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Congenital ostial stenosis of the right coronary artery repaired by vein patch angioplasty
The Journal of Thoracic and Cardiovascular Surgery
7 9 6 Briefcommunications
tion of the explanted valve revealed significant metal fatigue at the weld position of the minor strut, which fractured after manual manipulation. Postoperatively, the patient required cardiac support with pressor agents for 2 days and a tracheostomy for a I week period of mechanically assisted ventilation. The patient was discharged on postoperative day 27. At 6 month's follow-up, the patient has resumed her normal preoperative activities.
Discussion. Prosthetic valve failure resulting from disc embolization is a rare complication. Several cases of strut fracture with disc embolization have been reported in both the old and newly designed Bjork-Shiley prostheses." In each instance, fracture of either the inlet or outlet strut was observed at operation. Failure of the prosthesis because of a thrombotic event or large perivalvular leak was suspected in our patient preoperatively. Disc embolization was not considered likely because the preoperative chest roentgenogram demonstrated intact valve struts. The radiopaque marker of the disc was not visualized; however, on a plain x-ray film, one may suspect the valve to be in a closed position so that the marker would be obscured by the metal prosthetic ring. Although disc embolization after minor strut fracture is a rare occurrence, it is a widely recognized event. Sudden deterioration in the condition of a previously healthy patient with a prosthetic Bjork-Shiley mitral valve should alert the physician to this possibility, because delay in diagnosis seems to prejudice the outcome of the case.?" The presence of intact struts on the chest film of this patient would give credence to the metal fatigue theory of strut fracture. Apparently the strut-disc clearance in this patient had been altered by metal fatigue just enough to permit the disc to escape before fracture of the strut. This case serves to emphasize further the conclusions drawn by others, that early operation is essential for a successful outcome.t' When the clinical setting such as this is so indicative of prosthetic valve failure rather than left ventricular failure of another cause, precious time should not be wasted on further time-consuming diagnostic interventions. REFERENCES Bjork VO: A new central-flow tilting disc valve prosthesis. One year's clinical experience with 103 patients. J THORAC CARDIOVASC SURG 60:355-371, 1970 2 Ibarra F, Gutierrez A, Martinez F, Carreras L, Lopez C, Alonso-Lej F: Fracture of the outlet strut of a Bjork-Shiley mitral prosthesis. Emergency operation with survival. J THORAC CARDIOVASC SURG 87:315-318, 1984 3 Messmer BJ, Rothlin M, Senning A: Early disc dislodgment. An unusual complication after insertion of a Bjork-
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Shiley mitral valve prosthesis. J THORAC CARDIOVASC SURG 65:386-390, 1973 Fennerty MB, Pick RA, Clark MA: Outlet strut fracture of a Bjork-Shiley prosthesis in the mitral position. Am J Cardiol 54:923-924, 1984 Jaumin P, Panlot R, Schoevaertds JC, Brausseur L, Chalant CH: Strut fracture of the Bjork-Shiley aortic valve. J THORAC CARDIOVASC SURG 88:787-789, 1985 Norenberg DD, Evans RW, Gundersen AE, Abellera RM: Fracture and embolization of a Bjork-Shiley disc. Fatal failure of a prosthetic mitral valve. J THORAC CARDIOVASC SURG 74:925-927, 1977 Larrieu AJ, Puglia E, Allen P: Strut fracture and disc embolization of a Bjork-Shiley mitral valve prosthesis. Localization of embolized disc by computerized axial tomography. Ann Thorac Surg 34: 192-195, 1982 Tellez G, Maronas JM, Iglesias A: Expulsion of the disc of a Bjork-Shiley aortic prosthesis after temporary removal. Chest 73: 124, 1978 Patel RR, Senan P, Nair M, Ramesh ML, Ticzon AR: Successful outcome following a disrupted Bjork-Shiley prosthetic mitral valve. Texas Heart Inst J 12: 1985
Congenital ostial stenosis of the right coronary artery repaired by vein patch angioplasty John W. Lea IV, M.D., David L. Page, M.D., and John W. Hammon, Jr., M.D., Nashville. Tenn. From the Department of Cardiac and Thoracic Surgery, Department of Pathology, Vanderbilt University Hospital, Nashville, Tenn.
A case of congenital ostial stenosis of the right coronary artery is presented in which revascularization was performed by saphenous vein patch angioplasty.
Congenital anomalies of the coronary arteries are a rare but important cause of morbidity and mortality. Most congenital coronary malformations involve coronary arteriovenous malformations or anomalous origin from the pulmonary artery. We report a case of proximal congenital stenosis of the right coronary artery. Case report. A 52-year-old white woman had had transient hypertension that improved with weight loss and had smoked for 37 years, although she voluntarily stopped 1 month before evaluation. She was admitted to Vanderbilt Hospital with throat tightness and upper chest discomfort occurring at rest but aggravated by exertion. She had occasional associated diaphoresis and dyspnea. A treadmill exercise test was positive at 4 minutes with chest discomfort. A trial of calcium blockers failed to relieve the chest pain. Coronary angiography disclosed a severe right coronary ostial stenosis (Fig. I). The Address for reprints: John W. Hammon, Jr., M.D., 338 Medical Arts Building, 1211 21st Ave. S., Nashville, Tenn. 37212.
Volume 92 Number 4 October 1986
Brief communications
797
Fig. 2. Hematoxylin and eosin stain of full-thickness biopsy specimen of right coronary artery. Fig. 1. Preoperative right coronary angiogram. narrowing persisted after nitroglycerin and nifedipine administration. the remaining right coronary and left coronary arteries were otherwise normal and the left ventriculogram was normal. Coronary revascularization was recommended. At operation the heart was exposed through a median sternotomy. Both ventricles contracted normally without regional wall motion abnormalities, and there was no chamber enlargement. There was no evidence of atherosclerosis in the great arteries or throughout the coronary tree. The origin of the right coronary artery was dissected from the surrounding fat and proximal aorta. The origin appeared higher than usual on the aortic root. A fibrous stenosis was present at the origin of the right coronary artery. Cardiopulmonary bypass was instituted, the aorta was clamped, and cold hyperkalemic cardioplegic solution was instilled into the aortic root. An arteriotomy was performed across the stenotic area in the right coronary artery. A small full-thickness biopsy specimen was taken from the arterial wall (Fig. 2). A saphenous vein patch angioplasty, from the aorta onto the normal right coronary artery, corrected the severe stenosis. The patient was weaned from cardiopulmonary bypass without difficulty and had good hemodynamics. Her postoperative course was uneventful. A postoperative aortic root angiogram (Fig. 3) showed a widely patent right coronary artery. Two years postoperatively she is asymptomatic and requires no antianginal medication.
Discussion. Ogdon 1 reviewed 224 patients with congenital coronary malformations. He proposed three basic categories of coronary anomalies. Major anomalies are those in which there is an abnormal communication between an artery and a cardiac chamber of abnormal origin of a major coronary artery from the pulmonary artery. Minor anomalies involve variations of the location and caliber of the origin of the coronaries from the aorta with a normal distal circulation. Secondary anomalies are those associated with congenital heart defects and represent a circulatory response to a primary
Fig. 3. Postoperative aortic root angiogram showing patch angioplasty repair.
intracardiac pathologic defect. Only two cases of proximal coronary stenosis were reported by Ogdon. Lowe and Sabiston' reviewed surgically correctable coronary malformations. They discussed membranous obstruction of the ostium of the left main coronary artery. Hypoplasia or atresia of coronary arteries in infancy has been reported and usually produces severe impairment of ventricular function and death. These involve the left main coronary artery, and histologic examination shows that the artery has been replaced by fibromuscular tissue. Anomalous origin of the right coronary artery is a rare variation and appears to be compatible with longevity, unlike left-side lesions. This is a report of a rare proximal right coronary stenosis. This patient's hypertension and turbulent flow through a congenitally
The Journal of Thoracic and Cardiovascular Surgery
7 9 8 Brief communications
narrowed coronary ostium probably resulted in intimal thickening as a pathologic response to injury and may have resulted in the recent onset of symptoms. The biopsy tissue from the region of stenosis (Fig. 2) has elements of adventitia as well as media and intima, which indicates a full-thickness specimen had been obtained. The markedly thickened intima contains welloriented fibrous tissue, whereas the media contains smooth muscle cells in mild disarray separated focally by mucoid material. This disarray lends support to a congenital origin of the stenosis. There is no evidence that atheromatous alterations are present. Vein patch angioplasty appears to be an alternative to saphenous vein grafting for repair of such a lesion. This form of surgical treatment avoids the possible complication of vein occlusion inherent in vein bypass procedures and is technically easy to perform. REFERENCES Ogden JA: Congenital anomalies of the coronary arteries. Am J Cardiol 25:474-479, 1970 2 Lowe JE, Sabiston DC: Surgical correction of congenital malformations of the coronary circulation. South J 75:1508-1516, 1982
Moo
New membrane oxygenator (LPM 50): Influence on extravascular lung water and pulmonary function in comparison to bubble oxygenator Joachim Boldt, M.D., B. von Bormann, M.D., D. Kling, M.D., K. Ratthey, M.D., J. Mulch, M.D., and G. Hempelmann, M.D., Giessen, Federal Republic of Germany From the Department of Anesthesiology and Intensive Care Medicine (Head: Prof.Dr.med. G. Hempelmann), and the Department of Cardiovascular Surgery (Head: Prof.Dr.med. F. W. Hehrlein), Justus Liebig-University, Giessen, Federal Republic of Germany.
A prospective, randomized, clinical study involving 30 patients undergoing aorta-coronary bypass grafting was designed to compare the influence of a new membrane oxygenator and a commonly used bubble oxygenator on extravascular lung water and pulmonary function after extracorporeal circulation. Although membrane oxygenators might have some advantages from the biochemical and biophysical points of view, in this Address for reprints: Dr.med. Joachim Boldt, Department of Anesthesiology and Intensive Care Medicine, Justus Liebig-University, Klinikstr. 29, D-6300 Giessen, FRG.
clinical study no differences in lung water accumulation and pulmonary gas exchange could be detected between bubble and membrane oxygenators after extracorporeal circulation.
Although various beneficial biologic differences have been observed between membrane oxygenators and bubble oxygenators, the clinical importance of these differences is still unresolved.I This study was initiated to determine whether any detectable clinical differences, especially with regard to extravascular lung water (EVL W), could be demonstrated between a standard bubble oxygenator and a new type of membrane oxygenator. Patients and methods. Thirty patients were randomly assigned to have either a bubble oxygenator (BaS 10, American Bentley, Irvine, Calif.) or a new membrane oxygenator (LPM 50, Travenol Laboratories, Inc., Deerfield, Ill.) for extracorporeal circulation. The patients' management and extracorporeal circulation procedure were strictly standardized- and comparable for both groups. Hemodynamics, various laboratory parameters, and EVLW (double indicator-dilution method' with indocyanine green as the nondiffusible indicator) were measured at different times before, during, and after extracorporeal circulation. Analysis of variance was used to detect differences between the two groups within the investigation period. Results. No significant differences between the bubble oxygenator and the membrane oxygenator groups could be observed when comparing fluid input, urine output and free water clearance, colloid osmotic pressure, total protein and albumin, blood loss, and blood requirements. The increase in EVLW after extracorporeal circulation also did not differ significantly between the two groups (Fig. 1). Only 45 minutes after extracorporeal circulation the EVL W change in the membrane oxygenator group (+ 1.02 rnljkg) was different from control values (p = 0.1). Arterial oxygen tensions (POlS) (Fig. 1) before and after extracorporeal circulation were comparable for the two groups, but the course of arterial POl during extracorporeal circulation differed significantly. Intrapulmonary shunting showed no significant differences between the groups, and hemodynamics also were similar in the two groups. Discussion. Disturbances in capillary integrity and especially alterations in pulmonary capillaries because of extracorporeal oxygenation seem to have a confounding effect on the production of pulmonary edema with consecutive deterioration of pulmonary gas exchange.
7 9 6 Briefcommunications
tion of the explanted valve revealed significant metal fatigue at the weld position of the minor strut, which fractured after manual manipulation. Postoperatively, the patient required cardiac support with pressor agents for 2 days and a tracheostomy for a I week period of mechanically assisted ventilation. The patient was discharged on postoperative day 27. At 6 month's follow-up, the patient has resumed her normal preoperative activities.
Discussion. Prosthetic valve failure resulting from disc embolization is a rare complication. Several cases of strut fracture with disc embolization have been reported in both the old and newly designed Bjork-Shiley prostheses." In each instance, fracture of either the inlet or outlet strut was observed at operation. Failure of the prosthesis because of a thrombotic event or large perivalvular leak was suspected in our patient preoperatively. Disc embolization was not considered likely because the preoperative chest roentgenogram demonstrated intact valve struts. The radiopaque marker of the disc was not visualized; however, on a plain x-ray film, one may suspect the valve to be in a closed position so that the marker would be obscured by the metal prosthetic ring. Although disc embolization after minor strut fracture is a rare occurrence, it is a widely recognized event. Sudden deterioration in the condition of a previously healthy patient with a prosthetic Bjork-Shiley mitral valve should alert the physician to this possibility, because delay in diagnosis seems to prejudice the outcome of the case.?" The presence of intact struts on the chest film of this patient would give credence to the metal fatigue theory of strut fracture. Apparently the strut-disc clearance in this patient had been altered by metal fatigue just enough to permit the disc to escape before fracture of the strut. This case serves to emphasize further the conclusions drawn by others, that early operation is essential for a successful outcome.t' When the clinical setting such as this is so indicative of prosthetic valve failure rather than left ventricular failure of another cause, precious time should not be wasted on further time-consuming diagnostic interventions. REFERENCES Bjork VO: A new central-flow tilting disc valve prosthesis. One year's clinical experience with 103 patients. J THORAC CARDIOVASC SURG 60:355-371, 1970 2 Ibarra F, Gutierrez A, Martinez F, Carreras L, Lopez C, Alonso-Lej F: Fracture of the outlet strut of a Bjork-Shiley mitral prosthesis. Emergency operation with survival. J THORAC CARDIOVASC SURG 87:315-318, 1984 3 Messmer BJ, Rothlin M, Senning A: Early disc dislodgment. An unusual complication after insertion of a Bjork-
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Shiley mitral valve prosthesis. J THORAC CARDIOVASC SURG 65:386-390, 1973 Fennerty MB, Pick RA, Clark MA: Outlet strut fracture of a Bjork-Shiley prosthesis in the mitral position. Am J Cardiol 54:923-924, 1984 Jaumin P, Panlot R, Schoevaertds JC, Brausseur L, Chalant CH: Strut fracture of the Bjork-Shiley aortic valve. J THORAC CARDIOVASC SURG 88:787-789, 1985 Norenberg DD, Evans RW, Gundersen AE, Abellera RM: Fracture and embolization of a Bjork-Shiley disc. Fatal failure of a prosthetic mitral valve. J THORAC CARDIOVASC SURG 74:925-927, 1977 Larrieu AJ, Puglia E, Allen P: Strut fracture and disc embolization of a Bjork-Shiley mitral valve prosthesis. Localization of embolized disc by computerized axial tomography. Ann Thorac Surg 34: 192-195, 1982 Tellez G, Maronas JM, Iglesias A: Expulsion of the disc of a Bjork-Shiley aortic prosthesis after temporary removal. Chest 73: 124, 1978 Patel RR, Senan P, Nair M, Ramesh ML, Ticzon AR: Successful outcome following a disrupted Bjork-Shiley prosthetic mitral valve. Texas Heart Inst J 12: 1985
Congenital ostial stenosis of the right coronary artery repaired by vein patch angioplasty John W. Lea IV, M.D., David L. Page, M.D., and John W. Hammon, Jr., M.D., Nashville. Tenn. From the Department of Cardiac and Thoracic Surgery, Department of Pathology, Vanderbilt University Hospital, Nashville, Tenn.
A case of congenital ostial stenosis of the right coronary artery is presented in which revascularization was performed by saphenous vein patch angioplasty.
Congenital anomalies of the coronary arteries are a rare but important cause of morbidity and mortality. Most congenital coronary malformations involve coronary arteriovenous malformations or anomalous origin from the pulmonary artery. We report a case of proximal congenital stenosis of the right coronary artery. Case report. A 52-year-old white woman had had transient hypertension that improved with weight loss and had smoked for 37 years, although she voluntarily stopped 1 month before evaluation. She was admitted to Vanderbilt Hospital with throat tightness and upper chest discomfort occurring at rest but aggravated by exertion. She had occasional associated diaphoresis and dyspnea. A treadmill exercise test was positive at 4 minutes with chest discomfort. A trial of calcium blockers failed to relieve the chest pain. Coronary angiography disclosed a severe right coronary ostial stenosis (Fig. I). The Address for reprints: John W. Hammon, Jr., M.D., 338 Medical Arts Building, 1211 21st Ave. S., Nashville, Tenn. 37212.
Volume 92 Number 4 October 1986
Brief communications
797
Fig. 2. Hematoxylin and eosin stain of full-thickness biopsy specimen of right coronary artery. Fig. 1. Preoperative right coronary angiogram. narrowing persisted after nitroglycerin and nifedipine administration. the remaining right coronary and left coronary arteries were otherwise normal and the left ventriculogram was normal. Coronary revascularization was recommended. At operation the heart was exposed through a median sternotomy. Both ventricles contracted normally without regional wall motion abnormalities, and there was no chamber enlargement. There was no evidence of atherosclerosis in the great arteries or throughout the coronary tree. The origin of the right coronary artery was dissected from the surrounding fat and proximal aorta. The origin appeared higher than usual on the aortic root. A fibrous stenosis was present at the origin of the right coronary artery. Cardiopulmonary bypass was instituted, the aorta was clamped, and cold hyperkalemic cardioplegic solution was instilled into the aortic root. An arteriotomy was performed across the stenotic area in the right coronary artery. A small full-thickness biopsy specimen was taken from the arterial wall (Fig. 2). A saphenous vein patch angioplasty, from the aorta onto the normal right coronary artery, corrected the severe stenosis. The patient was weaned from cardiopulmonary bypass without difficulty and had good hemodynamics. Her postoperative course was uneventful. A postoperative aortic root angiogram (Fig. 3) showed a widely patent right coronary artery. Two years postoperatively she is asymptomatic and requires no antianginal medication.
Discussion. Ogdon 1 reviewed 224 patients with congenital coronary malformations. He proposed three basic categories of coronary anomalies. Major anomalies are those in which there is an abnormal communication between an artery and a cardiac chamber of abnormal origin of a major coronary artery from the pulmonary artery. Minor anomalies involve variations of the location and caliber of the origin of the coronaries from the aorta with a normal distal circulation. Secondary anomalies are those associated with congenital heart defects and represent a circulatory response to a primary
Fig. 3. Postoperative aortic root angiogram showing patch angioplasty repair.
intracardiac pathologic defect. Only two cases of proximal coronary stenosis were reported by Ogdon. Lowe and Sabiston' reviewed surgically correctable coronary malformations. They discussed membranous obstruction of the ostium of the left main coronary artery. Hypoplasia or atresia of coronary arteries in infancy has been reported and usually produces severe impairment of ventricular function and death. These involve the left main coronary artery, and histologic examination shows that the artery has been replaced by fibromuscular tissue. Anomalous origin of the right coronary artery is a rare variation and appears to be compatible with longevity, unlike left-side lesions. This is a report of a rare proximal right coronary stenosis. This patient's hypertension and turbulent flow through a congenitally
The Journal of Thoracic and Cardiovascular Surgery
7 9 8 Brief communications
narrowed coronary ostium probably resulted in intimal thickening as a pathologic response to injury and may have resulted in the recent onset of symptoms. The biopsy tissue from the region of stenosis (Fig. 2) has elements of adventitia as well as media and intima, which indicates a full-thickness specimen had been obtained. The markedly thickened intima contains welloriented fibrous tissue, whereas the media contains smooth muscle cells in mild disarray separated focally by mucoid material. This disarray lends support to a congenital origin of the stenosis. There is no evidence that atheromatous alterations are present. Vein patch angioplasty appears to be an alternative to saphenous vein grafting for repair of such a lesion. This form of surgical treatment avoids the possible complication of vein occlusion inherent in vein bypass procedures and is technically easy to perform. REFERENCES Ogden JA: Congenital anomalies of the coronary arteries. Am J Cardiol 25:474-479, 1970 2 Lowe JE, Sabiston DC: Surgical correction of congenital malformations of the coronary circulation. South J 75:1508-1516, 1982
Moo
New membrane oxygenator (LPM 50): Influence on extravascular lung water and pulmonary function in comparison to bubble oxygenator Joachim Boldt, M.D., B. von Bormann, M.D., D. Kling, M.D., K. Ratthey, M.D., J. Mulch, M.D., and G. Hempelmann, M.D., Giessen, Federal Republic of Germany From the Department of Anesthesiology and Intensive Care Medicine (Head: Prof.Dr.med. G. Hempelmann), and the Department of Cardiovascular Surgery (Head: Prof.Dr.med. F. W. Hehrlein), Justus Liebig-University, Giessen, Federal Republic of Germany.
A prospective, randomized, clinical study involving 30 patients undergoing aorta-coronary bypass grafting was designed to compare the influence of a new membrane oxygenator and a commonly used bubble oxygenator on extravascular lung water and pulmonary function after extracorporeal circulation. Although membrane oxygenators might have some advantages from the biochemical and biophysical points of view, in this Address for reprints: Dr.med. Joachim Boldt, Department of Anesthesiology and Intensive Care Medicine, Justus Liebig-University, Klinikstr. 29, D-6300 Giessen, FRG.
clinical study no differences in lung water accumulation and pulmonary gas exchange could be detected between bubble and membrane oxygenators after extracorporeal circulation.
Although various beneficial biologic differences have been observed between membrane oxygenators and bubble oxygenators, the clinical importance of these differences is still unresolved.I This study was initiated to determine whether any detectable clinical differences, especially with regard to extravascular lung water (EVL W), could be demonstrated between a standard bubble oxygenator and a new type of membrane oxygenator. Patients and methods. Thirty patients were randomly assigned to have either a bubble oxygenator (BaS 10, American Bentley, Irvine, Calif.) or a new membrane oxygenator (LPM 50, Travenol Laboratories, Inc., Deerfield, Ill.) for extracorporeal circulation. The patients' management and extracorporeal circulation procedure were strictly standardized- and comparable for both groups. Hemodynamics, various laboratory parameters, and EVLW (double indicator-dilution method' with indocyanine green as the nondiffusible indicator) were measured at different times before, during, and after extracorporeal circulation. Analysis of variance was used to detect differences between the two groups within the investigation period. Results. No significant differences between the bubble oxygenator and the membrane oxygenator groups could be observed when comparing fluid input, urine output and free water clearance, colloid osmotic pressure, total protein and albumin, blood loss, and blood requirements. The increase in EVLW after extracorporeal circulation also did not differ significantly between the two groups (Fig. 1). Only 45 minutes after extracorporeal circulation the EVL W change in the membrane oxygenator group (+ 1.02 rnljkg) was different from control values (p = 0.1). Arterial oxygen tensions (POlS) (Fig. 1) before and after extracorporeal circulation were comparable for the two groups, but the course of arterial POl during extracorporeal circulation differed significantly. Intrapulmonary shunting showed no significant differences between the groups, and hemodynamics also were similar in the two groups. Discussion. Disturbances in capillary integrity and especially alterations in pulmonary capillaries because of extracorporeal oxygenation seem to have a confounding effect on the production of pulmonary edema with consecutive deterioration of pulmonary gas exchange.