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Complex Thoracic Vascular Injury Repair Using Deep Hypothermia and Circulatory Arrest
Ann Thorac Surg 1997;63:557–9
CASE REPORT FULTON AND BRINK COMPLEX VASCULAR INJURY
557
Complex Thoracic Vascular Injury Repair Using Deep Hypothermia and Circulatory Arrest James O. Fulton, FCS(SA) , and Johan G. Brink, FCS(SA) Department of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
A 61-year-old man with a penetrating injury to the innominate artery, left common carotid artery, and left subclavian artery at their origins from the aortic arch with associated injuries to both innominate veins and an innominate artery to vein fistula after a single stab wound is described. The patient was managed successfully using cardiopulmonary bypass together with deep hypothermia and circulatory arrest. Presentation and management are discussed. (Ann Thorac Surg 1997;63:557–9) © 1997 by The Society of Thoracic Surgeons
F
ew patients with extensive injuries to the major arterial structures at the thoracic inlet have been reported, as rapid exsanguination into the pleural cavity or externally through the wound usually follows [1– 4]. Injuries of the aortic arch vessels close to their origins are particularly difficult to control and cardiopulmonary bypass with systemic hypothermia is an important adjunct to ensure a successful outcome [1, 3, 4]. We describe a patient with involvement of all three branches of the aortic arch and of both the major veins of the thoracic inlet who was managed successfully. A 61-year-old man was referred to the Department of Cardiothoracic Surgery at Groote Schuur Hospital, University of Cape Town from a peripheral hospital after a stab wound to his right chest at the level of the second right intercostal space parasternally. On arrival at our hospital 28 hours after injury he was hemodynamically stable with a continuous murmur at the right parasternal border and the chest roentgenogram revealed a widened mediastinum with evidence of previous lung and pleural disease involving the right lung (Fig 1). Eighteen years previously he had undergone a right thoracotomy for empyema thoracis. An aortic arch angiogram was ordered and is illustrated in Figure 2, showing the extensive vascular injuries. The patient was taken to the operating room, and under general anesthesia, the left femoral vein and artery were exposed. The vessels were cannulated and cardiopulmonary bypass with systemic hypothermia was com-
Accepted for publication Aug 16, 1996. Address reprint requests to Dr Brink, Department of Cardiothoracic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town 7925, South Africa.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Chest radiograph showing the massively widened mediastinum with evidence of fibrosis of the right lung with marked pleural thickening.
menced. Inadequate venous drainage resulted in only 50% of target pump flows being used initially but systemic perfusion pressures remained adequate during initial cooling. Ventricular fibrillation occurred at 28°C,
Fig 2. Arch angiogram illustrating all the injuries: (1) right innominate vein, (2) innominate artery false aneurysm with innominate artery to left innominate vein fistula with opacification of the great veins, (3) false aneurysm of the origin of the left common carotid artery, and (4) false aneurysm of the origin of the left subclavian artery. 0003-4975/97/$17.00 PII S0003-4975(96)01110-1
558
CASE REPORT FULTON AND BRINK COMPLEX VASCULAR INJURY
which necessitated immediate median sternotomy due to systemic hypotension. Torrential hemorrhage was encountered, and a brief period of circulatory arrest was needed to allow insertion of a second venous cannula into the right atrium. Full cardiopulmonary bypass was then resumed with digital compression of the bleeding areas with cooling to 20°C. Active hemorrhage continued during this cooling phase. At 20°C, circulatory arrest was resumed and the ascending aorta was cross-clamped and cold crystalloid cardioplegia was administered through the aortic root. The innominate artery was lacerated through two thirds of its circumference and the left common carotid and left subclavian arteries sustained through and through lacerations in close proximity to their origins from the aortic arch. The left innominate vein was lacerated in close proximity to the innominate artery laceration, resulting in an arteriovenous fistula, and the right innominate vein was lacerated at the site of entry of the subclavian vein. Adequate exposure for repair of the arterial injuries could not be accomplished from an extraluminal approach because of the proximity of the injuries to their origins from the aortic arch and extensive hematoma in the adventitial planes. An anterior longitudinal incision in the aortic arch incorporating the innominate artery laceration was used to facilitate transluminal repair. The lacerations in the subclavian and carotid arteries were repaired with continuous 5/0 polypropylene sutures from inside the aortic lumen, and the innominate artery repair was included in the closure of the aortotomy incision using 4/0 polypropylene. Before this aortotomy suture was tied, the patient was placed in steep Trendelenberg position and cardiopulmonary bypass was recommenced at low flow to facilitate deairing of the aorta and head and neck vessels. Full cardiopulmonary bypass was then reinstituted with rewarming to normothermia, and the aortic cross-clamp was released. Repair of the innominate veins was then accomplished using 5/0 polypropylene sutures. The right internal mammary vein, which was also lacerated, was ligated. At a temperature of 25°C normal sinus cardiac rhythm ensued, and weaning off cardiopulmonary bypass occurred at normothermia without difficulty. Decannulation of the right atrium and femoral vessels followed. Closure of the sternum and groin incisions was accomplished in routine fashion. Total circulatory arrest time was 40 minutes. The patient was ventilated overnight and was extubated the following morning with no neurologic deficit apparent. His recovery was otherwise uneventful, and he was discharged home on the 10th postoperative day. At a follow-up visit 2 weeks later he remained in good health.
Comment Injuries to the major vascular structures of the thoracic inlet are well described [1–5]. Complex injuries similar to the one described in this patient are exceedingly rare and usually cannot be repaired without the adjunct of cardiopulmonary bypass. The usual mode of presentation is that of hypovolemic shock and rapid exsanguination at
Ann Thorac Surg 1997;63:557–9
the scene of injury, and even with rapid resuscitation and transport facilities, the likelihood of survival is remote. The presence of dense pleural adhesions in his right chest from the previous suppurative lung disease and subsequent thoracotomy probably prevented exsanguination in this patient. A massive mediastinal hematoma tamponaded further bleeding. We also speculate that the arteriovenous fistula between the innominate artery and left innominate vein resulted in reduction of the tendency of these vessels to bleed further into the mediastinum. Hemodynamic stability allowed angiography to delineate the severe nature of his injuries. Without this knowledge, rapid demise due to bleeding would certainly have followed median sternotomy. Even on cardiopulmonary bypass, torrential hemorrhage was encountered at sternotomy necessitating the use of deep hypothermia and periods of circulatory arrest. This technique has found increasing use since first instituted for aortic operation in adults by Griepp and colleagues [6] and provides for a safe period of 45 minutes of circulatory arrest. The extension of this safe period of arrest with antegrade or retrograde cerebral perfusion could not be accomplished in this patient due to the extensive nature of his arterial and venous injuries and surrounding hematoma. Cardiopulmonary bypass with systemic hypothermia is also advised in patients in whom occlusion of both innominate and left common carotid arteries with interruption of cerebral blood flow is anticipated, as well as in injuries close to origins of the head and neck vessels from the aortic arch. Major injury to the aortic arch itself usually requires cardiopulmonary bypass with deep hypothermia and periods of circulatory arrest for successful repair [1, 4]. Unfortunately in unstable patients, other techniques have to be used as rapid institution of cardiopulmonary bypass is not possible in many trauma operating rooms [1, 3, 4]. The repair of the lacerations to the origins of these vessels could only be accomplished with the use of deep hypothermia and circulatory arrest as extensive hemorrhage and hematoma prevented adequate exposure of the vessels and their sites of injury while the circulation was maintained. The use of a transluminal approach in this patient resulted in superior exposure of the injuries and thus greatly facilitated repair. Extensive mobilization of the periaortic soft tissues to identify the sites of injury in the extensive surrounding hematoma is often difficult and can result in injury to nonvascular structures. Injuries to the posterior aortic wall (including through and through injuries) and the inferior surface of the aortic arch could also be repaired in this fashion. In conclusion, we recommend cardiopulmonary bypass and deep hypothermia and circulatory arrest in the management of complex vascular injuries of the thoracic inlet with angiography to allow adequate planning of operation in the patient who is hemodynamically stable. In the unstable patient, when such extensive injury is suspected, the expeditious institution of femorofemoral cardiopulmonary bypass (without previous angiography) with systemic cooling, deep hypothermia, and circulatory arrest and the identification and repair of vascular inju-
Ann Thorac Surg 1997;63:559 – 60
ries may be the only recourse for a successful outcome. When isolated single major vascular injuries of the thoracic inlet are confirmed on angiography, these can be repaired without the adjunct of cardiopulmonary bypass [1– 4].
References 1. Pate JW, Cole FH, Walker WA, et al. Penetrating injuries of the aortic arch and its branches. Ann Thorac Surg 1993;55: 586–92. 2. Johnston RH, Wall MJ, Mattox KL, et al. Innominate artery trauma: a 30 year experience. J Vasc Surg 1993:17:134– 40. 3. Buchan K, Robbs J. Surgical management of penetrating mediastinal arterial trauma. Eur J Cardio-Thorac Surg 1995:9: 90– 4. 4. Fulton JO, De Groot KM, Buckels NJ, von Oppell UO. Penetrating injuries involving the intrathoracic great vessels. South Afr J Surg(in press). 5. Mattox KM, Feliciano DV, Burch J, Beall AC, Jordan GL, De Bakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients— epidemiologic evolution 1958 to 1987. Ann Surg 1989;209:698 –705. 6. Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975; 70:1051– 65.
Technique for Reconstruction of the Sinotubular Junction Gopal Bhatnagar, MD, George T. Christakis, MD, Patricia M. Murphy, MD, Donald Oxorn, MD, and Bernard S. Goldman, MD Divisions of Cardiovascular Surgery and Anesthesia, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
Correct geometric relationships between the annulus and sinotubular junction during stentless valve implantation are critical to minimize the development of insufficiency. Some patients with aortic valve disease have dilatation of the sinotubular junction and are unable to have a stentless valve placed by standard techniques. We recently encountered such a patient and reconstructed the sinotubular junction by aortic crenation. Multiple interrupted plicating sutures were used to reduce the aorta from a diameter of 42 mm to 28 mm. This method allows tailoring of the aorta to appropriate size by varying the number of crenating sutures. (Ann Thorac Surg 1997;63:559 – 60) © 1997 by The Society of Thoracic Surgeons
T
he development of the stentless bioprosthesis for aortic valve replacement has provided a readily available alternative to homograft and stented valves [1–3]. Although the stentless bioprosthesis has superior
Accepted for publication Sep 26, 1996. Address reprint requests to Dr Bhatnagar, Division of Cardiovascular Surgery, Sunnybrook Health Science Centre, 2075 Bayview Ave 429, Toronto, ON, M4N 3M5, Canada.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT BHATNAGAR ET AL RECONSTRUCTION OF SINOTUBULAR JUNCTION
559
hemodynamics compared with a stented prosthesis [3, 4] and theoretic advantages in terms of left ventricular remodeling [4 – 6], the relationship between the valve annulus and the sinotubular junction (STJ) is an important factor in determining long-term competence [1, 5, 7–10]. In some instances patients who may otherwise be candidates for a stentless valve receive a stented valve because of large discrepancies between annular and sinotubular size [11]. Recently a 78-year-old woman with class III symptoms referable to her aortic stenosis was accepted for Stentless Porcine Valve (SPV) placement (Toronto SPV; St. Jude Medical, St. Paul, MN). Transesophageal echocardiography, however revealed an indistinct native STJ judged to be 29 mm, whereas the annulus was 27 mm. Additionally, the distance between the valve annulus and the presumed STJ was short, with the aorta above rapidly expanding to 42 mm. Intraoperative sizing revealed an enlarged STJ at 30 mm and an annulus appropriate for a 29-mm SPV. We decided to place the SPV and reconstruct a sinotubular junction as the patient had marked left ventricular hypertrophy and she required the maximum relief from left ventricular outflow tract obstruction that a bioprosthesis could provide. Complete aortic reconstruction or replacement was not considered as the maximum diameter was 42 mm and it was thought that potential morbidity would be high. Aortic cannulation was carried out toward the lesser curvature of the aorta close to the inominate artery takeoff, allowing a high aortotomy to be performed. Careful dissection of the pulmonary artery from a generous portion of the aorta was carried out with particular attention to the left mainstem origin. Anteriorly the root of the aorta was dissected until the takeoff of the right coronary artery was identified. After aortic cross-clamping, a transverse aortotomy was performed high enough above the right coronary artery takeoff to accommodate the SPV commissural posts and approximately 5 to 6 mm above the native STJ. The cut was made in a plane perpendicular to the direction of the aorta and carried down until only 2 cm of aorta remained in continuity posteriorly. The 29 mm valve was implanted using the standard techniques as described elsewhere [2, 4, 7]. Remodeling of the sinotubular junction was carried out during aortotomy closure (Fig 1). Plicating sutures were placed using 4-0 Prolene (Ethicon, Somerville, NJ), with each suture visually judged to crenate approximately 5 mm of aortic wall. Initially the aortotomy was bisected and each half of the remaining aortotomy was again bisected. No pledgets were used for the interrupted horizontal mattress plicating sutures. The aortotomy closure was initiated as a plicating suture using a Teflon pledgeted 4-0 Prolene suture and was performed using a two-layer McGoon-type closure (horizontal mattress with an over-and-over whip suture). A total of five plicating sutures were placed on each side of the aortotomy. Transesophageal echocardiography was carried out after separation from bypass, and the remodeled STJ was clearly visible, measuring 28 mm. This neo-STJ repre0003-4975/97/$17.00 PII S0003-4975(96)01036-3
CASE REPORT FULTON AND BRINK COMPLEX VASCULAR INJURY
557
Complex Thoracic Vascular Injury Repair Using Deep Hypothermia and Circulatory Arrest James O. Fulton, FCS(SA) , and Johan G. Brink, FCS(SA) Department of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
A 61-year-old man with a penetrating injury to the innominate artery, left common carotid artery, and left subclavian artery at their origins from the aortic arch with associated injuries to both innominate veins and an innominate artery to vein fistula after a single stab wound is described. The patient was managed successfully using cardiopulmonary bypass together with deep hypothermia and circulatory arrest. Presentation and management are discussed. (Ann Thorac Surg 1997;63:557–9) © 1997 by The Society of Thoracic Surgeons
F
ew patients with extensive injuries to the major arterial structures at the thoracic inlet have been reported, as rapid exsanguination into the pleural cavity or externally through the wound usually follows [1– 4]. Injuries of the aortic arch vessels close to their origins are particularly difficult to control and cardiopulmonary bypass with systemic hypothermia is an important adjunct to ensure a successful outcome [1, 3, 4]. We describe a patient with involvement of all three branches of the aortic arch and of both the major veins of the thoracic inlet who was managed successfully. A 61-year-old man was referred to the Department of Cardiothoracic Surgery at Groote Schuur Hospital, University of Cape Town from a peripheral hospital after a stab wound to his right chest at the level of the second right intercostal space parasternally. On arrival at our hospital 28 hours after injury he was hemodynamically stable with a continuous murmur at the right parasternal border and the chest roentgenogram revealed a widened mediastinum with evidence of previous lung and pleural disease involving the right lung (Fig 1). Eighteen years previously he had undergone a right thoracotomy for empyema thoracis. An aortic arch angiogram was ordered and is illustrated in Figure 2, showing the extensive vascular injuries. The patient was taken to the operating room, and under general anesthesia, the left femoral vein and artery were exposed. The vessels were cannulated and cardiopulmonary bypass with systemic hypothermia was com-
Accepted for publication Aug 16, 1996. Address reprint requests to Dr Brink, Department of Cardiothoracic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town 7925, South Africa.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Chest radiograph showing the massively widened mediastinum with evidence of fibrosis of the right lung with marked pleural thickening.
menced. Inadequate venous drainage resulted in only 50% of target pump flows being used initially but systemic perfusion pressures remained adequate during initial cooling. Ventricular fibrillation occurred at 28°C,
Fig 2. Arch angiogram illustrating all the injuries: (1) right innominate vein, (2) innominate artery false aneurysm with innominate artery to left innominate vein fistula with opacification of the great veins, (3) false aneurysm of the origin of the left common carotid artery, and (4) false aneurysm of the origin of the left subclavian artery. 0003-4975/97/$17.00 PII S0003-4975(96)01110-1
558
CASE REPORT FULTON AND BRINK COMPLEX VASCULAR INJURY
which necessitated immediate median sternotomy due to systemic hypotension. Torrential hemorrhage was encountered, and a brief period of circulatory arrest was needed to allow insertion of a second venous cannula into the right atrium. Full cardiopulmonary bypass was then resumed with digital compression of the bleeding areas with cooling to 20°C. Active hemorrhage continued during this cooling phase. At 20°C, circulatory arrest was resumed and the ascending aorta was cross-clamped and cold crystalloid cardioplegia was administered through the aortic root. The innominate artery was lacerated through two thirds of its circumference and the left common carotid and left subclavian arteries sustained through and through lacerations in close proximity to their origins from the aortic arch. The left innominate vein was lacerated in close proximity to the innominate artery laceration, resulting in an arteriovenous fistula, and the right innominate vein was lacerated at the site of entry of the subclavian vein. Adequate exposure for repair of the arterial injuries could not be accomplished from an extraluminal approach because of the proximity of the injuries to their origins from the aortic arch and extensive hematoma in the adventitial planes. An anterior longitudinal incision in the aortic arch incorporating the innominate artery laceration was used to facilitate transluminal repair. The lacerations in the subclavian and carotid arteries were repaired with continuous 5/0 polypropylene sutures from inside the aortic lumen, and the innominate artery repair was included in the closure of the aortotomy incision using 4/0 polypropylene. Before this aortotomy suture was tied, the patient was placed in steep Trendelenberg position and cardiopulmonary bypass was recommenced at low flow to facilitate deairing of the aorta and head and neck vessels. Full cardiopulmonary bypass was then reinstituted with rewarming to normothermia, and the aortic cross-clamp was released. Repair of the innominate veins was then accomplished using 5/0 polypropylene sutures. The right internal mammary vein, which was also lacerated, was ligated. At a temperature of 25°C normal sinus cardiac rhythm ensued, and weaning off cardiopulmonary bypass occurred at normothermia without difficulty. Decannulation of the right atrium and femoral vessels followed. Closure of the sternum and groin incisions was accomplished in routine fashion. Total circulatory arrest time was 40 minutes. The patient was ventilated overnight and was extubated the following morning with no neurologic deficit apparent. His recovery was otherwise uneventful, and he was discharged home on the 10th postoperative day. At a follow-up visit 2 weeks later he remained in good health.
Comment Injuries to the major vascular structures of the thoracic inlet are well described [1–5]. Complex injuries similar to the one described in this patient are exceedingly rare and usually cannot be repaired without the adjunct of cardiopulmonary bypass. The usual mode of presentation is that of hypovolemic shock and rapid exsanguination at
Ann Thorac Surg 1997;63:557–9
the scene of injury, and even with rapid resuscitation and transport facilities, the likelihood of survival is remote. The presence of dense pleural adhesions in his right chest from the previous suppurative lung disease and subsequent thoracotomy probably prevented exsanguination in this patient. A massive mediastinal hematoma tamponaded further bleeding. We also speculate that the arteriovenous fistula between the innominate artery and left innominate vein resulted in reduction of the tendency of these vessels to bleed further into the mediastinum. Hemodynamic stability allowed angiography to delineate the severe nature of his injuries. Without this knowledge, rapid demise due to bleeding would certainly have followed median sternotomy. Even on cardiopulmonary bypass, torrential hemorrhage was encountered at sternotomy necessitating the use of deep hypothermia and periods of circulatory arrest. This technique has found increasing use since first instituted for aortic operation in adults by Griepp and colleagues [6] and provides for a safe period of 45 minutes of circulatory arrest. The extension of this safe period of arrest with antegrade or retrograde cerebral perfusion could not be accomplished in this patient due to the extensive nature of his arterial and venous injuries and surrounding hematoma. Cardiopulmonary bypass with systemic hypothermia is also advised in patients in whom occlusion of both innominate and left common carotid arteries with interruption of cerebral blood flow is anticipated, as well as in injuries close to origins of the head and neck vessels from the aortic arch. Major injury to the aortic arch itself usually requires cardiopulmonary bypass with deep hypothermia and periods of circulatory arrest for successful repair [1, 4]. Unfortunately in unstable patients, other techniques have to be used as rapid institution of cardiopulmonary bypass is not possible in many trauma operating rooms [1, 3, 4]. The repair of the lacerations to the origins of these vessels could only be accomplished with the use of deep hypothermia and circulatory arrest as extensive hemorrhage and hematoma prevented adequate exposure of the vessels and their sites of injury while the circulation was maintained. The use of a transluminal approach in this patient resulted in superior exposure of the injuries and thus greatly facilitated repair. Extensive mobilization of the periaortic soft tissues to identify the sites of injury in the extensive surrounding hematoma is often difficult and can result in injury to nonvascular structures. Injuries to the posterior aortic wall (including through and through injuries) and the inferior surface of the aortic arch could also be repaired in this fashion. In conclusion, we recommend cardiopulmonary bypass and deep hypothermia and circulatory arrest in the management of complex vascular injuries of the thoracic inlet with angiography to allow adequate planning of operation in the patient who is hemodynamically stable. In the unstable patient, when such extensive injury is suspected, the expeditious institution of femorofemoral cardiopulmonary bypass (without previous angiography) with systemic cooling, deep hypothermia, and circulatory arrest and the identification and repair of vascular inju-
Ann Thorac Surg 1997;63:559 – 60
ries may be the only recourse for a successful outcome. When isolated single major vascular injuries of the thoracic inlet are confirmed on angiography, these can be repaired without the adjunct of cardiopulmonary bypass [1– 4].
References 1. Pate JW, Cole FH, Walker WA, et al. Penetrating injuries of the aortic arch and its branches. Ann Thorac Surg 1993;55: 586–92. 2. Johnston RH, Wall MJ, Mattox KL, et al. Innominate artery trauma: a 30 year experience. J Vasc Surg 1993:17:134– 40. 3. Buchan K, Robbs J. Surgical management of penetrating mediastinal arterial trauma. Eur J Cardio-Thorac Surg 1995:9: 90– 4. 4. Fulton JO, De Groot KM, Buckels NJ, von Oppell UO. Penetrating injuries involving the intrathoracic great vessels. South Afr J Surg(in press). 5. Mattox KM, Feliciano DV, Burch J, Beall AC, Jordan GL, De Bakey ME. Five thousand seven hundred sixty cardiovascular injuries in 4459 patients— epidemiologic evolution 1958 to 1987. Ann Surg 1989;209:698 –705. 6. Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975; 70:1051– 65.
Technique for Reconstruction of the Sinotubular Junction Gopal Bhatnagar, MD, George T. Christakis, MD, Patricia M. Murphy, MD, Donald Oxorn, MD, and Bernard S. Goldman, MD Divisions of Cardiovascular Surgery and Anesthesia, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
Correct geometric relationships between the annulus and sinotubular junction during stentless valve implantation are critical to minimize the development of insufficiency. Some patients with aortic valve disease have dilatation of the sinotubular junction and are unable to have a stentless valve placed by standard techniques. We recently encountered such a patient and reconstructed the sinotubular junction by aortic crenation. Multiple interrupted plicating sutures were used to reduce the aorta from a diameter of 42 mm to 28 mm. This method allows tailoring of the aorta to appropriate size by varying the number of crenating sutures. (Ann Thorac Surg 1997;63:559 – 60) © 1997 by The Society of Thoracic Surgeons
T
he development of the stentless bioprosthesis for aortic valve replacement has provided a readily available alternative to homograft and stented valves [1–3]. Although the stentless bioprosthesis has superior
Accepted for publication Sep 26, 1996. Address reprint requests to Dr Bhatnagar, Division of Cardiovascular Surgery, Sunnybrook Health Science Centre, 2075 Bayview Ave 429, Toronto, ON, M4N 3M5, Canada.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT BHATNAGAR ET AL RECONSTRUCTION OF SINOTUBULAR JUNCTION
559
hemodynamics compared with a stented prosthesis [3, 4] and theoretic advantages in terms of left ventricular remodeling [4 – 6], the relationship between the valve annulus and the sinotubular junction (STJ) is an important factor in determining long-term competence [1, 5, 7–10]. In some instances patients who may otherwise be candidates for a stentless valve receive a stented valve because of large discrepancies between annular and sinotubular size [11]. Recently a 78-year-old woman with class III symptoms referable to her aortic stenosis was accepted for Stentless Porcine Valve (SPV) placement (Toronto SPV; St. Jude Medical, St. Paul, MN). Transesophageal echocardiography, however revealed an indistinct native STJ judged to be 29 mm, whereas the annulus was 27 mm. Additionally, the distance between the valve annulus and the presumed STJ was short, with the aorta above rapidly expanding to 42 mm. Intraoperative sizing revealed an enlarged STJ at 30 mm and an annulus appropriate for a 29-mm SPV. We decided to place the SPV and reconstruct a sinotubular junction as the patient had marked left ventricular hypertrophy and she required the maximum relief from left ventricular outflow tract obstruction that a bioprosthesis could provide. Complete aortic reconstruction or replacement was not considered as the maximum diameter was 42 mm and it was thought that potential morbidity would be high. Aortic cannulation was carried out toward the lesser curvature of the aorta close to the inominate artery takeoff, allowing a high aortotomy to be performed. Careful dissection of the pulmonary artery from a generous portion of the aorta was carried out with particular attention to the left mainstem origin. Anteriorly the root of the aorta was dissected until the takeoff of the right coronary artery was identified. After aortic cross-clamping, a transverse aortotomy was performed high enough above the right coronary artery takeoff to accommodate the SPV commissural posts and approximately 5 to 6 mm above the native STJ. The cut was made in a plane perpendicular to the direction of the aorta and carried down until only 2 cm of aorta remained in continuity posteriorly. The 29 mm valve was implanted using the standard techniques as described elsewhere [2, 4, 7]. Remodeling of the sinotubular junction was carried out during aortotomy closure (Fig 1). Plicating sutures were placed using 4-0 Prolene (Ethicon, Somerville, NJ), with each suture visually judged to crenate approximately 5 mm of aortic wall. Initially the aortotomy was bisected and each half of the remaining aortotomy was again bisected. No pledgets were used for the interrupted horizontal mattress plicating sutures. The aortotomy closure was initiated as a plicating suture using a Teflon pledgeted 4-0 Prolene suture and was performed using a two-layer McGoon-type closure (horizontal mattress with an over-and-over whip suture). A total of five plicating sutures were placed on each side of the aortotomy. Transesophageal echocardiography was carried out after separation from bypass, and the remodeled STJ was clearly visible, measuring 28 mm. This neo-STJ repre0003-4975/97/$17.00 PII S0003-4975(96)01036-3