- Email: [email protected]
Ross Operation and Mitral Homograft for Aortic and Tricuspid Valve Endocarditis
1450
CASE REPORT PRAT ET AL PULMONARY AUTOGRAFT AND MITRAL HOMOGRAFT
syndrome who have a normal valve before dissection, this approach is not feasible for patients with a stenotic bicuspid valve or annuloaortic ectasia. Most of these patients require valve replacement. Although our policy of root repair for virtually all patients without Marfan’s syndrome has provided an overall operative mortality of 6% [1], others suggest that preservation of the native aortic valve is possible in only 70% to 80% of operations and advise radical root replacement for the remainder [4, 5]. A recent report from Ergin and colleagues [5] considered an operative mortality of 15.7% for root replacement as favorable compared with mortality rates of 15% for valve resuspension or 25% for separate valve and ascending aortic replacement in the combined Stanford-Duke series [4]. Although the Bentall procedure and radical root repair (with mobilization and reimplantation of dissected coronary arteries) can be achieved with acceptable operative mortality by those with experience, the majority of patients are operated on under emergency conditions by surgeons with limited exposure to aortic root surgery. We emphasize that operative survival is of paramount importance and an expeditious and simple operation is most likely to achieve this. Complete transection of the aorta above the sinotubular junction and exclusion of the dissected sinuses with a xenograft aortic root provided an effective alternative for this elderly patient in whom valve repair was inappropriate. Because the Dacron inflow cloth of the Freestyle valve prevents annular dilatation, the method may also be suitable for some patients with Marfan’s syndrome and others who would prefer to avoid anticoagulation. In conclusion, we consider the xenograft root inclusion method a simpler approach to radical root replacement when the native valve cannot be repaired.
References 1. Westaby S, Katsumata T, Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108–12. 2. Von Segesser LK, Renzelti E, Lachat M, et al. Aortic valve preservation in acute type A dissection. Is it sound? J Thorac Cardiovasc Surg 1996;111:381–91. 3. Fann JI, Glower DD, Miller DC, et al. Preservation of aortic valve in acute type A dissection complicated by aortic valve regurgitation. J Thorac Cardiovasc Surg 1991;102:62–75. 4. Miller DC, Mitchell RS, Oyer PE, et al. Independent determination of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl 1):153– 64. 5. Ergin MA, McCullough J, Galla JD, et al. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840–5. 6. Westaby S, Narasena N, Ormerod O, et al. Time related hemodynamic changes after aortic valve replacement with the Freestyle stentless valve. Ann Thorac Surg 1995;60:1633–9. 7. Bachet J, Goudot B, Teodori G, et al. Surgery of type A acute aortic dissection with gelatine-resorcine-formol biological glue. A twelve year experience. J Cardiovasc Surg 1990;31: 263–73. 8. Jin XY, Westaby S, Gibson R, et al. Left ventricular remodelling and improvement of Freestyle stentless valve haemodynamics. Eur J Cardiothorac Surg 1997;12:63–9. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1450 –2
Ross Operation and Mitral Homograft for Aortic and Tricuspid Valve Endocarditis Alain Prat, MD, Olivier H. Fabre, MD, Andre´ Vincentelli, MD, Vincent Doisy, MD, and Ghatfan Shaaban, MD Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Re´gional et Universitaire de Lille, Lille, France
We report here a case of concomitant aortic and tricuspid valve endocarditis occurring in a 26-year-old woman 2 weeks after she had given birth by cesarean delivery. Preoperative transthoracic echocardiography revealed a previously undetected aorta–right atrium fistula, which at operation appeared to be congenital in origin. Surgical treatment consisted of aortic valve replacement with a pulmonary autograft, tricuspid valve replacement with a cryopreserved mitral homograft, and closure of the fistulous communication. The postoperative recovery was uneventful. (Ann Thorac Surg 1998;65:1450 –2) © 1998 by The Society of Thoracic Surgeons
S
everal surgical techniques have been reported for the treatment of infective endocarditis. These include the use of mechanical valves, bioprotheses, homografts, or pulmonary autografts. Although the choice of surgical technique remains debatable, it has been established that the radical excision of all infected tissue is a prerequisite for the successful treatment of the condition. We report here a case of aortic and tricuspid valve endocarditis associated with a congenital aorta–right atrium fistula treated with a Ross procedure and a cryopreserved mitral homograft. A 26-year-old woman was referred to the emergency department in April 1997 for acute dyspnea, weakness, and persistent fever. Her medical history revealed only an unexplored grade 2/6 systolodiastolic murmur and a cesarean delivery 15 days earlier. A physical examination of the patient disclosed a grade 4/6 systolic and diastolic murmur. A chest radiograph showed mild cardiomegaly, and the electrocardiogram showed a sinusal tachycardia. Transthoracic Doppler echocardiography revealed a massive aortic and tricuspid regurgitation, and several vegetations were observed on the posterior leaflet of the tricuspid valve. A fistula was noted with a continuous flow (. 4 m/s) between the noncoronary sinus and the right atrium. These data confirmed the diagnosis of acute
Accepted for publication Dec 3, 1997. Address reprint requests to Dr Prat, Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Regional Universitaire, 59037 Lille Cedex, France (e-mail: [email protected]).
0003-4975/98/$19.00 PII S0003-4975(98)00100-3
Ann Thorac Surg 1998;65:1450 –2
aortic and tricuspid valve endocarditis. Blood cultures were positive for Staphylococcus epidermidis. Intravenous antibiotics including penicillin (semisynthetic b-lactamase–resistant) and gentamicin rapidly controlled the septic syndrome. Abdominal echography and a dental examination revealed no focal infection. Based on these findings, we concluded that the endocarditis was probably related to the recent obstetric procedure. Operation was indicated for the correction of the massive aortic and tricuspid incompetence. There was a direct fistulous communication 6 mm in diameter between the aortic noncoronary sinus and the right atrium. This fistula was a congenital form of aneurysm of the sinus of Valsalva, readily distinguishable from an acquired mycotic aneurysm (Fig 1). A total aortic root replacement with pulmonary autograft was performed to replace the damaged aortic valve. The proximal ostium of the fistula was incorporated into the proximal suture line of the autograft. The leaflets and chordae tendineae of the tricuspid valve were extensively damaged. They were excised with a 2-mm fringe of leaflet tissue left on the annulus for suture placement. The distal ostium of the fistula was oversewn, and the tricuspid valve was totally replaced with a 36-mm cryopreserved mitral homograft (Fig 2). Cross-clamp and bypass time were 129 minutes and 156 minutes. Pathologic studies confirmed the diagnosis of acute bacterial endocarditis with the presence of polymorphonuclear neutrophil leukocytes and microabscesses in both valves. The patient’s postoperative course was uneventful, and she was discharged from the hospital after 3 weeks of intravenous antibiotherapy. Oral antibiotics were then prescribed for 3 weeks. Postoperative echocardiography was unremarkable, with a peak systolic aortic gradient of 1.8 mm Hg and a grade 1/4 tricuspid regurgitation.
Comment The aortic valve is a more common site of infective endocarditis than the tricuspid valve. Valve replacement
Fig 1. Left (*) and right (**) coronary buttons detached from the aortic wall. The fistula originates from the noncoronary sinus (arrow).
CASE REPORT PRAT ET AL PULMONARY AUTOGRAFT AND MITRAL HOMOGRAFT
1451
Fig 2. Replacement of the tricuspid valve with a mitral homograft. The annular anastomosis was made with continuous running sutures.
is indicated in cases of uncontrolled sepsis, congestive heart failure, or recurrent systemic emboli. In young patients, advantages of the autograft include long-term durability of autologous tissue, excellent hemodynamics, an absence of thromboembolism, and no need for anticoagulation treatment [1]. Although a more complex procedure than a simple aortic valve replacement, aortic root replacement with a pulmonary autograft is safe [2]. Oswalt [3] reported no deaths and no recurrent infections for up to 3.5 years postoperatively in a group of 20 patients operated on for active endocarditis. Tricuspid valve endocarditis is rare and usually occurs in intravenous drug users. Cases have also been reported in patients with a right heart congenital defect [4]. The surgical management of patients with this condition remains disputable, with treatments ranging from tricuspid valve excision to valve repair or valve replacement. In the first procedure, tricuspid incompetence may lead to valve replacement as a second-stage procedure if infection is eradicated [5]. Tricuspid valve repair after partial resection is certainly the most attractive treatment, but it is not feasible in the case of massive valvular damage. Pomar and associates [6] have achieved good results using a cryopreserved mitral valve homograft as an alternative to other methods of tricuspid valve replacement in septic tricuspid endocarditis. The case of the patient described here is quite remarkable. This uncommon simultaneous left and right-sided endocarditis was the consequence of a fistula between the aortic noncoronary sinus and right atrium. In conclusion, autograft and homograft implantation is a good alternative to prosthetic valve replacement for the treatment of multivalvular endocarditis in carefully selected young patients.
References 1. Ross D, Jackson M, Davies J. The pulmonary autograft. A permanent aortic valve. Eur J Cardiothorac Surg 1992;6:113–7.
1452
CASE REPORT ZOLFAGHARI AND PFISTER MIDCABG FOLLOWED BY GI OPERATION
2. Prat AG, Doisy V, Savoye C, Moreau DC, Monier EJ, Stankowiak C. Total aortic root replacement with pulmonary autografts: short-term results in 45 consecutive patients. J Heart Valve Dis 1995;4:368–73. 3. Oswalt J. Management of infective endocarditis by autograft valve replacement. J Heart Valve Dis 1994;3:377–9. 4. Hvass U, Lansac E, Chatel D, Henri I. Mitral homograft for tricuspid valve endocarditis complicating a congenital fistula between the right coronary artery and right ventricle. J Heart Valve Dis 1996;5:564– 6. 5. Arbulu A, Holmes RJ, Asfaw I. Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years’ experience. J Heart Valve Dis 1992;2:129–37. 6. Pomar JL, Mestres CA, Pare JC, Miro JM. Management of persistent tricuspid endocarditis with transplantation of cryopreserved mitral homografts. J Thorac Cardiovasc Surg 1994; 107:1460–3.
MIDCABG Followed by a Gastrointestinal Operation in the Same Anesthetic Setting David Zolfaghari, MD, and Albert J. Pfister, MD Division of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
Cardiovascular complications continue to be a significant source of morbidity and mortality in patients having noncardiac operations. This especially is true in patients with known coronary artery disease facing intraabdominal operations. Minimally invasive direct coronary artery bypass grafting allows coronary artery grafting without cardiopulmonary bypass or a median sternotomy incision. Also, in combination with angioplasty (the “hybrid procedure”), it is possible to offer complete revascularization with far less surgical trauma. We present 2 cases of patients who had minimally invasive direct coronary artery bypass grafting followed by major gastrointestinal operations in the same anesthetic setting. (Ann Thorac Surg 1998;65:1452–3) © 1998 by The Society of Thoracic Surgeons
C
ardiovascular complications continue to be a clinically significant source of morbidity and mortality in high risk patients having noncardiac operations. Of the 25 million people who undergo noncardiac operations in the United States each year, 4 million have or are at risk for coronary artery disease. Approximately 20,000 people of this at-risk population die of cardiac causes during the perioperative period, and an additional 250,000 sustain perioperative myocardial infarction, heart failure, or dysrhythmias [1]. Ashton and associates [2] evaluated 1,487 men who were having major noncardiac operations. Among patients within this group at high risk for postoperative myocardial infarction, there was a myoAccepted for publication Dec 4, 1997. Address reprint requests to Dr Pfister, 106 Irving St, NW, #308, Washington, DC 20010.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1452–3
cardial infarction rate of 4.1% and a cardiac-related mortality rate of 2.3% [2]. As a result of these data, patients with known or suspected coronary artery disease frequently have cardiac evaluations before major noncardiac operations. Minimally invasive direct coronary artery bypass grafting (MIDCABG) has recently been introduced into the field of cardiac surgery. This innovation allows coronary grafting to be done without cardiopulmonary bypass or a median sternotomy incision. At this point, single-vessel disease involving the left anterior descending artery is the primary indication for MIDCABG. However, with the addition of catheter-based angioplasty of the right coronary artery and circumflex systems (the “hybrid procedure”), the indications are growing. Consequently, it is conceivable to offer complete revascularization with minimal surgical trauma. We present 2 cases of patients with indications for urgent major noncardiac operations who had significant coronary artery disease. Both patients had MIDCABG followed by major gastrointestinal operations in the same anesthetic setting.
Case Reports Patient 1 A 75-year-old man with a diagnosis of adenocarcinoma of the right colon had a preoperative workup that included a persantine thallium study that was positive for anterioseptal ischemia. A cardiac catheterization showed a 100% occlusion of the proximal left anterior descending artery (LAD) and a 75% to 90% stenosis of the mid-right coronary artery. The patient had a successful percutaneous transluminal coronary angioplasty of the right coronary artery lesion, but the angioplasty of the LAD was unsuccessful. On hospital day 2, the patient had one episode of rectal bleeding, with his hematocrit dropping from 35% to 26%. The patient was prepared for operation, and on hospital day 3, in the same anesthetic setting, he underwent a MIDCABG immediately followed by a right hemicolectomy. The MIDCABG was done through a left anterolateral thoracotomy without cardiopulmonary bypass, and the left internal mammary artery was harvested and anastomosed to the mid-LAD without technical difficulties. A right hemicolectomy was then done for a 4 3 5-cm mass located 10 cm from the cecum. The patient’s postoperative course was unremarkable. He was extubated on postoperative day 1 and transferred to the general ward on postoperative day 2. On postoperative day 6 he was discharged to home without cardiac complaints or electrocardiographic changes.
Patient 2 A 54-year-old man was admitted because of weakness and melena. During his resuscitation, which included 6 units of packed red blood cells, the patient had development of pulmonary edema, elevated creatine kinase-MB level, and Q waves in leads V1 and V2 on the electrocardiogram. A persantine thallium study was positive for inferior and septal wall ischemia, with a cardiac cathe0003-4975/98/$19.00 PII S0003-4975(98)00164-7
CASE REPORT PRAT ET AL PULMONARY AUTOGRAFT AND MITRAL HOMOGRAFT
syndrome who have a normal valve before dissection, this approach is not feasible for patients with a stenotic bicuspid valve or annuloaortic ectasia. Most of these patients require valve replacement. Although our policy of root repair for virtually all patients without Marfan’s syndrome has provided an overall operative mortality of 6% [1], others suggest that preservation of the native aortic valve is possible in only 70% to 80% of operations and advise radical root replacement for the remainder [4, 5]. A recent report from Ergin and colleagues [5] considered an operative mortality of 15.7% for root replacement as favorable compared with mortality rates of 15% for valve resuspension or 25% for separate valve and ascending aortic replacement in the combined Stanford-Duke series [4]. Although the Bentall procedure and radical root repair (with mobilization and reimplantation of dissected coronary arteries) can be achieved with acceptable operative mortality by those with experience, the majority of patients are operated on under emergency conditions by surgeons with limited exposure to aortic root surgery. We emphasize that operative survival is of paramount importance and an expeditious and simple operation is most likely to achieve this. Complete transection of the aorta above the sinotubular junction and exclusion of the dissected sinuses with a xenograft aortic root provided an effective alternative for this elderly patient in whom valve repair was inappropriate. Because the Dacron inflow cloth of the Freestyle valve prevents annular dilatation, the method may also be suitable for some patients with Marfan’s syndrome and others who would prefer to avoid anticoagulation. In conclusion, we consider the xenograft root inclusion method a simpler approach to radical root replacement when the native valve cannot be repaired.
References 1. Westaby S, Katsumata T, Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108–12. 2. Von Segesser LK, Renzelti E, Lachat M, et al. Aortic valve preservation in acute type A dissection. Is it sound? J Thorac Cardiovasc Surg 1996;111:381–91. 3. Fann JI, Glower DD, Miller DC, et al. Preservation of aortic valve in acute type A dissection complicated by aortic valve regurgitation. J Thorac Cardiovasc Surg 1991;102:62–75. 4. Miller DC, Mitchell RS, Oyer PE, et al. Independent determination of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl 1):153– 64. 5. Ergin MA, McCullough J, Galla JD, et al. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840–5. 6. Westaby S, Narasena N, Ormerod O, et al. Time related hemodynamic changes after aortic valve replacement with the Freestyle stentless valve. Ann Thorac Surg 1995;60:1633–9. 7. Bachet J, Goudot B, Teodori G, et al. Surgery of type A acute aortic dissection with gelatine-resorcine-formol biological glue. A twelve year experience. J Cardiovasc Surg 1990;31: 263–73. 8. Jin XY, Westaby S, Gibson R, et al. Left ventricular remodelling and improvement of Freestyle stentless valve haemodynamics. Eur J Cardiothorac Surg 1997;12:63–9. © 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1450 –2
Ross Operation and Mitral Homograft for Aortic and Tricuspid Valve Endocarditis Alain Prat, MD, Olivier H. Fabre, MD, Andre´ Vincentelli, MD, Vincent Doisy, MD, and Ghatfan Shaaban, MD Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Re´gional et Universitaire de Lille, Lille, France
We report here a case of concomitant aortic and tricuspid valve endocarditis occurring in a 26-year-old woman 2 weeks after she had given birth by cesarean delivery. Preoperative transthoracic echocardiography revealed a previously undetected aorta–right atrium fistula, which at operation appeared to be congenital in origin. Surgical treatment consisted of aortic valve replacement with a pulmonary autograft, tricuspid valve replacement with a cryopreserved mitral homograft, and closure of the fistulous communication. The postoperative recovery was uneventful. (Ann Thorac Surg 1998;65:1450 –2) © 1998 by The Society of Thoracic Surgeons
S
everal surgical techniques have been reported for the treatment of infective endocarditis. These include the use of mechanical valves, bioprotheses, homografts, or pulmonary autografts. Although the choice of surgical technique remains debatable, it has been established that the radical excision of all infected tissue is a prerequisite for the successful treatment of the condition. We report here a case of aortic and tricuspid valve endocarditis associated with a congenital aorta–right atrium fistula treated with a Ross procedure and a cryopreserved mitral homograft. A 26-year-old woman was referred to the emergency department in April 1997 for acute dyspnea, weakness, and persistent fever. Her medical history revealed only an unexplored grade 2/6 systolodiastolic murmur and a cesarean delivery 15 days earlier. A physical examination of the patient disclosed a grade 4/6 systolic and diastolic murmur. A chest radiograph showed mild cardiomegaly, and the electrocardiogram showed a sinusal tachycardia. Transthoracic Doppler echocardiography revealed a massive aortic and tricuspid regurgitation, and several vegetations were observed on the posterior leaflet of the tricuspid valve. A fistula was noted with a continuous flow (. 4 m/s) between the noncoronary sinus and the right atrium. These data confirmed the diagnosis of acute
Accepted for publication Dec 3, 1997. Address reprint requests to Dr Prat, Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Regional Universitaire, 59037 Lille Cedex, France (e-mail: [email protected]).
0003-4975/98/$19.00 PII S0003-4975(98)00100-3
Ann Thorac Surg 1998;65:1450 –2
aortic and tricuspid valve endocarditis. Blood cultures were positive for Staphylococcus epidermidis. Intravenous antibiotics including penicillin (semisynthetic b-lactamase–resistant) and gentamicin rapidly controlled the septic syndrome. Abdominal echography and a dental examination revealed no focal infection. Based on these findings, we concluded that the endocarditis was probably related to the recent obstetric procedure. Operation was indicated for the correction of the massive aortic and tricuspid incompetence. There was a direct fistulous communication 6 mm in diameter between the aortic noncoronary sinus and the right atrium. This fistula was a congenital form of aneurysm of the sinus of Valsalva, readily distinguishable from an acquired mycotic aneurysm (Fig 1). A total aortic root replacement with pulmonary autograft was performed to replace the damaged aortic valve. The proximal ostium of the fistula was incorporated into the proximal suture line of the autograft. The leaflets and chordae tendineae of the tricuspid valve were extensively damaged. They were excised with a 2-mm fringe of leaflet tissue left on the annulus for suture placement. The distal ostium of the fistula was oversewn, and the tricuspid valve was totally replaced with a 36-mm cryopreserved mitral homograft (Fig 2). Cross-clamp and bypass time were 129 minutes and 156 minutes. Pathologic studies confirmed the diagnosis of acute bacterial endocarditis with the presence of polymorphonuclear neutrophil leukocytes and microabscesses in both valves. The patient’s postoperative course was uneventful, and she was discharged from the hospital after 3 weeks of intravenous antibiotherapy. Oral antibiotics were then prescribed for 3 weeks. Postoperative echocardiography was unremarkable, with a peak systolic aortic gradient of 1.8 mm Hg and a grade 1/4 tricuspid regurgitation.
Comment The aortic valve is a more common site of infective endocarditis than the tricuspid valve. Valve replacement
Fig 1. Left (*) and right (**) coronary buttons detached from the aortic wall. The fistula originates from the noncoronary sinus (arrow).
CASE REPORT PRAT ET AL PULMONARY AUTOGRAFT AND MITRAL HOMOGRAFT
1451
Fig 2. Replacement of the tricuspid valve with a mitral homograft. The annular anastomosis was made with continuous running sutures.
is indicated in cases of uncontrolled sepsis, congestive heart failure, or recurrent systemic emboli. In young patients, advantages of the autograft include long-term durability of autologous tissue, excellent hemodynamics, an absence of thromboembolism, and no need for anticoagulation treatment [1]. Although a more complex procedure than a simple aortic valve replacement, aortic root replacement with a pulmonary autograft is safe [2]. Oswalt [3] reported no deaths and no recurrent infections for up to 3.5 years postoperatively in a group of 20 patients operated on for active endocarditis. Tricuspid valve endocarditis is rare and usually occurs in intravenous drug users. Cases have also been reported in patients with a right heart congenital defect [4]. The surgical management of patients with this condition remains disputable, with treatments ranging from tricuspid valve excision to valve repair or valve replacement. In the first procedure, tricuspid incompetence may lead to valve replacement as a second-stage procedure if infection is eradicated [5]. Tricuspid valve repair after partial resection is certainly the most attractive treatment, but it is not feasible in the case of massive valvular damage. Pomar and associates [6] have achieved good results using a cryopreserved mitral valve homograft as an alternative to other methods of tricuspid valve replacement in septic tricuspid endocarditis. The case of the patient described here is quite remarkable. This uncommon simultaneous left and right-sided endocarditis was the consequence of a fistula between the aortic noncoronary sinus and right atrium. In conclusion, autograft and homograft implantation is a good alternative to prosthetic valve replacement for the treatment of multivalvular endocarditis in carefully selected young patients.
References 1. Ross D, Jackson M, Davies J. The pulmonary autograft. A permanent aortic valve. Eur J Cardiothorac Surg 1992;6:113–7.
1452
CASE REPORT ZOLFAGHARI AND PFISTER MIDCABG FOLLOWED BY GI OPERATION
2. Prat AG, Doisy V, Savoye C, Moreau DC, Monier EJ, Stankowiak C. Total aortic root replacement with pulmonary autografts: short-term results in 45 consecutive patients. J Heart Valve Dis 1995;4:368–73. 3. Oswalt J. Management of infective endocarditis by autograft valve replacement. J Heart Valve Dis 1994;3:377–9. 4. Hvass U, Lansac E, Chatel D, Henri I. Mitral homograft for tricuspid valve endocarditis complicating a congenital fistula between the right coronary artery and right ventricle. J Heart Valve Dis 1996;5:564– 6. 5. Arbulu A, Holmes RJ, Asfaw I. Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years’ experience. J Heart Valve Dis 1992;2:129–37. 6. Pomar JL, Mestres CA, Pare JC, Miro JM. Management of persistent tricuspid endocarditis with transplantation of cryopreserved mitral homografts. J Thorac Cardiovasc Surg 1994; 107:1460–3.
MIDCABG Followed by a Gastrointestinal Operation in the Same Anesthetic Setting David Zolfaghari, MD, and Albert J. Pfister, MD Division of Cardiothoracic Surgery, Washington Hospital Center, Washington, DC
Cardiovascular complications continue to be a significant source of morbidity and mortality in patients having noncardiac operations. This especially is true in patients with known coronary artery disease facing intraabdominal operations. Minimally invasive direct coronary artery bypass grafting allows coronary artery grafting without cardiopulmonary bypass or a median sternotomy incision. Also, in combination with angioplasty (the “hybrid procedure”), it is possible to offer complete revascularization with far less surgical trauma. We present 2 cases of patients who had minimally invasive direct coronary artery bypass grafting followed by major gastrointestinal operations in the same anesthetic setting. (Ann Thorac Surg 1998;65:1452–3) © 1998 by The Society of Thoracic Surgeons
C
ardiovascular complications continue to be a clinically significant source of morbidity and mortality in high risk patients having noncardiac operations. Of the 25 million people who undergo noncardiac operations in the United States each year, 4 million have or are at risk for coronary artery disease. Approximately 20,000 people of this at-risk population die of cardiac causes during the perioperative period, and an additional 250,000 sustain perioperative myocardial infarction, heart failure, or dysrhythmias [1]. Ashton and associates [2] evaluated 1,487 men who were having major noncardiac operations. Among patients within this group at high risk for postoperative myocardial infarction, there was a myoAccepted for publication Dec 4, 1997. Address reprint requests to Dr Pfister, 106 Irving St, NW, #308, Washington, DC 20010.
© 1998 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1998;65:1452–3
cardial infarction rate of 4.1% and a cardiac-related mortality rate of 2.3% [2]. As a result of these data, patients with known or suspected coronary artery disease frequently have cardiac evaluations before major noncardiac operations. Minimally invasive direct coronary artery bypass grafting (MIDCABG) has recently been introduced into the field of cardiac surgery. This innovation allows coronary grafting to be done without cardiopulmonary bypass or a median sternotomy incision. At this point, single-vessel disease involving the left anterior descending artery is the primary indication for MIDCABG. However, with the addition of catheter-based angioplasty of the right coronary artery and circumflex systems (the “hybrid procedure”), the indications are growing. Consequently, it is conceivable to offer complete revascularization with minimal surgical trauma. We present 2 cases of patients with indications for urgent major noncardiac operations who had significant coronary artery disease. Both patients had MIDCABG followed by major gastrointestinal operations in the same anesthetic setting.
Case Reports Patient 1 A 75-year-old man with a diagnosis of adenocarcinoma of the right colon had a preoperative workup that included a persantine thallium study that was positive for anterioseptal ischemia. A cardiac catheterization showed a 100% occlusion of the proximal left anterior descending artery (LAD) and a 75% to 90% stenosis of the mid-right coronary artery. The patient had a successful percutaneous transluminal coronary angioplasty of the right coronary artery lesion, but the angioplasty of the LAD was unsuccessful. On hospital day 2, the patient had one episode of rectal bleeding, with his hematocrit dropping from 35% to 26%. The patient was prepared for operation, and on hospital day 3, in the same anesthetic setting, he underwent a MIDCABG immediately followed by a right hemicolectomy. The MIDCABG was done through a left anterolateral thoracotomy without cardiopulmonary bypass, and the left internal mammary artery was harvested and anastomosed to the mid-LAD without technical difficulties. A right hemicolectomy was then done for a 4 3 5-cm mass located 10 cm from the cecum. The patient’s postoperative course was unremarkable. He was extubated on postoperative day 1 and transferred to the general ward on postoperative day 2. On postoperative day 6 he was discharged to home without cardiac complaints or electrocardiographic changes.
Patient 2 A 54-year-old man was admitted because of weakness and melena. During his resuscitation, which included 6 units of packed red blood cells, the patient had development of pulmonary edema, elevated creatine kinase-MB level, and Q waves in leads V1 and V2 on the electrocardiogram. A persantine thallium study was positive for inferior and septal wall ischemia, with a cardiac cathe0003-4975/98/$19.00 PII S0003-4975(98)00164-7