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Strut Fracture and Disc Embolization
CORRESPONDENCE
Congenital Left Atrial Aneurysm To the Editor: I read with great interest the article entitled “Congenital Aneurysm of the Left Atrium” by Grinfeld and colleagues (Ann Thorac Surg 39:469, 1985). They stated that a review of the world literature revealed a range of patients from 2.5 to 52 years of age. I wish to bring to your attention a similar paper published in The journal of Thoracic and Cardiovascular S u r g e y in 1975 in which I reported a 3Vi-year-old child who was seen with a left atrial aneurysm and associated interatrial shunt and multiple left ventricular left atrial shunts [l].This defect was repaired by a pants-over-vest technique, which also allowed closure of the associated shunts. I believe the addition of this case will supplement the accumulated case reports in the world literature. joseph 1. Amato, M . D . Director of Pediatric and Adult Cardiothoracic S u r g e y University of Medicine and Dentist y of New jersey-New jersey Medical School and Children’s Hospital of New jersey 15 South 9th St Newark, N j 07107
Reference 1. Amato I], Sewell DH, Rheinlander HF, Cleveland RJ: Congenital aneurysm of the left atrium with associated defects in the fibrous skeleton of the heart. J Thorac Cardiovasc Surg 69:639, 1975
Reply To the Editor: We appreciate Dr. Amato’s comments and found his case report most interesting. We attempted to analyze only those left atrial aneurysms that presented as isolated pathology and specifically avoided patients with mitral insufficiency because of the remote possibility that the atrial enlargement was secondary to that regurgitation. Roberto Grinfeld, M . D . Department of Cardiovascular Surge y Instihfos Medicos Anfdrtida Rivadavia 4978, Argentina
Strut Fracture and Disc Embolization To the Editor: We were interested to read the recent case report of Davis and co-workers concerning strut fracture and disc embolization in Bjork-Shiley mitral valve convexoconcave prostheses (Ann Thorac Surg 40:65, 1985). We agree with their observations regarding the value of the chest roentgenogram in the diagnosis of this problem, but we also emphasize the importance of the physical findings in these patients. We 11, 21 have previously reported three instances of minor strut fracture in Bjork-Shiley mitral valve prostheses, and in each instance, the character of the prosthetic valve sounds had altered. One patient had noticed this change herself. On examination, 1 of the 3 patients had a mitral regurgitant murmur. In our view, any change in prosthetic valve sounds in 581 Ann Thorac Surg 41:581-584, May 1986
patients with an implanted mitral valve convexoconcave prosthesis, accompanied by signs of acute pulmonary edema, should alert the clinician to the possibility of thrombotic obstruction or mechanical disruption of the valve. In the latter instance, radiological screening will confirm the diagnosis immediately. We agree that early removal of embolized valve fragments should be undertaken as soon as possible. In our third reported case 121, the minor strut was removed from the right common carotid artery and the disc from the abdominal aorta at the time of mitral valve re-replacement without any untoward effects.
B . Sethia, B.Sc., F.R.C.S. W . H . Bain, M . D . , F.R.C.S. Department of Cardiac S u r g e y Western Infirma y Glasgow, Scotland
References 1. Sethia B, Quin RO, Bain WH: Disc embolisation after minor strut fracture in a Bjork-Shiley mitral valve prosthesis. Thorax 38390, 1983 2. Khalil Y, Sethia B, Quin RO, Bain WH. Disc and strut embolisation after minor strut fracture in a Bjork-Shiley mitral valve prosthesis. Thorax 40:158, 1985
Reply To the Editor: We appreciate Dr. Sethia‘s and Dr. Bain’s comments regarding our report. We are in complete agreement with their emphasis on change in prosthetic valve sounds in patients with implanted Bjork-Shiley mitral convexoconcave prostheses. The presence of a mitral regurgitant murmur is an inconsistent finding in patients with strut fracture and disc embolization, as their experience demonstrates. Rapid diagnosis and emergent operation are essential in salvaging these patients. Their experience in concurrent valve replacement and removal of embolized valve fragments reinforces ours, and suggests it should be performed as a single operation. Paul K . Davis, M . D . john L. Pennock, M . D . Department of S u r g e y Division of Cardiothoracic S u r g e y The Milton S . Hershey Medical Center The Pennsylvania State University PO Box 850 Hershey, PA 17033
Partial Pericardiectomy to Prevent Cardiac Compression in Open-Heart Surgery To the Editor: Following open-heart operations that require a longer than average pump time [l]and are complicated by poor cardiac performance [l-31, approximation of the sternum may occasionally produce cardiac compression. This leads to a precipitous drop in arterial pressure and an elevation in central venous pressure. Typically this syndrome is immediately corrected by reopening the sternum and reoccurs if sternal approximation is reat-
Congenital Left Atrial Aneurysm To the Editor: I read with great interest the article entitled “Congenital Aneurysm of the Left Atrium” by Grinfeld and colleagues (Ann Thorac Surg 39:469, 1985). They stated that a review of the world literature revealed a range of patients from 2.5 to 52 years of age. I wish to bring to your attention a similar paper published in The journal of Thoracic and Cardiovascular S u r g e y in 1975 in which I reported a 3Vi-year-old child who was seen with a left atrial aneurysm and associated interatrial shunt and multiple left ventricular left atrial shunts [l].This defect was repaired by a pants-over-vest technique, which also allowed closure of the associated shunts. I believe the addition of this case will supplement the accumulated case reports in the world literature. joseph 1. Amato, M . D . Director of Pediatric and Adult Cardiothoracic S u r g e y University of Medicine and Dentist y of New jersey-New jersey Medical School and Children’s Hospital of New jersey 15 South 9th St Newark, N j 07107
Reference 1. Amato I], Sewell DH, Rheinlander HF, Cleveland RJ: Congenital aneurysm of the left atrium with associated defects in the fibrous skeleton of the heart. J Thorac Cardiovasc Surg 69:639, 1975
Reply To the Editor: We appreciate Dr. Amato’s comments and found his case report most interesting. We attempted to analyze only those left atrial aneurysms that presented as isolated pathology and specifically avoided patients with mitral insufficiency because of the remote possibility that the atrial enlargement was secondary to that regurgitation. Roberto Grinfeld, M . D . Department of Cardiovascular Surge y Instihfos Medicos Anfdrtida Rivadavia 4978, Argentina
Strut Fracture and Disc Embolization To the Editor: We were interested to read the recent case report of Davis and co-workers concerning strut fracture and disc embolization in Bjork-Shiley mitral valve convexoconcave prostheses (Ann Thorac Surg 40:65, 1985). We agree with their observations regarding the value of the chest roentgenogram in the diagnosis of this problem, but we also emphasize the importance of the physical findings in these patients. We 11, 21 have previously reported three instances of minor strut fracture in Bjork-Shiley mitral valve prostheses, and in each instance, the character of the prosthetic valve sounds had altered. One patient had noticed this change herself. On examination, 1 of the 3 patients had a mitral regurgitant murmur. In our view, any change in prosthetic valve sounds in 581 Ann Thorac Surg 41:581-584, May 1986
patients with an implanted mitral valve convexoconcave prosthesis, accompanied by signs of acute pulmonary edema, should alert the clinician to the possibility of thrombotic obstruction or mechanical disruption of the valve. In the latter instance, radiological screening will confirm the diagnosis immediately. We agree that early removal of embolized valve fragments should be undertaken as soon as possible. In our third reported case 121, the minor strut was removed from the right common carotid artery and the disc from the abdominal aorta at the time of mitral valve re-replacement without any untoward effects.
B . Sethia, B.Sc., F.R.C.S. W . H . Bain, M . D . , F.R.C.S. Department of Cardiac S u r g e y Western Infirma y Glasgow, Scotland
References 1. Sethia B, Quin RO, Bain WH: Disc embolisation after minor strut fracture in a Bjork-Shiley mitral valve prosthesis. Thorax 38390, 1983 2. Khalil Y, Sethia B, Quin RO, Bain WH. Disc and strut embolisation after minor strut fracture in a Bjork-Shiley mitral valve prosthesis. Thorax 40:158, 1985
Reply To the Editor: We appreciate Dr. Sethia‘s and Dr. Bain’s comments regarding our report. We are in complete agreement with their emphasis on change in prosthetic valve sounds in patients with implanted Bjork-Shiley mitral convexoconcave prostheses. The presence of a mitral regurgitant murmur is an inconsistent finding in patients with strut fracture and disc embolization, as their experience demonstrates. Rapid diagnosis and emergent operation are essential in salvaging these patients. Their experience in concurrent valve replacement and removal of embolized valve fragments reinforces ours, and suggests it should be performed as a single operation. Paul K . Davis, M . D . john L. Pennock, M . D . Department of S u r g e y Division of Cardiothoracic S u r g e y The Milton S . Hershey Medical Center The Pennsylvania State University PO Box 850 Hershey, PA 17033
Partial Pericardiectomy to Prevent Cardiac Compression in Open-Heart Surgery To the Editor: Following open-heart operations that require a longer than average pump time [l]and are complicated by poor cardiac performance [l-31, approximation of the sternum may occasionally produce cardiac compression. This leads to a precipitous drop in arterial pressure and an elevation in central venous pressure. Typically this syndrome is immediately corrected by reopening the sternum and reoccurs if sternal approximation is reat-