- Email: [email protected]
Awake Heart Valve Surgery in a Patient With Severe Pulmonary Disease
Ann Thorac Surg 2008;86:293–5
References 1. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058 – 60. 2. Kadoba K, Jonas RA, Mayer JE, Castaneda AR. Mitral valve replacement in the first year of life. J Thorac Cardiovasc Surg 1990;100:762– 8. 3. Uva M, Galletti L, Gayet FL, et al. Surgery for congenital mitral valve disease in the first year of life. J Thorac Cardiovasc Surg 1995;109:164 –76. 4. De Vega N. Selective, adjustable and permanent annuloplasty. An original technic for the treatment of tricuspid insufficiency. Rev Esp Cardiol 1972;25:555– 6. 5. Kurlansky P, Rose EA, Malm JR. Adjustable annuloplasty for tricuspid insufficiency. Ann Thorac Surg 1987;44:404 – 6. 6. Kanter KR, Doelling NR, Fyfe DA, Sharma SH, Tam VKH. De Vega tricuspid annuloplasty for tricuspid regurgitation in children. Ann Thorac Surg 2001;72:1344 – 8. 7. Anagnostopoulos PV, Alphonso N, Nolke L, et al. Neonatal mitral and tricuspid valve repair for in utero papillary rupture. Ann Thorac Surg 2007;83:1458 – 62. 8. Suzuki Y, Minakawa M, Itaya H, Kuga T, Fukui K, Fukuda I. Mitral valve repair in a child with infectious endocarditis followed by meningitis. Jpn J Thorac Cardiovasc Surg 2004; 52:429 –31. 9. Healy DG, Wood AE. Anterior mitral leaflet reconstruction with pericardium in a 1.9 kg infant with endocarditis. Ann Thorac Surg 2006;81:2310 –2.
Awake Heart Valve Surgery in a Patient With Severe Pulmonary Disease Piotr Knapik, MD, PhD, Roman Przybylski, MD, Paweł Nadziakiewicz, MD, and Marian Zembala, MD, PhD Silesian Center for Heart Diseases, Zabrze, Poland
Cardiac operations may be performed in a conscious, spontaneously breathing patient, but it is difficult to justify an awake technique in patients undergoing coronary artery procedures with low operative risk. We describe an elderly patient with severe chronic obstructive pulmonary disease in whom general anesthesia was contraindicated. A valve procedure was performed under thoracic epidural anesthesia alone, thus avoiding intubation and mechanical ventilation. The patient had an uneventful postoperative course and excellent recovery. (Ann Thorac Surg 2008;86:293–5) © 2008 by The Society of Thoracic Surgeons Accepted for publication Jan 10, 2008. Address correspondence to Dr Knapik, Silesian Center for Heart Diseases, ul. Szpitalna 2, Zabrze, 41-800, Poland; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
293
C
ardiac surgical procedures may be performed in a conscious, spontaneously breathing patient. This issue remains very controversial [1]; however, more than 500 such cases have already been described in the medical literature. The awake technique has been used primarily for beating heart operations [2– 4], but it has also been proposed for valve operations and combined procedures [5, 6]. The technique is practicable, but it is unclear whether patients really benefit from its use [7]. Patients with significant chronic obstructive pulmonary disease (COPD) have higher risk in cardiac operations. Patients with mild-to-moderate COPD can be operated on quite safely, but death among elderly patients with severe COPD is so high that nonsurgical therapy is often proposed [8]. High thoracic epidural anesthesia (TEA), with complete avoidance of intubation and mechanical ventilation, could be a valuable option for such patients. We describe an elderly patient with severe COPD in whom general anesthesia was contraindicated. We were able to perform a complex valve operation under high TEA alone. The patient had an uneventful postoperative course and excellent recovery. A 74-year-old man with pulmonary hypertension and severely impaired left ventricular function was scheduled for urgent aortic valve replacement and mitral valve repair. The patient had extremely high operative risk. Comorbidities included severe emphysema (patient was taking oral and inhalational steroids), with forced expiratory volume in 1 second (FEV1) decreased to 33% and forced vital capacity (FVC) decreased to less than 49% of the predicted values. Oxygen saturation while breathing room air was 89%. The patient’s calculated additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 9, and the logistic EuroSCORE was 16.88%. His body weight was 57 kg, and his body mass index was 21. The anesthesiologist and cardiac surgeon in charge decided that an attempt would be made to perform the operation under TEA alone, without endotracheal intubation. An epidural catheter was inserted at the T2-T3 interspace. All catheters and lines were inserted under local anesthesia. During that time, the patient was breathing room air and proved that he was able to maintain satisfactory oxygen saturation while lying flat on the operating table. This confirmed that an awake cardiac operation was feasible in this patient. The operation was performed through a median sternotomy. No problems occurred during the initial phase, but pain was reported during the sternotomy. The epidural infusion was increased, and 10 mg of ketamine was given intravenously. This resulted in a temporary respiratory arrest and desaturation, requiring hand ventilation with a face mask. Spontaneous ventilation was restored after 5 minutes, whereupon the patient’s respiration was controlled by keeping his face mask tight whilst he breathed spontaneously. This enabled the an0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.01.034
FEATURE ARTICLES
nique and the second reported using MV leaflet reconstruction with fresh autologous pericardium [8, 9]. We chose to use the modified De Vega adjustable annuloplasty, which we believe provided better relief of MVR than mattress sutures to the MV commissures because the De Vega procedure produced a tight, even posterior MV annuloplasty.
CASE REPORT KNAPIK ET AL AWAKE HEART VALVE OPERATION
294
CASE REPORT KNAPIK ET AL AWAKE HEART VALVE OPERATION
Ann Thorac Surg 2008;86:293–5
Fig 1. Partial pressure of oxygen (PaO2, squares) and carbon dioxide (PaCO2, circles) in the arterial blood. (ECC ⫽ extracorporeal circulation.)
FEATURE ARTICLES
esthesiologist to provide the set mixture of oxygen and air, make sure that the airways were patent, and monitor respiration. At times, the face mask was released to communicate with the patient. Breathing stopped when cardiopulmonary bypass (CPB) started, and the patient could not be roused any more. The face mask was released, and the patient’s face was carefully observed for early detection of an abnormal breathing pattern, signs of discomfort, neurologic deterioration, and nausea or vomiting. The patient was cooled to 28°C, and CPB lasted 72 minutes. The severely calcified aortic valve was replaced with a mechanical valve. The mitral regurgitation was repaired in 5 minutes with Alfieri technique through the aortotomy. The course of CPB was uneventful, after which the perfusionist increased the partial arterial pressure of carbon dioxide (PaCO2) level to 58 mm Hg. Infusions of adrenaline and milrinone were started electively. A Guedel airway was inserted into the patient’s mouth, and a few artificial breaths were administered to eliminate atelectasis. No signs of spontaneous respiration appeared at the termination of CBP, and naloxone (.05 mg) was given intravenously. This resulted in a gradual restoration of the respiratory function, and 5 minutes later the patient was breathing spontaneously, although he still remained unresponsive. Communication with the patient was restored during sternal closure. The patient was transferred to the postoperative intensive care unit (ICU) fully conscious, complaining only of thirst. He did not remember much of the operation. During the procedure, arterial blood gases were measured on arrival to the operating theatre, after skin incision, after sternotomy, during CPB (4 times), after termination of CPB, and every 2 hours in the postoperative ICU. The range of pH values was 7.26 to 7.51; PaO2 and PaCO2 values are shown in Figure 1. The patient’s early postoperative course was compli-
cated by a right-sided pneumothorax, which occurred 4 hours postoperatively. His further postoperative course was completely uneventful. Inotropic drugs were gradually weaned, and the patient was transferred to a medium-care unit on postoperative day 2. The patient was discharged home in a stable condition 2 weeks after the operation.
Comment Inexorably, awake cardiac operations have become an established procedure in some centers. Although this technique is clearly viable, the course of such an “awake” procedure is a real challenge for both the anesthetist and the surgeon. Randomized trials comparing awake and other anesthetic techniques for cardiac operations are rare and do not identify patients with indications for such treatment [7]. Awake cardiac operations are also very controversial. Mora Mangano’s well-known editorial [1] clearly stated, that “there is no place for this trick in the cardiac anesthesiologist’s armamentarium.” Awake procedures are performed only in a few centers. The total number of publications (currently exceeding 20) is misleading, because the authors frequently report on their continuing experience in subsequent studies. The largest series of patients to date have been reported by Karagoz and colleagues [2], Aybek and colleagues [3], Chakravarthy and colleagues [4], Stritesky and colleagues [5], and very recently by Bottio and colleagues [6]. These five studies cover more than 90% of all reported patients. What was the reasoning behind performing conscious cardiac operations in these five centers? Karagoz and colleagues [2], Aybek and colleagues [3], and Chakravarthy and colleagues [4] confirmed the feasibility and safety of this technique in patients undergoing beating heart procedures. Additional criteria may be found in the
Ann Thorac Surg 2008;86:295–7
References 1. Mora Mangano CT. Risky business. J Thorac Cardiovasc Surg 2003;125:1204 –7. 2. Karagoz HY, Kurtoglu M, Bakkaloglu B, Sonmez B, Cetintas T, Bayazit K. Coronary artery bypass grafting in the awake patient: three years’ experience in 137 patients. J Thorac Cardiovasc Surg. 2003;125:1401– 4. 3. Aybek T, Kessler P, Khan MF, et al. Operative techniques in awake coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1394 – 400. 4. Chakravarthy M, Jawali V, Manohar M, et al. Conscious off pump coronary artery bypass surgery—an audit of our first 151 cases. Ann Thorac Cardiovasc Surg 2005;11:93–7. 5. Stritesky M, Semrad M, Kunstyr J, Hajek T, Demes R, Tosovsky J. On-pump cardiac surgery in a conscious patient using a thoracic epidural anesthesia—an ultra fast track method. Bratisl Lek Listy 2004;105:51–5. 6. Bottio T, Bisleri G, Piccoli P, Negri A, Manzato A, Muneretto C. Heart valve surgery in a very high-risk population: a preliminary experience in awake patients. J Heart Valve Dis 2007;16:187–94. 7. Kessler P, Aybek T, Neidhart G, et al. Comparison of three anesthetic techniques for off-pump coronary artery bypass grafting: general anesthesia, combined general and high tho© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
295
racic epidural anesthesia, or high thoracic epidural anesthesia alone. J Cardiothorac Vasc Anesth 2005;19:32–9. 8. Samuels LE, Kaufman MS, Morris RJ, Promisloff R, Brockman SK. Coronary artery bypass grafting in patients with COPD. Chest 1998;113:878 – 82.
Severe Pulmonary Valve Incompetence Late After Debanding: Repair by Bicuspidization Engin Usta, MD, Renate Kaulitz, MD, PhD, Shahriar Salehi-Gilani, MD, Michael Hofbeck, MD, PhD, and Gerhard Ziemer, MD, PhD Departments of Thoracic, Cardiac and Vascular Surgery, and Pediatric Cardiology, Children’s Hospital, University of Tübingen, Tübingen, Germany
We report a simple valve repair for severe pulmonary incompetence in a 25-year-old patient. The patient had been operated on twice before for ventricular septal defect and coarctation of the aorta. The first operation consisted of pulmonary artery banding and coarctectomy and end-to-end anastomosis at 4 months, followed by debanding and transinfundibular ventricular septal defect closure at 6 years of age. Massive pulmonary incompetence was due to destruction of one valve cusp with the right ventricular outflow tract and pulmonary artery dilated secondarily. Repair consisted of pulmonary valve bicuspidization and right ventricular remodelling. (Ann Thorac Surg 2008;86:295–7) © 2008 by The Society of Thoracic Surgeons
P
ulmonary incompetence (PI) can be without clinical impact for a long time. Later, symptoms of right ventricular (RV) dilatation and heart failure may occur. Although the most frequent cause of PI is status posttransannular RV outflow tract (RVOT)-patch enlargement for congenital lesions, symptoms developed in the patient presented in this report after previous surgical palliation in the presence of a normal pulmonary valve and RVOT to start with. A 25-year old man presented with progressive exercise intolerance and signs of congestive cardiac failure. He had undergone an operation for patent ductus arteriosus, aortic coarctation, and pulmonary artery banding at age 4 months. After normal growth and development, he had undergone a transinfundibar ventricular septal defect (VSD) closure and PA debanding at age 6 years. The patient had an uneventful course for 18 years, when progressive dyspnea developed on exertion. Diagnostic studies consisted of echocardiography, angiograAccepted for publication Dec 3, 2007. Address correspondence to Dr Ziemer, Department of Thoracic-, Cardiacand Vascular Surgery, Eberhard-Karls-University Tübingen, HoppeSeyler-Str. 3, Tübingen, 72076, Germany; e-mail: gerhard.ziemer@med. uni-tuebingen.de.
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.12.080
FEATURE ARTICLES
remaining two series [5, 6]. Stritesky and associates [5] included patients undergoing valve procedures, suggesting that the awake technique would be efficacious for patients with preoperative pulmonary dysfunction. Bottio and coworkers [6] went one stage further: Their study was performed entirely on a high-risk population undergoing heart valve operations and combined procedures. Many patients in this group had COPD (40%), pulmonary hypertension (62%), and various other comorbidities [6]. Our patient was similar to the patients in their population. Information in the literature may sometimes be quite contradictory. The article by Bottio and colleagues [6] stated, “during valve implant patients were totally conscious and cooperative with the surgeon’s suggestions,” while “typically, after starting CPB the patients stopped breathing. . .” Proper understanding of all these “minor” technical problems is crucial for the success of the whole procedure. Such practical information may be found in our case report. The safety of cardiac anesthesia during the awake procedure may not be comparable with the safety of general anesthesia; however, we were able to achieve satisfactory arterial blood gas results throughout the procedure and in the early postoperative period. During high epidural anesthesia, each spontaneously breathing patient should be carefully monitored for bilateral Horner’s syndrome. If this occurs, infusion of local anaesthetic agents should be stopped and respiratory insufficiency may be expected [2]. Is this technique reproducible for patients with severe respiratory insufficiency? To date, no randomized trials have compared the use of awake and conventional anesthesia techniques in a high-risk population. Such studies are urgently needed, because they will be able to answer the question whether awake cardiac operations are only a temporary trend or a firmly entrenched procedure.
CASE REPORT USTA ET AL BICUSPIDIZATION REPAIR OF PI
References 1. Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve. Ann Thorac Surg 1991;52:1058 – 60. 2. Kadoba K, Jonas RA, Mayer JE, Castaneda AR. Mitral valve replacement in the first year of life. J Thorac Cardiovasc Surg 1990;100:762– 8. 3. Uva M, Galletti L, Gayet FL, et al. Surgery for congenital mitral valve disease in the first year of life. J Thorac Cardiovasc Surg 1995;109:164 –76. 4. De Vega N. Selective, adjustable and permanent annuloplasty. An original technic for the treatment of tricuspid insufficiency. Rev Esp Cardiol 1972;25:555– 6. 5. Kurlansky P, Rose EA, Malm JR. Adjustable annuloplasty for tricuspid insufficiency. Ann Thorac Surg 1987;44:404 – 6. 6. Kanter KR, Doelling NR, Fyfe DA, Sharma SH, Tam VKH. De Vega tricuspid annuloplasty for tricuspid regurgitation in children. Ann Thorac Surg 2001;72:1344 – 8. 7. Anagnostopoulos PV, Alphonso N, Nolke L, et al. Neonatal mitral and tricuspid valve repair for in utero papillary rupture. Ann Thorac Surg 2007;83:1458 – 62. 8. Suzuki Y, Minakawa M, Itaya H, Kuga T, Fukui K, Fukuda I. Mitral valve repair in a child with infectious endocarditis followed by meningitis. Jpn J Thorac Cardiovasc Surg 2004; 52:429 –31. 9. Healy DG, Wood AE. Anterior mitral leaflet reconstruction with pericardium in a 1.9 kg infant with endocarditis. Ann Thorac Surg 2006;81:2310 –2.
Awake Heart Valve Surgery in a Patient With Severe Pulmonary Disease Piotr Knapik, MD, PhD, Roman Przybylski, MD, Paweł Nadziakiewicz, MD, and Marian Zembala, MD, PhD Silesian Center for Heart Diseases, Zabrze, Poland
Cardiac operations may be performed in a conscious, spontaneously breathing patient, but it is difficult to justify an awake technique in patients undergoing coronary artery procedures with low operative risk. We describe an elderly patient with severe chronic obstructive pulmonary disease in whom general anesthesia was contraindicated. A valve procedure was performed under thoracic epidural anesthesia alone, thus avoiding intubation and mechanical ventilation. The patient had an uneventful postoperative course and excellent recovery. (Ann Thorac Surg 2008;86:293–5) © 2008 by The Society of Thoracic Surgeons Accepted for publication Jan 10, 2008. Address correspondence to Dr Knapik, Silesian Center for Heart Diseases, ul. Szpitalna 2, Zabrze, 41-800, Poland; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
293
C
ardiac surgical procedures may be performed in a conscious, spontaneously breathing patient. This issue remains very controversial [1]; however, more than 500 such cases have already been described in the medical literature. The awake technique has been used primarily for beating heart operations [2– 4], but it has also been proposed for valve operations and combined procedures [5, 6]. The technique is practicable, but it is unclear whether patients really benefit from its use [7]. Patients with significant chronic obstructive pulmonary disease (COPD) have higher risk in cardiac operations. Patients with mild-to-moderate COPD can be operated on quite safely, but death among elderly patients with severe COPD is so high that nonsurgical therapy is often proposed [8]. High thoracic epidural anesthesia (TEA), with complete avoidance of intubation and mechanical ventilation, could be a valuable option for such patients. We describe an elderly patient with severe COPD in whom general anesthesia was contraindicated. We were able to perform a complex valve operation under high TEA alone. The patient had an uneventful postoperative course and excellent recovery. A 74-year-old man with pulmonary hypertension and severely impaired left ventricular function was scheduled for urgent aortic valve replacement and mitral valve repair. The patient had extremely high operative risk. Comorbidities included severe emphysema (patient was taking oral and inhalational steroids), with forced expiratory volume in 1 second (FEV1) decreased to 33% and forced vital capacity (FVC) decreased to less than 49% of the predicted values. Oxygen saturation while breathing room air was 89%. The patient’s calculated additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 9, and the logistic EuroSCORE was 16.88%. His body weight was 57 kg, and his body mass index was 21. The anesthesiologist and cardiac surgeon in charge decided that an attempt would be made to perform the operation under TEA alone, without endotracheal intubation. An epidural catheter was inserted at the T2-T3 interspace. All catheters and lines were inserted under local anesthesia. During that time, the patient was breathing room air and proved that he was able to maintain satisfactory oxygen saturation while lying flat on the operating table. This confirmed that an awake cardiac operation was feasible in this patient. The operation was performed through a median sternotomy. No problems occurred during the initial phase, but pain was reported during the sternotomy. The epidural infusion was increased, and 10 mg of ketamine was given intravenously. This resulted in a temporary respiratory arrest and desaturation, requiring hand ventilation with a face mask. Spontaneous ventilation was restored after 5 minutes, whereupon the patient’s respiration was controlled by keeping his face mask tight whilst he breathed spontaneously. This enabled the an0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.01.034
FEATURE ARTICLES
nique and the second reported using MV leaflet reconstruction with fresh autologous pericardium [8, 9]. We chose to use the modified De Vega adjustable annuloplasty, which we believe provided better relief of MVR than mattress sutures to the MV commissures because the De Vega procedure produced a tight, even posterior MV annuloplasty.
CASE REPORT KNAPIK ET AL AWAKE HEART VALVE OPERATION
294
CASE REPORT KNAPIK ET AL AWAKE HEART VALVE OPERATION
Ann Thorac Surg 2008;86:293–5
Fig 1. Partial pressure of oxygen (PaO2, squares) and carbon dioxide (PaCO2, circles) in the arterial blood. (ECC ⫽ extracorporeal circulation.)
FEATURE ARTICLES
esthesiologist to provide the set mixture of oxygen and air, make sure that the airways were patent, and monitor respiration. At times, the face mask was released to communicate with the patient. Breathing stopped when cardiopulmonary bypass (CPB) started, and the patient could not be roused any more. The face mask was released, and the patient’s face was carefully observed for early detection of an abnormal breathing pattern, signs of discomfort, neurologic deterioration, and nausea or vomiting. The patient was cooled to 28°C, and CPB lasted 72 minutes. The severely calcified aortic valve was replaced with a mechanical valve. The mitral regurgitation was repaired in 5 minutes with Alfieri technique through the aortotomy. The course of CPB was uneventful, after which the perfusionist increased the partial arterial pressure of carbon dioxide (PaCO2) level to 58 mm Hg. Infusions of adrenaline and milrinone were started electively. A Guedel airway was inserted into the patient’s mouth, and a few artificial breaths were administered to eliminate atelectasis. No signs of spontaneous respiration appeared at the termination of CBP, and naloxone (.05 mg) was given intravenously. This resulted in a gradual restoration of the respiratory function, and 5 minutes later the patient was breathing spontaneously, although he still remained unresponsive. Communication with the patient was restored during sternal closure. The patient was transferred to the postoperative intensive care unit (ICU) fully conscious, complaining only of thirst. He did not remember much of the operation. During the procedure, arterial blood gases were measured on arrival to the operating theatre, after skin incision, after sternotomy, during CPB (4 times), after termination of CPB, and every 2 hours in the postoperative ICU. The range of pH values was 7.26 to 7.51; PaO2 and PaCO2 values are shown in Figure 1. The patient’s early postoperative course was compli-
cated by a right-sided pneumothorax, which occurred 4 hours postoperatively. His further postoperative course was completely uneventful. Inotropic drugs were gradually weaned, and the patient was transferred to a medium-care unit on postoperative day 2. The patient was discharged home in a stable condition 2 weeks after the operation.
Comment Inexorably, awake cardiac operations have become an established procedure in some centers. Although this technique is clearly viable, the course of such an “awake” procedure is a real challenge for both the anesthetist and the surgeon. Randomized trials comparing awake and other anesthetic techniques for cardiac operations are rare and do not identify patients with indications for such treatment [7]. Awake cardiac operations are also very controversial. Mora Mangano’s well-known editorial [1] clearly stated, that “there is no place for this trick in the cardiac anesthesiologist’s armamentarium.” Awake procedures are performed only in a few centers. The total number of publications (currently exceeding 20) is misleading, because the authors frequently report on their continuing experience in subsequent studies. The largest series of patients to date have been reported by Karagoz and colleagues [2], Aybek and colleagues [3], Chakravarthy and colleagues [4], Stritesky and colleagues [5], and very recently by Bottio and colleagues [6]. These five studies cover more than 90% of all reported patients. What was the reasoning behind performing conscious cardiac operations in these five centers? Karagoz and colleagues [2], Aybek and colleagues [3], and Chakravarthy and colleagues [4] confirmed the feasibility and safety of this technique in patients undergoing beating heart procedures. Additional criteria may be found in the
Ann Thorac Surg 2008;86:295–7
References 1. Mora Mangano CT. Risky business. J Thorac Cardiovasc Surg 2003;125:1204 –7. 2. Karagoz HY, Kurtoglu M, Bakkaloglu B, Sonmez B, Cetintas T, Bayazit K. Coronary artery bypass grafting in the awake patient: three years’ experience in 137 patients. J Thorac Cardiovasc Surg. 2003;125:1401– 4. 3. Aybek T, Kessler P, Khan MF, et al. Operative techniques in awake coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1394 – 400. 4. Chakravarthy M, Jawali V, Manohar M, et al. Conscious off pump coronary artery bypass surgery—an audit of our first 151 cases. Ann Thorac Cardiovasc Surg 2005;11:93–7. 5. Stritesky M, Semrad M, Kunstyr J, Hajek T, Demes R, Tosovsky J. On-pump cardiac surgery in a conscious patient using a thoracic epidural anesthesia—an ultra fast track method. Bratisl Lek Listy 2004;105:51–5. 6. Bottio T, Bisleri G, Piccoli P, Negri A, Manzato A, Muneretto C. Heart valve surgery in a very high-risk population: a preliminary experience in awake patients. J Heart Valve Dis 2007;16:187–94. 7. Kessler P, Aybek T, Neidhart G, et al. Comparison of three anesthetic techniques for off-pump coronary artery bypass grafting: general anesthesia, combined general and high tho© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
295
racic epidural anesthesia, or high thoracic epidural anesthesia alone. J Cardiothorac Vasc Anesth 2005;19:32–9. 8. Samuels LE, Kaufman MS, Morris RJ, Promisloff R, Brockman SK. Coronary artery bypass grafting in patients with COPD. Chest 1998;113:878 – 82.
Severe Pulmonary Valve Incompetence Late After Debanding: Repair by Bicuspidization Engin Usta, MD, Renate Kaulitz, MD, PhD, Shahriar Salehi-Gilani, MD, Michael Hofbeck, MD, PhD, and Gerhard Ziemer, MD, PhD Departments of Thoracic, Cardiac and Vascular Surgery, and Pediatric Cardiology, Children’s Hospital, University of Tübingen, Tübingen, Germany
We report a simple valve repair for severe pulmonary incompetence in a 25-year-old patient. The patient had been operated on twice before for ventricular septal defect and coarctation of the aorta. The first operation consisted of pulmonary artery banding and coarctectomy and end-to-end anastomosis at 4 months, followed by debanding and transinfundibular ventricular septal defect closure at 6 years of age. Massive pulmonary incompetence was due to destruction of one valve cusp with the right ventricular outflow tract and pulmonary artery dilated secondarily. Repair consisted of pulmonary valve bicuspidization and right ventricular remodelling. (Ann Thorac Surg 2008;86:295–7) © 2008 by The Society of Thoracic Surgeons
P
ulmonary incompetence (PI) can be without clinical impact for a long time. Later, symptoms of right ventricular (RV) dilatation and heart failure may occur. Although the most frequent cause of PI is status posttransannular RV outflow tract (RVOT)-patch enlargement for congenital lesions, symptoms developed in the patient presented in this report after previous surgical palliation in the presence of a normal pulmonary valve and RVOT to start with. A 25-year old man presented with progressive exercise intolerance and signs of congestive cardiac failure. He had undergone an operation for patent ductus arteriosus, aortic coarctation, and pulmonary artery banding at age 4 months. After normal growth and development, he had undergone a transinfundibar ventricular septal defect (VSD) closure and PA debanding at age 6 years. The patient had an uneventful course for 18 years, when progressive dyspnea developed on exertion. Diagnostic studies consisted of echocardiography, angiograAccepted for publication Dec 3, 2007. Address correspondence to Dr Ziemer, Department of Thoracic-, Cardiacand Vascular Surgery, Eberhard-Karls-University Tübingen, HoppeSeyler-Str. 3, Tübingen, 72076, Germany; e-mail: gerhard.ziemer@med. uni-tuebingen.de.
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.12.080
FEATURE ARTICLES
remaining two series [5, 6]. Stritesky and associates [5] included patients undergoing valve procedures, suggesting that the awake technique would be efficacious for patients with preoperative pulmonary dysfunction. Bottio and coworkers [6] went one stage further: Their study was performed entirely on a high-risk population undergoing heart valve operations and combined procedures. Many patients in this group had COPD (40%), pulmonary hypertension (62%), and various other comorbidities [6]. Our patient was similar to the patients in their population. Information in the literature may sometimes be quite contradictory. The article by Bottio and colleagues [6] stated, “during valve implant patients were totally conscious and cooperative with the surgeon’s suggestions,” while “typically, after starting CPB the patients stopped breathing. . .” Proper understanding of all these “minor” technical problems is crucial for the success of the whole procedure. Such practical information may be found in our case report. The safety of cardiac anesthesia during the awake procedure may not be comparable with the safety of general anesthesia; however, we were able to achieve satisfactory arterial blood gas results throughout the procedure and in the early postoperative period. During high epidural anesthesia, each spontaneously breathing patient should be carefully monitored for bilateral Horner’s syndrome. If this occurs, infusion of local anaesthetic agents should be stopped and respiratory insufficiency may be expected [2]. Is this technique reproducible for patients with severe respiratory insufficiency? To date, no randomized trials have compared the use of awake and conventional anesthesia techniques in a high-risk population. Such studies are urgently needed, because they will be able to answer the question whether awake cardiac operations are only a temporary trend or a firmly entrenched procedure.
CASE REPORT USTA ET AL BICUSPIDIZATION REPAIR OF PI