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Cardiac tamponade due to spontaneous rupture of right coronary artery aneurysm
Ann Thorac Surg 1996;62:575-6
fail to join in the midline resulting in a complete sternal cleft [1l. This challenging deformity with the alarming pulsations of the heart a n d its u n p r o t e c t e d position necessitates p r o m p t operative correction. Most of the cases r e p o r t e d in the available literature were m a n a g e d during infancy a n d childhood [1, 3-5]. In infancy it is possible to suture the two halves of the s t e r n u m together, but operative m a n a g e m e n t at 25 years of age is difficult because of rigidity of the thoracic cage, associated abnormalities, a n d lack of space available to the intrathoracic organs if the defect were to be directly closed. The heart is less tolerant of the s u d d e n decrease in the space available to it caused b y direct closure [1]. Operative p r o c e d u r e s d e s c r i b e d earlier are excision of the sternal bars along the length of defect a n d direct closure with an encircling suture [4], c h o n d r o t o m y of involved costal cartilages, freeing of periostium from the anterior surface of sternal r e m n a n t s a n d costal cartilages, a n d oblique sliding c h o n d r o t o m i e s (Sibson, 1958) [1]. Ravitch used Teflon felt to fill the sternal gap, b u t later he used autogenous rib grafts in addition to a Teflon sheet [1]. Methyl methacrylate sandwich b e t w e e n two layers of Marlex [4] a n d an autogenous periosteal graft were used in two layers in a 5-cm-wide sternal defect [3, 6]. All these p r o c e d u r e s m a y either interfere with respiratory or mechanical functions of the rib cage, p r o d u c e u n t o w a r d reactions to synthetic materials, or p r o d u c e b r a d y c a r d i a or h y p o t e n s i o n [1, 5, 7]. By definition, in the technique of pectoralis major V-Y myoplasty, the sternocostal s e g m e n t is a d v a n c e d medially onto the s t e r n u m after splitting from the clavicular a n d external s e g m e n t of the muscle followed by closure of donor site defect in a V-to-Y fashion, preserving the function of the entire motor unit and the axillary fold [8]. Because our patient was 25 years old, our effort was to preserve the n o r m a l anatomic a n d mechanical sanctity of the thoracic cage as well as to achieve p r o p e r closure of the defect while protecting the heart and great vessels without using any synthetic material, with a good cosmetic result. We thank Mr Vijay K. Bakshi for medical illustration.
References 1. Ravitch MM. Disorder of the sternum and the thoracic wall. In: Sabiston DC Jr, Spencer FC, eds. Gibbon's surgery of the chest, 4th ed. Philadelphia: Saunders, 1983:318-60. 2. Petersen KK, Smussen OS, Jurik AG. Complete sternal cleft. Rontgenblatter 1989;42:525-6. 3. Knox L, Tuggle D, Knott-Craig CJ. Repair of congenital sternal clefts in adolescence and infancy. J Pediatr Surg 1994;29:1513-6. 4. Sabiston DC Jr. The surgical management of congenital bifid sternum with a partial ectopia cordis. J Thorac Cardiovasc Surg 1958;35:118-22. 5. Navarro Gomez A, Sanchez Diaz F, Lopez Perez GA. Complete sternal fissure. Use of autogenic grafts in modified surgery. Chir Pediatr 1985;26:44-5. 6. Valla JS, Bechraoui T, Belghith M. Congenital sternal cleft. Closed with a periosteal graft. Chir Pediatr 1989;30:219-21. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
CASE REPORT WAN ET AL TAMPONADE DUE TO ANEURYSMRUPTURE
575
7. Hummer HP, Rupprecht H. Atypical thoracic deformities: evaluation and operative sequelae. Z Orthop 1985;123:913-7. 8. Tobin GR. Pectoralis major segmental anatomy and segmentally split pectoralis major flaps. Plast Reconstruct Surg 1985; 75:814-24.
Cardiac Tamponade Due to Spontaneous Rupture of Right Coronary Artery Aneurysm Song Wan, MD, Jean-Louis LeClerc, MD, Jean-Luc Vachiery, MD, a n d Jean-Louis Vincent, MD, PhD Departments of Cardiac Surgery, Cardiology, and Intensive Care, University Hospital Erasme, Free University of Brussels, Brussels, Belgium
A case of acute cardiac tamponade caused by spontaneous rupture of a right coronary artery aneurysm is reported. The aneurysm, which was present distally, was ligated during operation. Postoperative angiography suggested the aneurysm was congenital. The patient is doing well 5 months after operation.
(Ann Thorac Surg 1996;62:575-6) oronary artery a n e u r y s m is an u n c o m m o n abnormality that has b e e n f o u n d in a r o u n d one p e r c e n t of routine autopsies [1] or coronary angiograms [2]. Although more than 80% of coronary artery a n e u r y s m s are acquired [1, 2], they can also be congenital. Most recently, r e p o r t e d cases of coronary artery a n e u r y s m s were associated with p e r c u t a n e o u s transluminal coronary angioplasty or directional coronary atherectomy [3]. Rupture of a coronary artery a n e u r y s m is very rare [1-3], a n d has b e e n r e p o r t e d w h e n it resulted in false a n e u r y s m [4, 5] or fistulous connection to the right atrium or ventricle [6, 7]. We successfully treated a patient who p r e s e n t e d with acute cardiac t a m p o n a d e caused by s p o n t a n e o u s r u p t u r e of a coronary artery aneurysm.
C
A 49-year-old m a n with no prior cardiac or traumatic history was a d m i t t e d in the early morning, 3 hours after he started to experience mild chest a n d u p p e r a b d o m i n a l pain with malaise. The s y m p t o m s woke him from sleep a n d were r a p i d l y followed by dyspnea. On admission, the heart rate was 130 b e a t s / m i n in sinus rhythm. Peripheral arterial blood p r e s s u r e was 95/70 m m Hg. No cardiac m u r m u r was audible. Electrocardiogram s h o w e d low voltage b u t no evidence of myocardial ischemia. Chest r o e n t g e n o g r a p h y s h o w e d mediastinal widening. Comp u t e d t o m o g r a p h i c scanning revealed a pericardial effusion (Fig 1), a n d some contrast images in the aorta were compatible with an aortic dissection, although this diagAccepted for publication Feb 27, 1996. Address reprint requests to Dr LeClerc, Department of Cardiac Surgery, University,Hospital Erasme, Free University of Brussels, Route de Lennik 808, B-1070, Brussels, Belgium. 0003-4975/96/$15.00 PII S0003-4975(96)00249-4
576
CASEREPORT WAN ET AL TAMPONADEDUE TO ANEURYSMRUPTURE
Fig 1. Preoperative computed tomographic scanning revealed pericardial effusion.
nosis was far from ascertained. Transesophageal echocardiography showed signs of cardiac t a m p o n a d e but no evidence of aortic dissection. The patient's blood pressure dropped to 70/40 m m Hg, so d o p a m i n e administration was started and an emergency operation was decided on. As the patient was prepared for operation of aortic dissection, cooling to 20°C was obtained after the institution of cardiopulmonary bypass through the femoral vessels. A m e d i a n sternotomy was performed. The pericardial sac contained about 400 mL of blood a n d clot. However, the aorta was normal. Active arterial bleeding was seen at the distal part of the marginal branch of the right coronary artery, through the rupture of a small a n e u r y s m whose diameter was about twice the diameter of that coronary branch. The wall of the a n e u r y s m was extremely thin. Because the a n e u r y s m was present distally on a relatively small coronary vessel the a n e u r y s m was then simply ligated on the beating heart with a 7-0 r u n n i n g mattress suture. The patient's postoperative recovery was uneventful. Daily electrocardiogram showed no evidence of myocardial infarction. The concentration of the MB fraction of creatine kinase rose to 42 IU/L after operation b u t ret u r n e d to normal on the third postoperative day. Eight days after the operation, the patient u n d e r w e n t a coronary angiogram that showed normal left and right coronary arteries. The patient was discharged on the 9th postoperative day. He is in normal condition 5 months after the operation.
Comment A coronary artery a n e u r y s m can be defined as a coronary dilatation that exceeds by 1.5 times the diameter of normal adjacent segments [3]. Coronary artery a n e u -
Ann Thorac Surg 1996;62:575-6
rysms may be classified as acquired or congenital. It has b e e n found that atherosclerosis was a p r e d o m i n a n t cause in the majority, w h e r e a s congenital a n e u r y s m s accounted for less than 20% of all cases [1, 2]. Spontaneous rupture of an atherosclerotic coronary artery has b e e n discovered at autopsy as a cause of cardiac tamponade, but no coronary a n e u r y s m was found [8]. In general, s p o n t a n e o u s rupture of a coronary artery a n e u r y s m is rare because an atherosclerotic a n e u r y s m is a true, usually thick-walled a n e u r y s m [1-3]. Hence, the presence of an atherosclerotic a n e u r y s m is not considered as a surgical indication [3]. However, a congenital coronary artery a n e u r y s m is often large a n d situated on one coronary artery, a n d is c o m m o n l y f o u n d in a y o u n g patient [1, 4, 6, 7]. A congenital a n e u r y s m appears prone to rupture, a n d this usually occurs on the right coronary artery [2, 6, 7], so its recognition may indicate surgical intervention. In the case presented here, the origin of the coronary a n e u r y s m is most likely congenital, as the other parts of the coronary tree were normal. It is possible that some patients may have died after acute cardiac t a m p o n a d e secondary to s p o n t a n e o u s rupture of a coronary artery a n e u r y s m without a correct diagnosis. The occurrence of cardiac t a m p o n a d e in a relatively y o u n g patient without prior cardiac or traumatic history should raise the possibility of spontaneous rupture of a coronary artery a n e u r y s m or perforation of a coronary vessel, imposing an emergency surgical intervention. W h e n the diagnosis is uncertain, the support of cardiopulmonary bypass via femoral c a n n u l a t i o n could be r e c o m m e n d e d . W h e n the a n e u r y s m is located on the proximal portion of the coronary vessel, ligation or plication of the a n e u r y s m should be followed by distal bypass with arterial or venous graft [3].
References 1. Daoud AS, Pankin D, Tulgan H, Florentin RA. Aneurysms of the coronary artery: report of ten cases and review of the literature. Am J Cardiol 1963;11:228-37. 2. Letac B, Cazor JL, Cribier A, Sibille C, Toussaint C, Large multiple coronary artery aneurysm in adult patients: a report on three patients and a review of the literature. Am Heart J 1980;99:694-700. 3. Dralle JG, Turner C, Hsu J, Replogle RL. Coronary artery aneurysms after angioplasty and atherectomy. Ann Thorac Surg 1995;59:1030-5. 4. Chun PKC, Davia JE, Cheitlin MD, Green DC, Bowen TE, Brott WH. Giant coronary pseudoaneurysm: five-year follow-up after bypass grafting. J Thorac Cardiovasc Surg 1981; 81:92-5. 5. Hearne SF, Holmes DR Jr, Pluth JR, Lie JT. False aneurysm of the left coronary artery. J Thorac Cardiovasc Surg 1981;82: 915-21. 6. Chapman RWG, Watkins J. Rupture of right coronary artery aneurysm into the right atrium. Br Heart J 1978;40:938-9. 7. Wright JS, McCredie RM, Horton DA, Bennett DJ. Giant right coronary artery, aneurysm with fistula in childhood. J Thorac Cardiovasc Surg 1971;61:242-5. 8. Semple T, Williams BO, Baxter RH. Spontaneous coronary artery perforation with tamponade: demonstration by necropsy selective coronary arteriography. Br Heart J 1978;40: 1423-5.
fail to join in the midline resulting in a complete sternal cleft [1l. This challenging deformity with the alarming pulsations of the heart a n d its u n p r o t e c t e d position necessitates p r o m p t operative correction. Most of the cases r e p o r t e d in the available literature were m a n a g e d during infancy a n d childhood [1, 3-5]. In infancy it is possible to suture the two halves of the s t e r n u m together, but operative m a n a g e m e n t at 25 years of age is difficult because of rigidity of the thoracic cage, associated abnormalities, a n d lack of space available to the intrathoracic organs if the defect were to be directly closed. The heart is less tolerant of the s u d d e n decrease in the space available to it caused b y direct closure [1]. Operative p r o c e d u r e s d e s c r i b e d earlier are excision of the sternal bars along the length of defect a n d direct closure with an encircling suture [4], c h o n d r o t o m y of involved costal cartilages, freeing of periostium from the anterior surface of sternal r e m n a n t s a n d costal cartilages, a n d oblique sliding c h o n d r o t o m i e s (Sibson, 1958) [1]. Ravitch used Teflon felt to fill the sternal gap, b u t later he used autogenous rib grafts in addition to a Teflon sheet [1]. Methyl methacrylate sandwich b e t w e e n two layers of Marlex [4] a n d an autogenous periosteal graft were used in two layers in a 5-cm-wide sternal defect [3, 6]. All these p r o c e d u r e s m a y either interfere with respiratory or mechanical functions of the rib cage, p r o d u c e u n t o w a r d reactions to synthetic materials, or p r o d u c e b r a d y c a r d i a or h y p o t e n s i o n [1, 5, 7]. By definition, in the technique of pectoralis major V-Y myoplasty, the sternocostal s e g m e n t is a d v a n c e d medially onto the s t e r n u m after splitting from the clavicular a n d external s e g m e n t of the muscle followed by closure of donor site defect in a V-to-Y fashion, preserving the function of the entire motor unit and the axillary fold [8]. Because our patient was 25 years old, our effort was to preserve the n o r m a l anatomic a n d mechanical sanctity of the thoracic cage as well as to achieve p r o p e r closure of the defect while protecting the heart and great vessels without using any synthetic material, with a good cosmetic result. We thank Mr Vijay K. Bakshi for medical illustration.
References 1. Ravitch MM. Disorder of the sternum and the thoracic wall. In: Sabiston DC Jr, Spencer FC, eds. Gibbon's surgery of the chest, 4th ed. Philadelphia: Saunders, 1983:318-60. 2. Petersen KK, Smussen OS, Jurik AG. Complete sternal cleft. Rontgenblatter 1989;42:525-6. 3. Knox L, Tuggle D, Knott-Craig CJ. Repair of congenital sternal clefts in adolescence and infancy. J Pediatr Surg 1994;29:1513-6. 4. Sabiston DC Jr. The surgical management of congenital bifid sternum with a partial ectopia cordis. J Thorac Cardiovasc Surg 1958;35:118-22. 5. Navarro Gomez A, Sanchez Diaz F, Lopez Perez GA. Complete sternal fissure. Use of autogenic grafts in modified surgery. Chir Pediatr 1985;26:44-5. 6. Valla JS, Bechraoui T, Belghith M. Congenital sternal cleft. Closed with a periosteal graft. Chir Pediatr 1989;30:219-21. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science lnc
CASE REPORT WAN ET AL TAMPONADE DUE TO ANEURYSMRUPTURE
575
7. Hummer HP, Rupprecht H. Atypical thoracic deformities: evaluation and operative sequelae. Z Orthop 1985;123:913-7. 8. Tobin GR. Pectoralis major segmental anatomy and segmentally split pectoralis major flaps. Plast Reconstruct Surg 1985; 75:814-24.
Cardiac Tamponade Due to Spontaneous Rupture of Right Coronary Artery Aneurysm Song Wan, MD, Jean-Louis LeClerc, MD, Jean-Luc Vachiery, MD, a n d Jean-Louis Vincent, MD, PhD Departments of Cardiac Surgery, Cardiology, and Intensive Care, University Hospital Erasme, Free University of Brussels, Brussels, Belgium
A case of acute cardiac tamponade caused by spontaneous rupture of a right coronary artery aneurysm is reported. The aneurysm, which was present distally, was ligated during operation. Postoperative angiography suggested the aneurysm was congenital. The patient is doing well 5 months after operation.
(Ann Thorac Surg 1996;62:575-6) oronary artery a n e u r y s m is an u n c o m m o n abnormality that has b e e n f o u n d in a r o u n d one p e r c e n t of routine autopsies [1] or coronary angiograms [2]. Although more than 80% of coronary artery a n e u r y s m s are acquired [1, 2], they can also be congenital. Most recently, r e p o r t e d cases of coronary artery a n e u r y s m s were associated with p e r c u t a n e o u s transluminal coronary angioplasty or directional coronary atherectomy [3]. Rupture of a coronary artery a n e u r y s m is very rare [1-3], a n d has b e e n r e p o r t e d w h e n it resulted in false a n e u r y s m [4, 5] or fistulous connection to the right atrium or ventricle [6, 7]. We successfully treated a patient who p r e s e n t e d with acute cardiac t a m p o n a d e caused by s p o n t a n e o u s r u p t u r e of a coronary artery aneurysm.
C
A 49-year-old m a n with no prior cardiac or traumatic history was a d m i t t e d in the early morning, 3 hours after he started to experience mild chest a n d u p p e r a b d o m i n a l pain with malaise. The s y m p t o m s woke him from sleep a n d were r a p i d l y followed by dyspnea. On admission, the heart rate was 130 b e a t s / m i n in sinus rhythm. Peripheral arterial blood p r e s s u r e was 95/70 m m Hg. No cardiac m u r m u r was audible. Electrocardiogram s h o w e d low voltage b u t no evidence of myocardial ischemia. Chest r o e n t g e n o g r a p h y s h o w e d mediastinal widening. Comp u t e d t o m o g r a p h i c scanning revealed a pericardial effusion (Fig 1), a n d some contrast images in the aorta were compatible with an aortic dissection, although this diagAccepted for publication Feb 27, 1996. Address reprint requests to Dr LeClerc, Department of Cardiac Surgery, University,Hospital Erasme, Free University of Brussels, Route de Lennik 808, B-1070, Brussels, Belgium. 0003-4975/96/$15.00 PII S0003-4975(96)00249-4
576
CASEREPORT WAN ET AL TAMPONADEDUE TO ANEURYSMRUPTURE
Fig 1. Preoperative computed tomographic scanning revealed pericardial effusion.
nosis was far from ascertained. Transesophageal echocardiography showed signs of cardiac t a m p o n a d e but no evidence of aortic dissection. The patient's blood pressure dropped to 70/40 m m Hg, so d o p a m i n e administration was started and an emergency operation was decided on. As the patient was prepared for operation of aortic dissection, cooling to 20°C was obtained after the institution of cardiopulmonary bypass through the femoral vessels. A m e d i a n sternotomy was performed. The pericardial sac contained about 400 mL of blood a n d clot. However, the aorta was normal. Active arterial bleeding was seen at the distal part of the marginal branch of the right coronary artery, through the rupture of a small a n e u r y s m whose diameter was about twice the diameter of that coronary branch. The wall of the a n e u r y s m was extremely thin. Because the a n e u r y s m was present distally on a relatively small coronary vessel the a n e u r y s m was then simply ligated on the beating heart with a 7-0 r u n n i n g mattress suture. The patient's postoperative recovery was uneventful. Daily electrocardiogram showed no evidence of myocardial infarction. The concentration of the MB fraction of creatine kinase rose to 42 IU/L after operation b u t ret u r n e d to normal on the third postoperative day. Eight days after the operation, the patient u n d e r w e n t a coronary angiogram that showed normal left and right coronary arteries. The patient was discharged on the 9th postoperative day. He is in normal condition 5 months after the operation.
Comment A coronary artery a n e u r y s m can be defined as a coronary dilatation that exceeds by 1.5 times the diameter of normal adjacent segments [3]. Coronary artery a n e u -
Ann Thorac Surg 1996;62:575-6
rysms may be classified as acquired or congenital. It has b e e n found that atherosclerosis was a p r e d o m i n a n t cause in the majority, w h e r e a s congenital a n e u r y s m s accounted for less than 20% of all cases [1, 2]. Spontaneous rupture of an atherosclerotic coronary artery has b e e n discovered at autopsy as a cause of cardiac tamponade, but no coronary a n e u r y s m was found [8]. In general, s p o n t a n e o u s rupture of a coronary artery a n e u r y s m is rare because an atherosclerotic a n e u r y s m is a true, usually thick-walled a n e u r y s m [1-3]. Hence, the presence of an atherosclerotic a n e u r y s m is not considered as a surgical indication [3]. However, a congenital coronary artery a n e u r y s m is often large a n d situated on one coronary artery, a n d is c o m m o n l y f o u n d in a y o u n g patient [1, 4, 6, 7]. A congenital a n e u r y s m appears prone to rupture, a n d this usually occurs on the right coronary artery [2, 6, 7], so its recognition may indicate surgical intervention. In the case presented here, the origin of the coronary a n e u r y s m is most likely congenital, as the other parts of the coronary tree were normal. It is possible that some patients may have died after acute cardiac t a m p o n a d e secondary to s p o n t a n e o u s rupture of a coronary artery a n e u r y s m without a correct diagnosis. The occurrence of cardiac t a m p o n a d e in a relatively y o u n g patient without prior cardiac or traumatic history should raise the possibility of spontaneous rupture of a coronary artery a n e u r y s m or perforation of a coronary vessel, imposing an emergency surgical intervention. W h e n the diagnosis is uncertain, the support of cardiopulmonary bypass via femoral c a n n u l a t i o n could be r e c o m m e n d e d . W h e n the a n e u r y s m is located on the proximal portion of the coronary vessel, ligation or plication of the a n e u r y s m should be followed by distal bypass with arterial or venous graft [3].
References 1. Daoud AS, Pankin D, Tulgan H, Florentin RA. Aneurysms of the coronary artery: report of ten cases and review of the literature. Am J Cardiol 1963;11:228-37. 2. Letac B, Cazor JL, Cribier A, Sibille C, Toussaint C, Large multiple coronary artery aneurysm in adult patients: a report on three patients and a review of the literature. Am Heart J 1980;99:694-700. 3. Dralle JG, Turner C, Hsu J, Replogle RL. Coronary artery aneurysms after angioplasty and atherectomy. Ann Thorac Surg 1995;59:1030-5. 4. Chun PKC, Davia JE, Cheitlin MD, Green DC, Bowen TE, Brott WH. Giant coronary pseudoaneurysm: five-year follow-up after bypass grafting. J Thorac Cardiovasc Surg 1981; 81:92-5. 5. Hearne SF, Holmes DR Jr, Pluth JR, Lie JT. False aneurysm of the left coronary artery. J Thorac Cardiovasc Surg 1981;82: 915-21. 6. Chapman RWG, Watkins J. Rupture of right coronary artery aneurysm into the right atrium. Br Heart J 1978;40:938-9. 7. Wright JS, McCredie RM, Horton DA, Bennett DJ. Giant right coronary artery, aneurysm with fistula in childhood. J Thorac Cardiovasc Surg 1971;61:242-5. 8. Semple T, Williams BO, Baxter RH. Spontaneous coronary artery perforation with tamponade: demonstration by necropsy selective coronary arteriography. Br Heart J 1978;40: 1423-5.