Management for intraoperative acute aortic dissection during minimally invasive aortic valve replacement
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《血管的通路杂志》
a Department of Cardiovascular Surgery, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582 Japan
b Department of Pathology, Graduate School of Medical Science, Kyushu University, Japan
Abstract
Although minimally invasive cardiac surgery is more popular nowadays, how we treat an unpredictable intraoperative complication is very important. We report a successful case of minimally invasive aortic valve replacement complicated with an intraoperative acute aortic dissection. We coped with this complication by replacing the ascending aorta with a mini-incision under deep hypothermic circulatory arrest with retrograde cerebral perfusion. Expanding the sternotomy was not done simply because it was felt that it would not provide any additional required exposure for treatment of the dissection. We need to keep in mind that there is a possibility of having an unpredictable complication like this case during minimally invasive surgery.
Key Words: Intraoperative aortic dissection; Minimally invasive cardiac surgery; Aortic valve replacement; Takayasu arteritis
1. Introduction
Intraoperative acute aortic dissection is a very serious complication. If this complication occurs during minimally invasive cardiac surgery (MICS), it is very difficult because of the limited surgical view. We report a successful surgery case of minimally invasive aortic valve replacement (Mini-AVR) complicated with an intraoperative acute aortic dissection.
2. Case
A 42-year-old female, whose diagnosis was severe aortic regurgitation with chronic heart failure, was admitted to the Kyushu University Hospital. The patient's heart rate was 60 bpm, blood pressure was 120/0 mmHg. The peripheral pulsation was good. CTR was 50.6% on chest X-ray. A high pitched diastolic regurgitant murmur (III/VI) was heard on auscultation. The echocardiograph showed severe aortic regurgitation (grade IV) with dilated left ventricular chamber (LVDd/Ds:65/45). The patient requested bioprosthesis for AVR. A small median incision (6.5 cm) was done with its upper limit of Louis angle. An upper partial sternotomy was performed. Although there was an inflammatory response around the ascending aorta, the aorta was soft. The epiaortic echocardiogram and trans-esophageal echocardiogram showed only a mild thickness of the aortic wall and no significant calcification or any atheromatous change of the ascending aorta. The arterial perfusion cannula (Flexible Soft Flow 7.0 mm, Sarns, Terumo Cardiovascular System, Ann Arbor, MI) and the two-stage venous cannula (Flexmate Two Stage 28Fr./28Fr., TOYOBO, Osaka, Japan) were placed in the upper part of the ascending aorta and via the right atrial appendage, respectively. Cardiopulmonary bypass using the vacuum assisted venous return method was started. The left ventricular vent line was placed via the right superior pulmonary vein. The aortic cross clamp was applied with a Cosgrove Flex Clamp. During oblique aortotomy, a small medial dissection occurred due to the fragile aortic wall. The aortic valve was tricuspid, and all of the leaflets were severely redundant. After cold crystalloid cardioplegia was selectively delivered from coronary ostia, AVR was done using a Carpentier-Edwards bovine pericardial valve #21 (Edwards Lifesciences, Irvine, CA) as usual. After closure of the aortotomy, the cardioplegia needle for hot shot cardioplegia was placed in the ascending aorta. After the hot shot, the aortic cross clamp was released. Confirming de-airing, we removed the cardioplegia line. Just after removing it, the ascending aorta dilated and showed discoloration. The trans-esophageal echocardiogram and epiaortic echocardiogram demonstrated aortic dissection; flap of the anterior wall of the ascending aorta, but it was limited in the ascending aorta. We planned to perform a replacement of the ascending aorta under deep hypothermic circulatory arrest with retrograde cerebral perfusion. The skin incision was extended upward by 3 cm and a satisfactory surgical view could be obtained for the replacement of the ascending aorta. Right angle venous cannula (Flexmate 22Fr., TOYOBO, Osaka, Japan) was placed in the superior vena cava. During systemic cooling, the ascending aorta was clamped and opened. The anterior wall was dissected and the entry was the site of the cardioplegia needle. The dissection did not extend to the Valsalva sinus proximally. The proximal stump of the ascending aorta was trimmed and reinforced with Teflon strips inside and outside using 3-0 Prolene (Ethicon, Inc., a Johnson & Johnson company, Somerville, NJ) interrupted sutures. The Woven Double Velour Vascular Graft #22 (one branched, Hemashield Gold, Boston Scientific, Wayne, NJ) was anastomosed to the reinforced proximal stump using a 3-0 Prolene running suture. The distal part of the Hemashield graft was clamped and reperfusion of the heart was started with a branch of the Hemashield graft. Then retrograde cerebral perfusion was done using SVC venous cannula during deep hypothermic circulatory arrest. The dissection was limited only in the ascending aorta. The aortic perfusion cannula was removed. The distal part of the ascending aorta was trimmed. Dissection was closed with GRF glue and the distal stump was reinforced as proximal stump. The distal part of the Hemashield Gold graft was anastomosed to distal stump using a 3-0 Prolene running suture.
The patient was extubated and out of ICU on the 1st post-operative day (1POD). The postoperative course was good except for a drug-induced liver dysfunction. Postoperative enhanced chest CT demonstrated no residual dissection. Histology of the aortic wall showed that the elastic fibers of the dissected wall and the other outer portion of the media were markedly fragmented and partly replaced by fibrosis, and that thick fibrosis and mild chronic inflammatory cell infiltration was seen in the adventitia. These findings strongly suggested aortitis syndrome (Takayasu arteritis). The patient was discharged on the 19th POD in good condition. She is doing well 1 year after surgery.
3. Comment
Although minimally invasive cardiac surgery (MICS) is becoming popular these days [1,2], it is very important to manage the unpredictable complication appropriately [3]. Intraoperative acute aortic dissection is a very serious complication, which occurs in 0.16–0.35% of patients with open heart surgery, and is associated with substantial mortality (14.8–33%) in previous reports [4–6]. Prompt diagnosis and adequate surgical management is vital in order to save the patient. The transesophageal echocar- diogram and epiaortic echocardiogram were useful for the diagnosis of the acute dissection. Intraoperative aortic dissection occurred at the site of the cardioplegia needle in this case. We did not perform full sternotomy for the ascending aorta replacement, because full sternotomy may improve the surgical field around the heart, but does not improve the view around the ascending aorta greatly. We think that a patient's safety should never be compromised due to a choice of incision and a wish to absolutely stick with the small incision. Although we did not necessarily stick to a small incision, full sternotomy was not needed to treat this complication in this case. Findings of pathological examination strongly suggested Takayasu arteritis [7]. It was difficult to diagnose this disease preoperatively in this case. Previous studies demonstrate that younger patients with elevated erythrocyte sedimentation rate, intact major branches of the aortic arch, no sign of classical pulseless disease, and severe aortic regurgitation due to Takayasu arteritis have a poor prognosis [8]. Close follow-up is necessary for this patient.
We need to keep in mind that the possibility of having unexpected complications during minimally invasive surgery as it happens during conventional surgery through sternotomy.
Acknowledgments
We express our gratitude to Mr Philip Harding (Planet English, Fukuoka, Japan) for comments on this manuscript.
References
Cosgrove DM, Sabik JF. A minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596–597.
Gillinov AM, Cosgrove DM. Minimally invasive mitral valve surgery: mini- sternotomy with extended transseptal approach. Semin Thorac Cardiovasc Surg 1999;11:206–211.
Mestres CA, Cassinello N, Fuentes M. Minimally invasive valve replacement: Surgical disasters might also be expected. Asian Cardiovasc Thorac Ann 1998;6:60–61.
Still RJ, Hilgenberg AD, Akins CW, Daggett WM, Buckley MJ. Intraoperative aortic dissection. Ann Thorac Surg 1992;53:374–379.
Gott JP, Cohen CL, Jones EL. Management of ascending aortic dissections and aneurysms early and late following cardiac operations. J Card Surg 1990;5:2–13.
Murphy DA, Craver JM, Jones EL, Bone DK, Guyton RA, Hatcher CR. Recognition and management of ascending aortic dissection complicating cardiac surgical operations. J Thorac Cardiovasc Surg 1983;85:247–56.
Hotchi M. Pathological studies on Takayasu arteritis. Heart Vessels 1992;7:11–17.
Morii S. Follow-up study of Takayasu arteritis with aortic regurgitation. (Japanese) J Cardiology 1995;26:293–298.(Shigehiko Tokunaga, Shige)
b Department of Pathology, Graduate School of Medical Science, Kyushu University, Japan
Abstract
Although minimally invasive cardiac surgery is more popular nowadays, how we treat an unpredictable intraoperative complication is very important. We report a successful case of minimally invasive aortic valve replacement complicated with an intraoperative acute aortic dissection. We coped with this complication by replacing the ascending aorta with a mini-incision under deep hypothermic circulatory arrest with retrograde cerebral perfusion. Expanding the sternotomy was not done simply because it was felt that it would not provide any additional required exposure for treatment of the dissection. We need to keep in mind that there is a possibility of having an unpredictable complication like this case during minimally invasive surgery.
Key Words: Intraoperative aortic dissection; Minimally invasive cardiac surgery; Aortic valve replacement; Takayasu arteritis
1. Introduction
Intraoperative acute aortic dissection is a very serious complication. If this complication occurs during minimally invasive cardiac surgery (MICS), it is very difficult because of the limited surgical view. We report a successful surgery case of minimally invasive aortic valve replacement (Mini-AVR) complicated with an intraoperative acute aortic dissection.
2. Case
A 42-year-old female, whose diagnosis was severe aortic regurgitation with chronic heart failure, was admitted to the Kyushu University Hospital. The patient's heart rate was 60 bpm, blood pressure was 120/0 mmHg. The peripheral pulsation was good. CTR was 50.6% on chest X-ray. A high pitched diastolic regurgitant murmur (III/VI) was heard on auscultation. The echocardiograph showed severe aortic regurgitation (grade IV) with dilated left ventricular chamber (LVDd/Ds:65/45). The patient requested bioprosthesis for AVR. A small median incision (6.5 cm) was done with its upper limit of Louis angle. An upper partial sternotomy was performed. Although there was an inflammatory response around the ascending aorta, the aorta was soft. The epiaortic echocardiogram and trans-esophageal echocardiogram showed only a mild thickness of the aortic wall and no significant calcification or any atheromatous change of the ascending aorta. The arterial perfusion cannula (Flexible Soft Flow 7.0 mm, Sarns, Terumo Cardiovascular System, Ann Arbor, MI) and the two-stage venous cannula (Flexmate Two Stage 28Fr./28Fr., TOYOBO, Osaka, Japan) were placed in the upper part of the ascending aorta and via the right atrial appendage, respectively. Cardiopulmonary bypass using the vacuum assisted venous return method was started. The left ventricular vent line was placed via the right superior pulmonary vein. The aortic cross clamp was applied with a Cosgrove Flex Clamp. During oblique aortotomy, a small medial dissection occurred due to the fragile aortic wall. The aortic valve was tricuspid, and all of the leaflets were severely redundant. After cold crystalloid cardioplegia was selectively delivered from coronary ostia, AVR was done using a Carpentier-Edwards bovine pericardial valve #21 (Edwards Lifesciences, Irvine, CA) as usual. After closure of the aortotomy, the cardioplegia needle for hot shot cardioplegia was placed in the ascending aorta. After the hot shot, the aortic cross clamp was released. Confirming de-airing, we removed the cardioplegia line. Just after removing it, the ascending aorta dilated and showed discoloration. The trans-esophageal echocardiogram and epiaortic echocardiogram demonstrated aortic dissection; flap of the anterior wall of the ascending aorta, but it was limited in the ascending aorta. We planned to perform a replacement of the ascending aorta under deep hypothermic circulatory arrest with retrograde cerebral perfusion. The skin incision was extended upward by 3 cm and a satisfactory surgical view could be obtained for the replacement of the ascending aorta. Right angle venous cannula (Flexmate 22Fr., TOYOBO, Osaka, Japan) was placed in the superior vena cava. During systemic cooling, the ascending aorta was clamped and opened. The anterior wall was dissected and the entry was the site of the cardioplegia needle. The dissection did not extend to the Valsalva sinus proximally. The proximal stump of the ascending aorta was trimmed and reinforced with Teflon strips inside and outside using 3-0 Prolene (Ethicon, Inc., a Johnson & Johnson company, Somerville, NJ) interrupted sutures. The Woven Double Velour Vascular Graft #22 (one branched, Hemashield Gold, Boston Scientific, Wayne, NJ) was anastomosed to the reinforced proximal stump using a 3-0 Prolene running suture. The distal part of the Hemashield graft was clamped and reperfusion of the heart was started with a branch of the Hemashield graft. Then retrograde cerebral perfusion was done using SVC venous cannula during deep hypothermic circulatory arrest. The dissection was limited only in the ascending aorta. The aortic perfusion cannula was removed. The distal part of the ascending aorta was trimmed. Dissection was closed with GRF glue and the distal stump was reinforced as proximal stump. The distal part of the Hemashield Gold graft was anastomosed to distal stump using a 3-0 Prolene running suture.
The patient was extubated and out of ICU on the 1st post-operative day (1POD). The postoperative course was good except for a drug-induced liver dysfunction. Postoperative enhanced chest CT demonstrated no residual dissection. Histology of the aortic wall showed that the elastic fibers of the dissected wall and the other outer portion of the media were markedly fragmented and partly replaced by fibrosis, and that thick fibrosis and mild chronic inflammatory cell infiltration was seen in the adventitia. These findings strongly suggested aortitis syndrome (Takayasu arteritis). The patient was discharged on the 19th POD in good condition. She is doing well 1 year after surgery.
3. Comment
Although minimally invasive cardiac surgery (MICS) is becoming popular these days [1,2], it is very important to manage the unpredictable complication appropriately [3]. Intraoperative acute aortic dissection is a very serious complication, which occurs in 0.16–0.35% of patients with open heart surgery, and is associated with substantial mortality (14.8–33%) in previous reports [4–6]. Prompt diagnosis and adequate surgical management is vital in order to save the patient. The transesophageal echocar- diogram and epiaortic echocardiogram were useful for the diagnosis of the acute dissection. Intraoperative aortic dissection occurred at the site of the cardioplegia needle in this case. We did not perform full sternotomy for the ascending aorta replacement, because full sternotomy may improve the surgical field around the heart, but does not improve the view around the ascending aorta greatly. We think that a patient's safety should never be compromised due to a choice of incision and a wish to absolutely stick with the small incision. Although we did not necessarily stick to a small incision, full sternotomy was not needed to treat this complication in this case. Findings of pathological examination strongly suggested Takayasu arteritis [7]. It was difficult to diagnose this disease preoperatively in this case. Previous studies demonstrate that younger patients with elevated erythrocyte sedimentation rate, intact major branches of the aortic arch, no sign of classical pulseless disease, and severe aortic regurgitation due to Takayasu arteritis have a poor prognosis [8]. Close follow-up is necessary for this patient.
We need to keep in mind that the possibility of having unexpected complications during minimally invasive surgery as it happens during conventional surgery through sternotomy.
Acknowledgments
We express our gratitude to Mr Philip Harding (Planet English, Fukuoka, Japan) for comments on this manuscript.
References
Cosgrove DM, Sabik JF. A minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596–597.
Gillinov AM, Cosgrove DM. Minimally invasive mitral valve surgery: mini- sternotomy with extended transseptal approach. Semin Thorac Cardiovasc Surg 1999;11:206–211.
Mestres CA, Cassinello N, Fuentes M. Minimally invasive valve replacement: Surgical disasters might also be expected. Asian Cardiovasc Thorac Ann 1998;6:60–61.
Still RJ, Hilgenberg AD, Akins CW, Daggett WM, Buckley MJ. Intraoperative aortic dissection. Ann Thorac Surg 1992;53:374–379.
Gott JP, Cohen CL, Jones EL. Management of ascending aortic dissections and aneurysms early and late following cardiac operations. J Card Surg 1990;5:2–13.
Murphy DA, Craver JM, Jones EL, Bone DK, Guyton RA, Hatcher CR. Recognition and management of ascending aortic dissection complicating cardiac surgical operations. J Thorac Cardiovasc Surg 1983;85:247–56.
Hotchi M. Pathological studies on Takayasu arteritis. Heart Vessels 1992;7:11–17.
Morii S. Follow-up study of Takayasu arteritis with aortic regurgitation. (Japanese) J Cardiology 1995;26:293–298.(Shigehiko Tokunaga, Shige)