- Email: [email protected]
Magnetic Resonance Imaging Diagnosis of Left Atrial Abscess After Ablation of Atrial Fibrillation
Ann Thorac Surg 2013;96:1473e5
CASE REPORT TANG ET AL ATRIAL ABSCESS AFTER CATHETER ABLATION
1473
treatment option. We consider this strategy beneficial to patients with an infected thoracic aortic arch aneurysm. It decreases the risk of perioperative complications related to cardiopulmonary bypass with the patient under circulatory arrest, and it prevents the recurrence of infection, compared with a one-stage corrective open operation.
Fig 3. After explantation of the stent graft and wide debridement, the aortic arch was replaced with a refampicin-bonded four-branched Dacron graft. The left axillary artery was reconstructed by the second branch of the graft.
unknown. Stent graft placement in the infected field may not be optimal, and its acceptability remains controversial. The gold standard of treatment for an infected thoracic aortic aneurysm is still surgical debridement of infected tissue followed by in situ revascularization or extraanatomic grafting with long-term antibiotic therapy. Endovascular repair should be an alternative for high-risk patients or used as a bridge while they await an open procedure. In the present case, extraanatomic repair was considered to be inappropriate because the aneurysm was in the distal arch, and the aortic arch was heavily calcified. Therefore, we performed in situ replacement of the aortic arch with a rifampicin-bonded prosthetic graft. The use of a rifampicin-bonded graft has been associated with favorable outcomes for graft infection, and this has recently been applied to the treatment of infected aortic aneurysms [7]. Sugimoto and colleagues [8] reported that timely surgical intervention after control of sepsis provided excellent outcomes, whereas the mortality rate of patients with sepsis or rupture was high. Although it is needless to say that preoperative medical treatment is crucial, the risk of lethal rupture always exists even when antibiotic therapy is given; that is the dilemma of the treatment of an infected aortic aneurysm. In this regard, the bridge use of TEVAR to prevent early rupture and temporarily stabilize the patient’s condition before a second-stage open operation can be a reasonable Ó 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Kan CD, Yen HT, Kan CB, et al. The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms. J Vasc Surg 2012;55:55–60. 2. Kritpracha B, Premprabha D, Sungsiri J, et al. Endovascular therapy for infected aortic aneurysms. J Vasc Surg 2011;54: 1259–65. 3. Moneta GL, Taylor LM Jr, Yeager RA, et al. Surgical treatment of infected aortic aneurysm. Am J Surg 1998;175:396–9. 4. Fillmore AJ, Valentine RJ. Surgical mortality in patients with infected aortic aneurysms. J Am Coll Surg 2003;196: 435–41. 5. Muller BT, Wegener OR, Grabitzs L, et al. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg 2001;33:106–13. 6. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900–8. 7. Totsugawa T, Kuinose M, Yoshitaka H, et al. Mycotic aortic aneurysm induced by Klebsiella pneumoniae successfully treated by in situ replacement with rifampicin-bonded prosthesis: report of three cases. Circ J 2007;71:1317–20. 8. Sugimoto M, Banno H, Idetsu A, et al. Surgical experience of 13 infected infrarenal aortoiliac aneurysms: pre-operative control of septic condition determines early outcome. Surgery 2011;149:699–704.
Magnetic Resonance Imaging Diagnosis of Left Atrial Abscess After Ablation of Atrial Fibrillation Gilbert H.L. Tang, MD, MS, Amit Pawale, MD, Grant R. Simons, MD, and Paul E. Stelzer, MD Department of Cardiothoracic Surgery and Division of Cardiology, Mount Sinai Medical Center, New York, New York
We report a 52-year-old patient with a late presentation of a fistula that occurred after catheter ablation for atrial fibrillation. A secondary left atrial wall abscess was diagnosed by upper endoscopy and cardiac magnetic resonance imaging. Emergency operative repair was successful, with no adverse cardiac or gastrointestinal sequelae. (Ann Thorac Surg 2013;96:1473e5) Ó 2013 by The Society of Thoracic Surgeons
Accepted for publication Aug 1, 2012. Address correspondence to Dr Stelzer, Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Ave, Box 1028, New York, NY 10029; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.08.121
FEATURE ARTICLES
References
1474
CASE REPORT TANG ET AL ATRIAL ABSCESS AFTER CATHETER ABLATION
Ann Thorac Surg 2013;96:1473e5
Fig 1. Magnetic resonance imaging of the thorax in (A) axial and (B) sagittal views demonstrates the presence of a mass (*) in the posterior left atrium (LA) between the confluence of left and right pulmonary veins. There was no evidence of pneumomediastinum or perforation of the esophagus. (LV ¼ left ventricle.)
trioesophageal (AE) fistula is a rare but potentially fatal complication after catheter ablation for atrial fibrillation. Patients often present with fever and neurologic symptoms.
A
FEATURE ARTICLES
An active, 52-year-old man underwent radiofrequency catheter ablation for paroxysmal atrial fibrillation. His medical history was notable for a gastric bypass operation. Pulmonary vein isolation was performed using electroanatomic mapping and an esophageal temperature probe. There were no significant increases in esophageal temperature during the procedure. He was discharged home uneventfully with dabigatran therapy. The patient maintained normal sinus rhythm, but fever developed 2 weeks after, and he was prescribed oral antibiotics for presumed bronchitis. He presented 5 weeks later with a rigor and a fever of 39.4°C, and intravenous ceftriaxone was administered. Blood cultures grew group F β-hemolytic Streptococcus. One day later, he reported transient right hand and facial numbness, with a suspected transient ischemic attack. Computed tomography (CT) imaging of the head without contrast was unremarkable. An AE fistula was suspected, and the patient was made nothing by mouth. Chest CT revealed only nonspecific mild thickening of the distal esophageal wall. An upper endoscopy revealed a healed ulceration of the esophagus at the level of the left atrium, with no signs of perforation. Transthoracic echocardiography was unremarkable, including prolonged (10 minutes) observation for air bubbles on 2 separate days. Given the esophageal finding on endoscopy, a feeding gastrostomy was placed for nutritional support. Results of repeat blood cultures were negative. Because of the extremely late presentation after ablation (8 weeks at that point), negative repeat blood cultures on antibiotic therapy, and white blood cell count within normal reference ranges, conservative therapy with gastric tube feedings was chosen to manage the suspected AE fistula. Anticoagulation was continued for the recent atrial fibrillation ablation. The patient remained in the hospital for observation, but daily fevers to 40°C, with rigors, developed, despite
a white blood cell count within normal reference ranges. Repeat blood cultures were negative. After 5 days, his white cell count rose to 16,000/μL. Chest magnetic resonance imaging was performed to better image the left atrium and esophagus and to rule out other sources of infection. A 1.6-cm mass was found embedded in the wall of the posterior left atrium, near the area of the previous atrial ablation (Fig 1). This was interpreted as an infected thrombus, which was suspected to be a late complication of an AE fistula. He was therefore urgently referred to our institution for removal of the intracardiac mass. The plan was to treat this like an AE fistula, with appropriate repair and drainage as part of the operation. Because of the location of the problem on the magnetic resonance image, we decided that proceeding from the right chest would provide the greatest exposure for central cannulation for cardiopulmonary bypass and access to the left atrium and esophagus. An emergency operation through a right posterolateral thoracotomy showed a left atrial wall abscess with frank pus, with a healed fistula to the esophagus (Fig 2). The atrial mass was excised, along with the adjacent infected portion of the left atrial wall, and the fistula was repaired with a reinforcement of the healed esophageal wall plus interposition of a pedicled flap of autologous pericardium between the left atrium and the esophagus. The patient was discharged home uneventfully with intravenous antibiotic therapy. There was no residual esophageal leak or infection. Intraoperative culture of the wall abscess confirmed the same microorganism as found in the blood.
Comment AE fistula is a rare but frequently lethal complication after catheter ablation for atrial fibrillation, with a mortality rate of 67% among 49 patients reported in the literature [1]. The diagnosis should always be suspected after catheter atrial fibrillation ablation when a patient presents with fever or neurologic symptoms, as evidenced in most of the reported cases [1]. Although echocardiography has not been found helpful
Ann Thorac Surg 2013;96:1475e8
CASE REPORT BANACK ET AL AORTIC VALVE REPLACEMENT AFTER LUNG TRANSPLANTATION
1475
4. Vassileva CM, Shawgo T, Shabosky J, Soliman S, Hazelrigg S. Repair of left atrial-esophageal fistula following percutaneous radiofrequency ablation for atrial fibrillation. J Card Surg 2011;26:556–8.
Aortic Valve Replacement for Critical Aortic Stenosis After Bilateral Lung Transplantation Trevor Banack, MD, Bulat A. Ziganshin, MD, Paul Barash, MD, and John A. Elefteriades, MD Department of Anesthesia and Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
in diagnosing AE fistula, CT may reveal pneumomediastinum or air bubbles in the left atrium. Results of both studies were negative in our patient, and this was the first report that magnetic resonance imaging was required to discover an intracardiac mass in the left atrium as a secondary manifestation of the AE fistula. Esophagogastroduodenoscopy is rarely used to diagnose AE fistula given the risk of iatrogenic esophageal perforation with endoscope manipulation but was performed in this patient because of the clinical suspicion of the fistula, despite negative findings on echocardiography and CT. This unusual presentation of AE fistula was likely responsible for the initial transient ischemic attack and persistent symptoms of infection in our patient. Indeed, resection of the mass exposed the underlying atrial wall abscess, but the fistula had actually healed before the operation. The healed fistula communication between the left atrium and esophagus likely explains the delayed clinical presentation of AE fistula in this patient. Extracardiac and intracardiac repairs of AE fistula have both been reported, with mortality exceeding 50% [2e4]. The intermittent antibiotic use and continuous anticoagulation likely protected the patient and allowed the fistula to heal, with a satisfactory surgical outcome.
References 1. Siegel MO, Parenti DM, Simon GL. Atrial-esophageal fistula after atrial radiofrequency catheter ablation. Clin Infectious Dis 2010;51:73–6. 2. Finsterer J, Stollberger C, Pulgram T. Neurological manifestations of atrio-esophageal fistulas from left atrial ablation. Eur J Neurol 2011;18:1212–9. 3. St. Julien J, Putnam JB Jr, Nesbitt JC, Lambright ES, Petracek MR, Grogan EL. Successful treatment of atrioesophageal fistula by cervical esophageal ligation and decompression. Ann Thorac Surg 2011;91:e85–6. Ó 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
ince Cooper’s first report in 1983, 38,119 lung transplantations have been recorded [1]. Some of these patients require cardiac surgical interventions. Yet, minimal experience has been reported in the literature on open-heart procedures after lung transplantation [2e4].
S
A 62-year-old man had undergone bilateral lung transplantation elsewhere in 2008 for end-stage idiopathic pulmonary fibrosis, performed with cardiopulmonary bypass through a clamshell incision. Postoperative complications included loculated pleural effusions and hemothorax. Decortication was ultimately required. Two weeks later, the patient sustained a pulmonary embolism, treated medically. Long-term immunosuppression included tacrolimus, mycophenolate, and prednisone. Thirteen weeks after transplantation, during bronchoscopy, the patient experienced hypoxic respiratory failure, requiring transient intubation. The patient was later found to have a paralyzed right vocal cord. After medialization of the cord, the patient was discharged home using biphasic positive airway pressure. One year later, the patient sustained a rejection episode and multiorgan failure, requiring tracheostomy and long-term mechanical ventilation. He recovered from these events. Four years later, the patient experienced progressive exertional dyspnea and decreased exercise tolerance. Comorbidities included chronic renal failure (creatinine 2.1 mg/dL), gastroesophageal reflux, hypertension,
Accepted for publication Jan 4, 2013. Address correspondence to Dr Elefteriades, Section of Cardiac Surgery, Yale University School of Medicine, Boardman 204, 333 Cedar St, New Haven, CT 06510; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.01.022
FEATURE ARTICLES
Fig 2. Intraoperative photograph shows the mass (*) in the left atrium (LA), which upon resection revealed an underlying abscess with frank pus. The attachment of the atrial wall mass is close to the orifice of the right inferior pulmonary vein (#).
Four years after bilateral lung transplantation, a 62-yearold man with critical aortic stenosis required aortic valve replacement. This is the first report of aortic valve replacement after bilateral lung transplantation. Anesthetic and surgical management are described. (Ann Thorac Surg 2013;96:1475e8) Ó 2012 by The Society of Thoracic Surgeons
CASE REPORT TANG ET AL ATRIAL ABSCESS AFTER CATHETER ABLATION
1473
treatment option. We consider this strategy beneficial to patients with an infected thoracic aortic arch aneurysm. It decreases the risk of perioperative complications related to cardiopulmonary bypass with the patient under circulatory arrest, and it prevents the recurrence of infection, compared with a one-stage corrective open operation.
Fig 3. After explantation of the stent graft and wide debridement, the aortic arch was replaced with a refampicin-bonded four-branched Dacron graft. The left axillary artery was reconstructed by the second branch of the graft.
unknown. Stent graft placement in the infected field may not be optimal, and its acceptability remains controversial. The gold standard of treatment for an infected thoracic aortic aneurysm is still surgical debridement of infected tissue followed by in situ revascularization or extraanatomic grafting with long-term antibiotic therapy. Endovascular repair should be an alternative for high-risk patients or used as a bridge while they await an open procedure. In the present case, extraanatomic repair was considered to be inappropriate because the aneurysm was in the distal arch, and the aortic arch was heavily calcified. Therefore, we performed in situ replacement of the aortic arch with a rifampicin-bonded prosthetic graft. The use of a rifampicin-bonded graft has been associated with favorable outcomes for graft infection, and this has recently been applied to the treatment of infected aortic aneurysms [7]. Sugimoto and colleagues [8] reported that timely surgical intervention after control of sepsis provided excellent outcomes, whereas the mortality rate of patients with sepsis or rupture was high. Although it is needless to say that preoperative medical treatment is crucial, the risk of lethal rupture always exists even when antibiotic therapy is given; that is the dilemma of the treatment of an infected aortic aneurysm. In this regard, the bridge use of TEVAR to prevent early rupture and temporarily stabilize the patient’s condition before a second-stage open operation can be a reasonable Ó 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Kan CD, Yen HT, Kan CB, et al. The feasibility of endovascular aortic repair strategy in treating infected aortic aneurysms. J Vasc Surg 2012;55:55–60. 2. Kritpracha B, Premprabha D, Sungsiri J, et al. Endovascular therapy for infected aortic aneurysms. J Vasc Surg 2011;54: 1259–65. 3. Moneta GL, Taylor LM Jr, Yeager RA, et al. Surgical treatment of infected aortic aneurysm. Am J Surg 1998;175:396–9. 4. Fillmore AJ, Valentine RJ. Surgical mortality in patients with infected aortic aneurysms. J Am Coll Surg 2003;196: 435–41. 5. Muller BT, Wegener OR, Grabitzs L, et al. Mycotic aneurysms of the thoracic and abdominal aorta and iliac arteries: experience with anatomic and extra-anatomic repair in 33 cases. J Vasc Surg 2001;33:106–13. 6. Oderich GS, Panneton JM, Bower TC, et al. Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. J Vasc Surg 2001;34:900–8. 7. Totsugawa T, Kuinose M, Yoshitaka H, et al. Mycotic aortic aneurysm induced by Klebsiella pneumoniae successfully treated by in situ replacement with rifampicin-bonded prosthesis: report of three cases. Circ J 2007;71:1317–20. 8. Sugimoto M, Banno H, Idetsu A, et al. Surgical experience of 13 infected infrarenal aortoiliac aneurysms: pre-operative control of septic condition determines early outcome. Surgery 2011;149:699–704.
Magnetic Resonance Imaging Diagnosis of Left Atrial Abscess After Ablation of Atrial Fibrillation Gilbert H.L. Tang, MD, MS, Amit Pawale, MD, Grant R. Simons, MD, and Paul E. Stelzer, MD Department of Cardiothoracic Surgery and Division of Cardiology, Mount Sinai Medical Center, New York, New York
We report a 52-year-old patient with a late presentation of a fistula that occurred after catheter ablation for atrial fibrillation. A secondary left atrial wall abscess was diagnosed by upper endoscopy and cardiac magnetic resonance imaging. Emergency operative repair was successful, with no adverse cardiac or gastrointestinal sequelae. (Ann Thorac Surg 2013;96:1473e5) Ó 2013 by The Society of Thoracic Surgeons
Accepted for publication Aug 1, 2012. Address correspondence to Dr Stelzer, Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Ave, Box 1028, New York, NY 10029; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.08.121
FEATURE ARTICLES
References
1474
CASE REPORT TANG ET AL ATRIAL ABSCESS AFTER CATHETER ABLATION
Ann Thorac Surg 2013;96:1473e5
Fig 1. Magnetic resonance imaging of the thorax in (A) axial and (B) sagittal views demonstrates the presence of a mass (*) in the posterior left atrium (LA) between the confluence of left and right pulmonary veins. There was no evidence of pneumomediastinum or perforation of the esophagus. (LV ¼ left ventricle.)
trioesophageal (AE) fistula is a rare but potentially fatal complication after catheter ablation for atrial fibrillation. Patients often present with fever and neurologic symptoms.
A
FEATURE ARTICLES
An active, 52-year-old man underwent radiofrequency catheter ablation for paroxysmal atrial fibrillation. His medical history was notable for a gastric bypass operation. Pulmonary vein isolation was performed using electroanatomic mapping and an esophageal temperature probe. There were no significant increases in esophageal temperature during the procedure. He was discharged home uneventfully with dabigatran therapy. The patient maintained normal sinus rhythm, but fever developed 2 weeks after, and he was prescribed oral antibiotics for presumed bronchitis. He presented 5 weeks later with a rigor and a fever of 39.4°C, and intravenous ceftriaxone was administered. Blood cultures grew group F β-hemolytic Streptococcus. One day later, he reported transient right hand and facial numbness, with a suspected transient ischemic attack. Computed tomography (CT) imaging of the head without contrast was unremarkable. An AE fistula was suspected, and the patient was made nothing by mouth. Chest CT revealed only nonspecific mild thickening of the distal esophageal wall. An upper endoscopy revealed a healed ulceration of the esophagus at the level of the left atrium, with no signs of perforation. Transthoracic echocardiography was unremarkable, including prolonged (10 minutes) observation for air bubbles on 2 separate days. Given the esophageal finding on endoscopy, a feeding gastrostomy was placed for nutritional support. Results of repeat blood cultures were negative. Because of the extremely late presentation after ablation (8 weeks at that point), negative repeat blood cultures on antibiotic therapy, and white blood cell count within normal reference ranges, conservative therapy with gastric tube feedings was chosen to manage the suspected AE fistula. Anticoagulation was continued for the recent atrial fibrillation ablation. The patient remained in the hospital for observation, but daily fevers to 40°C, with rigors, developed, despite
a white blood cell count within normal reference ranges. Repeat blood cultures were negative. After 5 days, his white cell count rose to 16,000/μL. Chest magnetic resonance imaging was performed to better image the left atrium and esophagus and to rule out other sources of infection. A 1.6-cm mass was found embedded in the wall of the posterior left atrium, near the area of the previous atrial ablation (Fig 1). This was interpreted as an infected thrombus, which was suspected to be a late complication of an AE fistula. He was therefore urgently referred to our institution for removal of the intracardiac mass. The plan was to treat this like an AE fistula, with appropriate repair and drainage as part of the operation. Because of the location of the problem on the magnetic resonance image, we decided that proceeding from the right chest would provide the greatest exposure for central cannulation for cardiopulmonary bypass and access to the left atrium and esophagus. An emergency operation through a right posterolateral thoracotomy showed a left atrial wall abscess with frank pus, with a healed fistula to the esophagus (Fig 2). The atrial mass was excised, along with the adjacent infected portion of the left atrial wall, and the fistula was repaired with a reinforcement of the healed esophageal wall plus interposition of a pedicled flap of autologous pericardium between the left atrium and the esophagus. The patient was discharged home uneventfully with intravenous antibiotic therapy. There was no residual esophageal leak or infection. Intraoperative culture of the wall abscess confirmed the same microorganism as found in the blood.
Comment AE fistula is a rare but frequently lethal complication after catheter ablation for atrial fibrillation, with a mortality rate of 67% among 49 patients reported in the literature [1]. The diagnosis should always be suspected after catheter atrial fibrillation ablation when a patient presents with fever or neurologic symptoms, as evidenced in most of the reported cases [1]. Although echocardiography has not been found helpful
Ann Thorac Surg 2013;96:1475e8
CASE REPORT BANACK ET AL AORTIC VALVE REPLACEMENT AFTER LUNG TRANSPLANTATION
1475
4. Vassileva CM, Shawgo T, Shabosky J, Soliman S, Hazelrigg S. Repair of left atrial-esophageal fistula following percutaneous radiofrequency ablation for atrial fibrillation. J Card Surg 2011;26:556–8.
Aortic Valve Replacement for Critical Aortic Stenosis After Bilateral Lung Transplantation Trevor Banack, MD, Bulat A. Ziganshin, MD, Paul Barash, MD, and John A. Elefteriades, MD Department of Anesthesia and Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
in diagnosing AE fistula, CT may reveal pneumomediastinum or air bubbles in the left atrium. Results of both studies were negative in our patient, and this was the first report that magnetic resonance imaging was required to discover an intracardiac mass in the left atrium as a secondary manifestation of the AE fistula. Esophagogastroduodenoscopy is rarely used to diagnose AE fistula given the risk of iatrogenic esophageal perforation with endoscope manipulation but was performed in this patient because of the clinical suspicion of the fistula, despite negative findings on echocardiography and CT. This unusual presentation of AE fistula was likely responsible for the initial transient ischemic attack and persistent symptoms of infection in our patient. Indeed, resection of the mass exposed the underlying atrial wall abscess, but the fistula had actually healed before the operation. The healed fistula communication between the left atrium and esophagus likely explains the delayed clinical presentation of AE fistula in this patient. Extracardiac and intracardiac repairs of AE fistula have both been reported, with mortality exceeding 50% [2e4]. The intermittent antibiotic use and continuous anticoagulation likely protected the patient and allowed the fistula to heal, with a satisfactory surgical outcome.
References 1. Siegel MO, Parenti DM, Simon GL. Atrial-esophageal fistula after atrial radiofrequency catheter ablation. Clin Infectious Dis 2010;51:73–6. 2. Finsterer J, Stollberger C, Pulgram T. Neurological manifestations of atrio-esophageal fistulas from left atrial ablation. Eur J Neurol 2011;18:1212–9. 3. St. Julien J, Putnam JB Jr, Nesbitt JC, Lambright ES, Petracek MR, Grogan EL. Successful treatment of atrioesophageal fistula by cervical esophageal ligation and decompression. Ann Thorac Surg 2011;91:e85–6. Ó 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
ince Cooper’s first report in 1983, 38,119 lung transplantations have been recorded [1]. Some of these patients require cardiac surgical interventions. Yet, minimal experience has been reported in the literature on open-heart procedures after lung transplantation [2e4].
S
A 62-year-old man had undergone bilateral lung transplantation elsewhere in 2008 for end-stage idiopathic pulmonary fibrosis, performed with cardiopulmonary bypass through a clamshell incision. Postoperative complications included loculated pleural effusions and hemothorax. Decortication was ultimately required. Two weeks later, the patient sustained a pulmonary embolism, treated medically. Long-term immunosuppression included tacrolimus, mycophenolate, and prednisone. Thirteen weeks after transplantation, during bronchoscopy, the patient experienced hypoxic respiratory failure, requiring transient intubation. The patient was later found to have a paralyzed right vocal cord. After medialization of the cord, the patient was discharged home using biphasic positive airway pressure. One year later, the patient sustained a rejection episode and multiorgan failure, requiring tracheostomy and long-term mechanical ventilation. He recovered from these events. Four years later, the patient experienced progressive exertional dyspnea and decreased exercise tolerance. Comorbidities included chronic renal failure (creatinine 2.1 mg/dL), gastroesophageal reflux, hypertension,
Accepted for publication Jan 4, 2013. Address correspondence to Dr Elefteriades, Section of Cardiac Surgery, Yale University School of Medicine, Boardman 204, 333 Cedar St, New Haven, CT 06510; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.01.022
FEATURE ARTICLES
Fig 2. Intraoperative photograph shows the mass (*) in the left atrium (LA), which upon resection revealed an underlying abscess with frank pus. The attachment of the atrial wall mass is close to the orifice of the right inferior pulmonary vein (#).
Four years after bilateral lung transplantation, a 62-yearold man with critical aortic stenosis required aortic valve replacement. This is the first report of aortic valve replacement after bilateral lung transplantation. Anesthetic and surgical management are described. (Ann Thorac Surg 2013;96:1475e8) Ó 2012 by The Society of Thoracic Surgeons