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Autotransplantation for Threatened Cardiac Rupture After Left Ventricular Repair
Autotransplantation for Threatened Cardiac Rupture After Left Ventricular Repair Hiroaki Hata, MD, PhD, Motomi Shiono, MD, PhD, Mitsuru Iida, MD, PhD, Akira Sezai, MD, PhD, Shunji Osaka, MD, PhD, and Masashi Tanaka, MD, PhD Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, and Department of Cardiovascular Surgery, Teikyo University School of Medicine, Tokyo, Japan
A 26-year-old Japanese woman experienced threatened cardiac rupture after mitral valve replacement and debridement of a left ventricular (LV) posterior wall abscess caused by infectious endocarditis. We performed cardiac autotransplantation using the bicaval technique to allow bench repair of the recurrent abscess. A balloon catheter was inflated in the inferior vena cava to obtain a bloodless anastomotic field. This is the first report of autotransplantation for threatened LV rupture after posterior wall repair. (Ann Thorac Surg 2017;103:e163–5) Ó 2017 by The Society of Thoracic Surgeons
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ardiac rupture is the most severe adverse event of cardiac operations. Repair is usually performed by the extracardiac [1] or intracardiac [2] approach. We encountered a patient with threatened rupture after debridement of a left ventricular (LV) posterior wall abscess and mitral valve (MV) replacement as a result of infectious endocarditis, for whom autotransplantation [3] was a life-saving procedure. A 26-year-old woman experienced disturbance of consciousness and sepsis while studying in Europe. MV endocarditis with a posterior perimitral leaflet abscess was diagnosed, and debridement of the abscess was performed. The LV posterior wall was repaired with felt and mattress sutures and was reinforced with a pericardial patch, and MV replacement was done with a 25-mm biologic valve (Epic; St Jude Medical, St. Paul, MN). She returned to Japan, but her fever recurred, and she was urgently admitted to our hospital. Her laboratory test results suggested severe inflammation (white blood cell count, 12.9 103/L; C-reactive protein, 15.47 mg/dL). Computed tomography (Fig 1) and magnetic resonance imaging (MRI) revealed a large abscess in the LV posterior wall. The left circumflex artery was disrupted in the atrioventricular groove and seemed to be sewn into the pericardial patch (Fig 1C). Uncontrollable chest pain occurred, and we diagnosed threatened rupture at the LV abscess repair site. For extracardiac repair of the LV posterior wall through the standard anterior approach, the Accepted for publication July 10, 2016. Address correspondence to Dr Hata, Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchikamimachi, Itabashi-ku, Tokyo, 173-8610, Japan; email: [email protected].
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier
cardiac apex must be elevated, but there was a high risk that the biologic valve stent would impinge on the LV wall and enlarge the myocardial defect. To avoid this, it was necessary to remove the prosthetic MV before repairing the LV wall and then re-replace the valve. Conventional left atriotomy or the transseptal approach was considered, but complete debridement of the abscess and adequate LV posterior wall repair would have been impossible. Although it is possible to approach the LV posterior wall through a left thoracotomy without elevating the cardiac apex [4], manipulation of the LV inside for complete debridement is difficult. In fact, neither the anterior nor the lateral approach provides satisfactory surgical fields for maneuvers both inside and outside the LV. Accordingly, we selected removal of the heart for a bench repair and subsequent autotransplantation [3]. Three months after the first procedure, median sternotomy was performed, followed by autotransplantation by the bicaval method [5]. Extracorporeal circulation was established with cannulas in the distal ascending aorta (inflow), distal superior vena cava (SVC) (removal), and right femoral vein (removal). The left atrium was incised, and the SVC, ascending aorta, and main pulmonary trunk were transected. The left atrial incision was extended until the atrium was separated. The inferior vena cava (IVC) was also transected. Performing anastomosis while the IVC is clamped can cause deformation and stenosis [6], so a 20F balloon catheter was inflated in the transected IVC to obtain a bloodless anastomotic site (Fig 2A). Then the heart was removed from the thorax and placed on a cooled towel, the cut stump of the ascending aorta was clamped, and cold crystalloid cardioplegic solution was intermittently infused into the aortic root. A large abscess was found in the LV posterior wall under the pericardial patch. Approximately 60 mL of yellow creamy pus (sterile by bacterial culture) spouted from the abscess at the commencement of debridement and irrigation (Fig 2B). We detected a small communication between the LV cavity and the abscess. The biologic valve showed no abnormalities. After debridement of the abscess cavity, two bovine pericardial patches (approximately 8 8 cm) were applied to both surfaces of the thin, scarred posterior LV wall, with interrupted sutures at the border of the scar to minimize damage to the residual circumflex branches. Re-replacement of the MV was done with a mechanical valve (25-mm ATS: ATS Medical, Inc, Minneapolis, MN) (Fig 2C). Interrupted sutures attaching the pericardial patch near the atrioventricular groove also fixed the valve ring. The aortic clamp time was 324 minutes, and the cardiopulmonary bypass time was 397 minutes. The postoperative maximum creatine kinase-MB was 56 U/L. The patient was discharged 26 days after operation. At 36 months postoperatively, there has been no recurrence of endocarditis and no anastomotic narrowing, and the abscess cavity is obliterated (Fig 3). Cardiac function is good, with normal sinus rhythm.
Comment Ventricular rupture is a potentially fatal adverse event of cardiac operations, mainly related to MV replacement [7]. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.07.025
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CASE REPORT HATA ET AL AUTOTRANSPLANTATION FOR CARDIAC RUPTURE
Ann Thorac Surg 2017;103:e163–5
Fig 1. Preoperative enhanced computed tomography. (A) Axial view. (B) Sagittal view. (C) Three-dimensional volume rendered image. The left ventricle is displaced anteriorly by the posterior wall abscess (*). Felt used for ventricular repair (arrowheads) is seen between the abscess cavity and the posterior wall. (LA ¼ left atrium; LV¼ left ventricle; RA ¼ right atrium; RCA ¼ right coronary artery; RV ¼ right ventricle.)
Extracardiac repair may be attempted, or the MV may be extracted by left atriotomy or the transseptal approach for intracavity repair, but such operations are challenging. Autotransplantation has been reported to be useful in patients for whom in situ operations are inadequate, such as those with cardiac tumors [3]. We considered that autotransplantation was the only option to salvage the present patient. The bicaval technique was used to prevent arrhythmia, atrial deformation,
and atrioventricular valve dysfunction [5]. It is more difficult than the conventional biatrial technique because more anastomoses are required and the outlet seam is smaller. Anastomosis of the IVC is particularly difficult, and various methods have been reported [6, 8]. In this patient, balloon catheter occlusion of the IVC provided a bloodless anastomotic field while avoiding torsion, deformation, or laceration of the IVC, and a vascular graft was not needed.
Fig 2. (A) Extraction of the heart by the bicaval technique. The IVC is occluded by a 20F balloon catheter (black arrow). The left atrium (**) is separated anterior to the left and right pulmonary veins, and the abscess cavity is seen (*). (B) Extracted heart before repair. The abscess wall (*) was reinforced by a felt strip (arrows), but communication with the ventricular cavity was observed. The abscess is covered by a pericardial patch (**). (C) Left ventricular repair and mitral valve re-replacement. The pericardial patch covering the abscess (*) was resected, and the abscess cavity was opened (**). Bovine pericardial patches were sutured sandwich-style (***) to reinforce the posterior wall. Then the annular ring stitch (black arrows) was threaded, and the mechanical was sutured. (Ao ¼ ascending aorta; LA ¼ left atrium; MV ¼ mitral valve; PA ¼ pulmonary artery; SVC ¼ superior vena cava.)
Ann Thorac Surg 2017;103:e163–5
CASE REPORT HATA ET AL AUTOTRANSPLANTATION FOR CARDIAC RUPTURE
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Fig. 3. MRI at 19 months after operation. (A) Axial view. (B) Sagittal view. The abscess has resolved, and cardiac morphology is normal. (LV ¼ left ventricle; RV ¼ right ventricle.)
In conclusion, this is the first report of autotransplantation for threatened ventricular rupture after LV posterior wall repair.
References 1. David TE. Left ventricular rupture after mitral valve replacement: endocardial repair with pericardial patch. J Thorac Cardiovasc Surg 1987;93:935–6. 2. Celemín D, Nu~ nez L, Gil-Aguado M, Larrea JL. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 1982;33: 638–40. 3. Ramlawi B, Al-Jabbari O, Blau LN, et al. Autotransplantation for the resection of complex left heart tumors. Ann Thorac Surg 2014;98:863–8.
4. Victorino G, Young JN, DeCampli WM, Ennix CL Jr. Left thoracotomy for emergent repair of ventricular rupture during mitral valve replacement. Ann Thorac Surg 1995;59: 1011–3. 5. Sievers HH, Weyand M, Kraatz EG, Bernhard A. An alternative technique for orthotopic cardiac transplantation, with preservation of the normal anatomy of the right atrium. Thorac Cardiovasc Surg 1991;39:70–2. 6. Aklog L, Sepic J, Filsoufi F, Byrne JG, Adams DH. Open inferior vena caval anastomosis during bicaval heart transplantation. Ann Thorac Surg 2002;73:671–2. 7. Bj€ ork VO, Henze A, Rodriguez L. Left ventricular rupture as a complication of mitral valve replacement. J Thorac Cardiovasc Surg 1977;73:14–22. 8. Conklin LD, Reardon MJ. Autotransplantation of the heart for primary cardiac malignancy: development and surgical technique. Tex Heart Inst J 2002;29:105–8.
A 26-year-old Japanese woman experienced threatened cardiac rupture after mitral valve replacement and debridement of a left ventricular (LV) posterior wall abscess caused by infectious endocarditis. We performed cardiac autotransplantation using the bicaval technique to allow bench repair of the recurrent abscess. A balloon catheter was inflated in the inferior vena cava to obtain a bloodless anastomotic field. This is the first report of autotransplantation for threatened LV rupture after posterior wall repair. (Ann Thorac Surg 2017;103:e163–5) Ó 2017 by The Society of Thoracic Surgeons
C
ardiac rupture is the most severe adverse event of cardiac operations. Repair is usually performed by the extracardiac [1] or intracardiac [2] approach. We encountered a patient with threatened rupture after debridement of a left ventricular (LV) posterior wall abscess and mitral valve (MV) replacement as a result of infectious endocarditis, for whom autotransplantation [3] was a life-saving procedure. A 26-year-old woman experienced disturbance of consciousness and sepsis while studying in Europe. MV endocarditis with a posterior perimitral leaflet abscess was diagnosed, and debridement of the abscess was performed. The LV posterior wall was repaired with felt and mattress sutures and was reinforced with a pericardial patch, and MV replacement was done with a 25-mm biologic valve (Epic; St Jude Medical, St. Paul, MN). She returned to Japan, but her fever recurred, and she was urgently admitted to our hospital. Her laboratory test results suggested severe inflammation (white blood cell count, 12.9 103/L; C-reactive protein, 15.47 mg/dL). Computed tomography (Fig 1) and magnetic resonance imaging (MRI) revealed a large abscess in the LV posterior wall. The left circumflex artery was disrupted in the atrioventricular groove and seemed to be sewn into the pericardial patch (Fig 1C). Uncontrollable chest pain occurred, and we diagnosed threatened rupture at the LV abscess repair site. For extracardiac repair of the LV posterior wall through the standard anterior approach, the Accepted for publication July 10, 2016. Address correspondence to Dr Hata, Department of Cardiovascular Surgery, Nihon University School of Medicine, 30-1 Oyaguchikamimachi, Itabashi-ku, Tokyo, 173-8610, Japan; email: [email protected].
Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier
cardiac apex must be elevated, but there was a high risk that the biologic valve stent would impinge on the LV wall and enlarge the myocardial defect. To avoid this, it was necessary to remove the prosthetic MV before repairing the LV wall and then re-replace the valve. Conventional left atriotomy or the transseptal approach was considered, but complete debridement of the abscess and adequate LV posterior wall repair would have been impossible. Although it is possible to approach the LV posterior wall through a left thoracotomy without elevating the cardiac apex [4], manipulation of the LV inside for complete debridement is difficult. In fact, neither the anterior nor the lateral approach provides satisfactory surgical fields for maneuvers both inside and outside the LV. Accordingly, we selected removal of the heart for a bench repair and subsequent autotransplantation [3]. Three months after the first procedure, median sternotomy was performed, followed by autotransplantation by the bicaval method [5]. Extracorporeal circulation was established with cannulas in the distal ascending aorta (inflow), distal superior vena cava (SVC) (removal), and right femoral vein (removal). The left atrium was incised, and the SVC, ascending aorta, and main pulmonary trunk were transected. The left atrial incision was extended until the atrium was separated. The inferior vena cava (IVC) was also transected. Performing anastomosis while the IVC is clamped can cause deformation and stenosis [6], so a 20F balloon catheter was inflated in the transected IVC to obtain a bloodless anastomotic site (Fig 2A). Then the heart was removed from the thorax and placed on a cooled towel, the cut stump of the ascending aorta was clamped, and cold crystalloid cardioplegic solution was intermittently infused into the aortic root. A large abscess was found in the LV posterior wall under the pericardial patch. Approximately 60 mL of yellow creamy pus (sterile by bacterial culture) spouted from the abscess at the commencement of debridement and irrigation (Fig 2B). We detected a small communication between the LV cavity and the abscess. The biologic valve showed no abnormalities. After debridement of the abscess cavity, two bovine pericardial patches (approximately 8 8 cm) were applied to both surfaces of the thin, scarred posterior LV wall, with interrupted sutures at the border of the scar to minimize damage to the residual circumflex branches. Re-replacement of the MV was done with a mechanical valve (25-mm ATS: ATS Medical, Inc, Minneapolis, MN) (Fig 2C). Interrupted sutures attaching the pericardial patch near the atrioventricular groove also fixed the valve ring. The aortic clamp time was 324 minutes, and the cardiopulmonary bypass time was 397 minutes. The postoperative maximum creatine kinase-MB was 56 U/L. The patient was discharged 26 days after operation. At 36 months postoperatively, there has been no recurrence of endocarditis and no anastomotic narrowing, and the abscess cavity is obliterated (Fig 3). Cardiac function is good, with normal sinus rhythm.
Comment Ventricular rupture is a potentially fatal adverse event of cardiac operations, mainly related to MV replacement [7]. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2016.07.025
e164
CASE REPORT HATA ET AL AUTOTRANSPLANTATION FOR CARDIAC RUPTURE
Ann Thorac Surg 2017;103:e163–5
Fig 1. Preoperative enhanced computed tomography. (A) Axial view. (B) Sagittal view. (C) Three-dimensional volume rendered image. The left ventricle is displaced anteriorly by the posterior wall abscess (*). Felt used for ventricular repair (arrowheads) is seen between the abscess cavity and the posterior wall. (LA ¼ left atrium; LV¼ left ventricle; RA ¼ right atrium; RCA ¼ right coronary artery; RV ¼ right ventricle.)
Extracardiac repair may be attempted, or the MV may be extracted by left atriotomy or the transseptal approach for intracavity repair, but such operations are challenging. Autotransplantation has been reported to be useful in patients for whom in situ operations are inadequate, such as those with cardiac tumors [3]. We considered that autotransplantation was the only option to salvage the present patient. The bicaval technique was used to prevent arrhythmia, atrial deformation,
and atrioventricular valve dysfunction [5]. It is more difficult than the conventional biatrial technique because more anastomoses are required and the outlet seam is smaller. Anastomosis of the IVC is particularly difficult, and various methods have been reported [6, 8]. In this patient, balloon catheter occlusion of the IVC provided a bloodless anastomotic field while avoiding torsion, deformation, or laceration of the IVC, and a vascular graft was not needed.
Fig 2. (A) Extraction of the heart by the bicaval technique. The IVC is occluded by a 20F balloon catheter (black arrow). The left atrium (**) is separated anterior to the left and right pulmonary veins, and the abscess cavity is seen (*). (B) Extracted heart before repair. The abscess wall (*) was reinforced by a felt strip (arrows), but communication with the ventricular cavity was observed. The abscess is covered by a pericardial patch (**). (C) Left ventricular repair and mitral valve re-replacement. The pericardial patch covering the abscess (*) was resected, and the abscess cavity was opened (**). Bovine pericardial patches were sutured sandwich-style (***) to reinforce the posterior wall. Then the annular ring stitch (black arrows) was threaded, and the mechanical was sutured. (Ao ¼ ascending aorta; LA ¼ left atrium; MV ¼ mitral valve; PA ¼ pulmonary artery; SVC ¼ superior vena cava.)
Ann Thorac Surg 2017;103:e163–5
CASE REPORT HATA ET AL AUTOTRANSPLANTATION FOR CARDIAC RUPTURE
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Fig. 3. MRI at 19 months after operation. (A) Axial view. (B) Sagittal view. The abscess has resolved, and cardiac morphology is normal. (LV ¼ left ventricle; RV ¼ right ventricle.)
In conclusion, this is the first report of autotransplantation for threatened ventricular rupture after LV posterior wall repair.
References 1. David TE. Left ventricular rupture after mitral valve replacement: endocardial repair with pericardial patch. J Thorac Cardiovasc Surg 1987;93:935–6. 2. Celemín D, Nu~ nez L, Gil-Aguado M, Larrea JL. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 1982;33: 638–40. 3. Ramlawi B, Al-Jabbari O, Blau LN, et al. Autotransplantation for the resection of complex left heart tumors. Ann Thorac Surg 2014;98:863–8.
4. Victorino G, Young JN, DeCampli WM, Ennix CL Jr. Left thoracotomy for emergent repair of ventricular rupture during mitral valve replacement. Ann Thorac Surg 1995;59: 1011–3. 5. Sievers HH, Weyand M, Kraatz EG, Bernhard A. An alternative technique for orthotopic cardiac transplantation, with preservation of the normal anatomy of the right atrium. Thorac Cardiovasc Surg 1991;39:70–2. 6. Aklog L, Sepic J, Filsoufi F, Byrne JG, Adams DH. Open inferior vena caval anastomosis during bicaval heart transplantation. Ann Thorac Surg 2002;73:671–2. 7. Bj€ ork VO, Henze A, Rodriguez L. Left ventricular rupture as a complication of mitral valve replacement. J Thorac Cardiovasc Surg 1977;73:14–22. 8. Conklin LD, Reardon MJ. Autotransplantation of the heart for primary cardiac malignancy: development and surgical technique. Tex Heart Inst J 2002;29:105–8.