted in a significant decrease in right ventricular systolic pressure. This case illustrates that arterial switch operations can be successfully performed in adult patients after a long period of p u l m o n a r y artery b a n d i n g (17 years in the present case). Because the a n a t o m y of the conal septum plays an important role in d e t e r m i n i n g the surgical procedure, even during arterial switch operations [3, 5, 7, 8], the d e v e l o p m e n t of a right ventricular outflow muscular obstruction m u s t be considered, even despite the absence of preoperative indications for this. Prophylactic transatrial partial resection of the conal septum in patients after a long period of p u l m o n a r y artery b a n d i n g may be beneficial in preventing right ventricular outflow tract obstruction d u r i n g the early postoperative period.

7. Kanter KR, Anderson RH, Lincoln C, Rigby ML, Shinebourne EA. Anatomic correction for complete transposition and double outlet right ventricle. J Thorac Cardiovasc Surg 1985;90: 690-9. 8. Vogel M, Freedom RM, Smallhorn JF, Burrows P, Williams WG, Trusler GA. Morphologische Variationen bei 37 Patienten mit Taussig-Bing Herzen und deren Bedeutung fiir die chirurgische Behandlung. Z Herz Thorax Gef~i/3chir 1991;5: 110-4.

We thank Jonathan Davis for proofreading the manuscript.

successfully closed with direct suture closures by opening the aneurysm under complete cardiopulmonary bypass. The distal terminated orifice of the fistula, which drained to the coronary sinus, was also closed. Finally, aneurysmorrhaphy with overlapping mattress sutures was performed. The postoperative angiographic study demonstrated normal coronary artery distribution, and the patient was asymptomatic without recurrence at 2 years after the operation. (Ann Thorac Surg 1996;61:1520-3)

References 1. Brawn WJ, Mee RBB. Early results for anatomic correction of transposition of the great arteries and for double-outlet right ventricle with subpulmonary ventricular septal defect. J Thorac Cardiovasc Surg 1988;95:230-8. 2. Trehen H, Ott DA. Arterial switch procedure in an adult. Ann Thorac Surg 1991;51:122-4. 3. Kurosawa H, van Mierop LHS. Surgical anatomy of the infundibular septum in transposition of the great arteries with ventricular septal defect. J Thorac Cardiovasc Surg 1986;91:123-32. 4. Waldman JD, Schneeweiss A, Edwards WD, Lamberti JF, Shem-Tov A, Neufeld HN. The obstructive subaortic conus. Circulation 1984;70:339-94. 5. Quaegebeur JM, Bartelings M, Gittenberger-de Groot AC. Double outlet right ventricle with sub-pulmonary ventricular septal defect: an anatomical basis for surgical repair [Abstract]. Presented at the XXI Annual Meeting of the Association of European Pediatric Cardiologists, Vienna, Austria, May 1-4, 1984:60. 6. Yacoub MH, Radley-Smith R. Anatomic correction of the Taussig-Bing anomaly. J Thorac Cardiovasc Surg 1984;88: 380-8. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc

Successful Repair of Coronary Artery-Coronary Sinus Fistula With Aneurysm in an Adult Tomio Abe, MD, Koji Kamata, MD, Katsuhiko Nakanishi, MD, Kiyofumi Morishita, MD, a n d Sakuzo Komatsu, MD Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University, School of Medicine, Sapporo, Japan We report a very rare case of an adult with coronary artery fistula and aneurysm formation. This fistula was

o m m u n i c a t i o n s b e t w e e n a coronary artery a n d a chamber of the heart are u n c o m m o n congenital diseases, a n d coronary artery fistula with coronary artery a n e u r y s m drained to the coronary sinus in an adult is very rare [1]. We describe a congenital case of right coronary fistula with coronary artery a n e u r y s m d r a i n e d

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Accepted for publicationOct 24, 1995. Address reprint requests to Dr Abe,Departmentof Thoracicand Cardiovascular Surgery, Sapporo Medical University,South 1, West 17, Chuoku, Sapporo, Hokkaida, 060 Japan. 0003-4975/96/$15.00 PII S0003-4975(96)00019-7