Porcelain Aorta in a Patient Undergoing Coronary Artery Bypass

Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) e59–e68

Contents lists available at ScienceDirect

journal homepage: www.jcvaonline.com

Letter to the Editor Porcelain Aorta in a Patient Undergoing Coronary Artery Bypass Grafting Surgery

To the Editor: The term porcelain aorta defines an extensive calcification of the aorta that can be completely or almost completely circumferential. Not so usual in the general population, it has an increasing incidence in older patients and in those with coronary artery disease or aortic stenosis. Considering that it may complicate surgical procedures, it is relevant to be determined before any cardiac surgery. We report a very interesting case of porcelain aorta from our hospital. A 64-year-old woman was referred for coronary

artery bypass grafting surgery after myocardial infarction without ST-segment elevation. Cinecoronariography revealed severe ostial stenosis of the left mainstem coronary artery, severe stenosis of the proximal left anterior descending coronary artery, and severe proximal right coronary artery stenosis. On chest radiography, prominent linear calcifications were noted along the thoracic aorta (Fig 1A). A computed tomographic scan of the chest further delineated the dense circumferential calcification present in the wall of the ectatic ascending and descending thoracic aorta, involving the aortic cross (Figs 1B-D), a finding that was consistent with a porcelain aorta. Given these imaging findings, coronary artery bypass grafting surgery without cardiopulmonary bypass with no-touch aorta technique was performed. The left internal thoracic artery (ITA) was anastomosed proximally to the left anterior descending artery

Fig 1. (A) Chest X-ray showing extensive aortic calcification. (B) Computed tomography (CT) scanning showing calcification of both ascending and descending thoracic aorta. (C) CT scanning showing calcification of the transverse aortic arch. (D) CT scanning showing calcification of both ascending and descending thoracic aorta.

e60

Letter to the Editor / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) e59–e68

and a composite Y-ITA-saphenous vein graft to the right coronary artery was performed. Fortunately, the patient had no postoperative complications. The diagnosis of porcelain or unclampable aorta needs to be anticipated before the surgical procedure because it requires adequate techniques for better protection against the complications related to the management of the aorta with calcified atheromas. An adequate assessment of risk factors and physical examination associated with techniques such as chest X-ray, computed tomography, and transesophageal echocardiography may provide better screening. Various techniques have been described to reduce the risk of atheroembolism that may cause cerebrovascular events in patients with atherosclerotic ascending aorta. These include no-touch technique1 and placement of proximal saphenous vein grafts onto the ITA.2 Furthermore, coronary artery bypass on a beating heart (off-pump surgery) can be performed safely in patients with a severely calcified (porcelain) ascending aorta,3 in addition to the use of ITA grafts associated with the no-touch aorta technique and placing proximal anastomoses on the ITA, which are useful strategies to reduce the perioperative risk of cerebrovascular events due to atheroembolism.4 Eduardo Cavalcanti Santos Lapa, MD, MSc André Gustavo Santos Lima, MD Michel Pompeu Barros Oliveira Sá, MD, MSc, PhD Edmilson Cardoso dos Santos Filho, MD, MSc Jéssica Cordeiro de Siqueira Campos, MD George Augusto da Fonseca Carvalho Antunes Lima, MD Department of Cardiology and Cardiovascular Surgery Hospital Dom Helder Câmara, HDH Cabo de Santo Agostinho Pernambuco Brazil

References 1 Emmert MY, Seifert B, Wilhelm M, et al. Aortic no-touch technique makes the difference in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2011;142:1499–506. 2 Demirsoy E, Unal M, Arbatlı H, et al. Extraanatomic coronary artery bypass graftings in patients with porcelain aorta. J Cardiovasc Surg (Torino) 2004;45:111–5. 3 Lev-Ran O, Braunstein R, Sharony R, et al. No-touch aorta off-pump coronary surgery: The effect on stroke. J Thorac Cardiovasc Surg 2005;129: 307–13. 4 Sirin G, Sarkislali K, Konakci M, et al. Extraanatomical coronary artery bypass grafting in patients with severely atherosclerotic (porcelain) aorta. J Cardiothorac Surg 2013;8:86. http://dx.doi.org/10.1053/j.jvca.2017.02.012

Unilateral Dilated Fixed Pupil After Thoracic Surgery: Need for Concern? To the Editor: A 38-year-old male patient presented with shortness of breath on routine activities. He was investigated and found to have an anterior mediastinal mass compressing the left upper lobe bronchus. He was scheduled for thoracic surgery for the

resection of the mass. After a midline sternotomy, the mediastinal mass, along with the left upper lung lobe, were resected. There was no attachment of the mediastinal mass to any cardiovascular structure. After uneventful surgery, the patient was shifted to the intensive care unit. The patient was extubated and duolin nebulization (ipratropium bromide and levosalbutamol) through the facemask was administered. After half an hour of extubation, the patient complained about haziness and blurring of vision. Examination revealed a rightsided dilated pupil (approximately 6 mm) with no reaction to light. The left pupil was normal in size and normally reacting to light. Extraocular muscle movements were normal. There was no other neurologic deficit observed. Magnetic resonance imaging of the brain was performed. It excluded any kind of brain abnormality. After 24 hours, the right pupil became normal size, and his vision through the same eye became clear. Pupillary miosis or mydriasis is controlled by the balance between the 2 muscle actions, circularly arranged iris sphincter muscle fibers and radially arranged iris dilator muscle fibers. Stimulation of beta2-adrenergic receptors causes relaxation or dilation of the radial muscle resulting into pupil dilation. Parasympathetic stimulation causes contraction of the circular sphincter muscle with resultant miosis. Nebulization of pharmacologic bronchodilator drugs causing unilateral mydriasis has been reported in the literature.1 This phenomenon was observed more commonly in the pediatric population due to an ill-fitting facemask. Ipratropium bromide nebulization is the most commonly reported drug; whereas, we observed salbutamol along with ipratropium bromide as the culprit agent in the present case. Anticholinergic ipratropium bromide causes pupil dilation by inhibiting parasympathetic action on the iris sphincter muscle. Improper fitting of the facemask, faulty seal on the mask, mechanical contamination of the nebulizer with the eye, and faulty nebulizer circuit were the proposed causes.1 It took almost 24-to-48 hours for the mydriasis to resolve after the discontinuation of ipratropium bromide.2,3 In the present case, improper placement and fitting of the nebulizer facemask may have directed the flow of vapors to the right eye particularly. Corneal deposition of the drugs may further promote drug absorption resulting in mydriasis. Salbutamol-induced beta2-stimulation in the iris dilator muscle and ipratropium bromide-induced inhibition of the iris sphincter results in mydriasis. Newly-appearing unilateral mydriasis often is suggestive of an imminent evolving intracranial mass lesion; for example, intracranial hemorrhage, tumor-causing uncal herniation, or posterior communicating artery abnormality, such as an aneurysm compressing the third cranial nerve. It always increases the need for further evaluation. However, unilateral mydriasis in such cases generally is associated with other neurologic findings or symptoms. Pilocarpine administration can be a useful confirmatory test in such situations. Pilocarpine will constrict the pupil in nonpharmacologic etiologies but there will be no response if the mydriasis is due to a pharmacologic agent.1,4,5 Pupillary dilation not resolving even after 48 hours of discontinuation of the drugs also may suggest the requirement