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Coronary artery air embolism following pulmonary valvotomy for pulmonary atresia: A note of caution
Volume 86 Number 2 August, 1983
Fig. 3. The postoperative angiogram shows the catheter passing from the subclavian artery through the ductus and partitioned pulmonary artery into the ascending aorta. The dye shows the ascending aorta, partitioned pulmonary artery, and ductus arteriosus filling the descending aorta.
our case. The aortopulmonary anastomosis would appear to be the site with the least potential for growth in these patients. The diameter of this anastomosis should be as close to that of the usual adult aortic isthmus as possible.The remainder of the reconstruction would seem to have a relatively normal potential for growth, because the normal. undisturbed arterial wall constitutes approximately three fourths of the vascular circumference. REFERENCES Barratt-Boyes BG, Nicholls TT, Brandt PWT, Neutze JM: Aortic arch interrupted associated with patent ductus arteriosus, ventricular septal defect, and total anomalous pulmonary venous connection. J THORAC CARDIOVASC SURG 63:367-373, 1972 2 Ito K, Kohguchi N, Ohkawa Y, Akasaka T, Ohara H, Takarada M, Aoki H, Ogata M, Nishibatake M, Fukatsu 0, Matsushima K: Total one-stage repair of interrupted aortic arch associated with aortic septal defect and patent ductus arteriosus. J THORAC CARDIOVASC SURG 74:913917,1977
Brief communications
311
3 Tyson KRT, Harris LC, Nghiem QX: Repair of aortic arch interruption in the neonate. Surgery 67:1006-1010, 1970 4 Murphy DA, Lemire GG, Tessler I, Dunn GL: Correction of type B aortic arch interruption with ventricular and atrial septal defects in a three-day-old infant. J THORAC CARDIOVASC SURG 65:882-886, 1973 5 Bailey LL, Jacobson JG, Vyhmeister E, Petry E: Interrupted aortic arch complex. Successful total correction in the neonate. Ann Thorac Surg 25:66-70, 1978 6 Bailey LL, Jacobson JG, Doroshow RW, Merritt WH, Petry EL: Anatomic correction of interrupted aortic arch complex in neonates. Surgery 89:553-557, 1981 7 Trusler GA, Izukawa T: Interrupted aortic arch and ventricular septal defect. J THORAC CARDIOVASC SURG 69:126-131, 1975 8 Ventemiglia R, Oglietti J, Wukasch DC, Hallman GL, Cooley DA: Interruption of the aortic arch. Surgical considerations. J THORAC CARDIOVASC SURG 72:235-242, 1976 9 Kawashima Y, Oyama C, Mori T, Manabe H: Interruption of the aortic arch associated with patent ductus arteriosus and ventricular septal defect. Proposal of a new surgical technique for total correction. J Cardiovasc Surg 16:426-431,1975 10 Monro JL, Brawn W, Conway N: Correction of type B interrupted aortic arch with ventricular septal defect in infancy. J THORAC CARDIOVASC SURG 74:618-623, 1977 11 Muraoka R, Yokota M, Aoshima M, Nomoto S, Osaragi M, Kyoku I, Nakano H, Veda K, Saito A: Simplified method for total correction of interrupted aortic arch with ventricular septal defect in infancy. J THORAe CARDIOVASC SURG 78:744-749, 1979 12 Van Praagh R, Bernhard WF, Rosenthal Am, Parisi LF, Fyler DC: Interrupted aortic arch. Surgical treatment. Am J Cardiol 27:200-211, 1971 13 Fishman NH, Bronstein MH, Berman W Jr, Roe BB, Edmunds LH Jr, Robinson SJ, Rudolf AM: Surgical management of severe aortic coarctation and interrupted aortic arch in neonates. J THORAC CARDIOVASC SURG 71:35-48, 1976
Coronary artery air embolism following pulmonary valvotomy for pulmonary atresia: A note of caution Scott Stewart, M.D., J. Peter Harris, M.D., and James A. Manning, M.D., Rochester, N. Y. From the Division of Cardiothoracic Surgery and the Pediatric Cardiology Unit, University of Rochester, 601 Elmwood Ave., Rochester, N. Y. 19462.
A case of coronary artery air embolism following open pulmonary valvotomy for pulmonary atresia with intact ventricularseptum is reported. The presumptive source ofthis
3I2
Brief communications
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. Posteroanterior (Aj and lateral (Bj projections of the right ventricular cineangiogram. A large sinusoid (arrowj arises from the anterior wall of the ventricle and enters the left anterior descending coronary artery system. The infundibulum is severely hypoplastic.
complication is a fistulous communication between the coronary artery and right ventricle, and may be preventable by certain modifications in technique.
Pulmonary valvotomy and construction of a systemic-pulmonary artery shunt are complementary procedures in the management of pulmonary atresia with intact ventricular septum in the neonate. Several techniques of pulmonary valvotomy have been used, including blind instrumentation through the infundibulum and open exposure of the valve with either inflow occlusion or cardiopulmonary bypass. This communication describes the previously unrecognized potential complication of coronary artery air embolism during pulmonary valvotomy when inflow occlusion is used.
Fig. 2. The heart as visualized at autopsy. The large fistula from the right ventricle to the left anterior descending coronary artery has been exposed. Inset. An artist's rendition of air escaping from the right ventricle into the fistula and the coronary artery system.
Case report. The diagnosis of pulmonary atresia with intact ventricular septum was made at 16 hours of age. The right ventricular angiogram showed a small right ventricle with a severely hypoplastic infundibulum and an atretic pulmonary valve. Multiple myocardial sinusoids, including a particularly large one anteriorly, drained into the coronary artery system (Fig. I). The right ventricular pressure was equal to systemic pressure. An urgent right Blalock-Taussig anastomosis resulted in significant improvement in cyanosis. One week later an elective pulmonary valvotomy was performed by means of inflow occlusion. A very large, tortuous coronary vessel was noted to lie over the base of the right ventricle. The cavae were occluded with tapes, the aorta and pulmonary artery cross-clamped, and the pulmonary artery was opened. The valve was atretic. It was incised and dilated with a small
Volume 86 Number 2 August, 1983
clamp. The incision in the pulmonary artery was closed and thecaval tapes and aortic and pulmonary artery cross-clamp were released. Cardiac function appeared satisfactory initially but then deteriorated progressively. A large amount of air was noted in the coronary arterial andvenous systems. An attempt to force this air through the coronary bed with cardiac massage and epinephrine was partially successful, but a satisfactory hemodynamic state could never be sustained and the infant died 4 hours after operation. The autopsy confirmed the diagnosis of pulmonary atresia with intact ventricular septum. In addition, a very large fistulous communication between the anterior wall of the right ventricle and the coronary artery system was identified (Fig. 2). Discussion. Air presumably was introduced into the coronary artery system through the large fistulous communication arising from the right ventricle. The presence of such communications in pulmonary atresia with intact ventricular septum have been recognized for some time, but their potential clinical signillcance during pulmonary valvotomy has not been described.'? Although it is possible that air passed across the patent foramen ovale,the likelihood of this occurrence is small. It does not seem probable that enough blood would have been aspirated from the right side of the heart to permit its level to fall below that of the foramen ovale. The presenceof large right ventricle--eoronary artery fistulas may be identified from the preoperative right ventricular angiogram, and this foreknowledge should alert the surgeon to the potential for coronary artery air embolism. At operation the appearance of large, serpentine vessels over the surface of the right ventricle would strongly suggest the presence of an abnormal coronary
Brief communications
3 13
artery communication with the underlying chamber. We still prefer the open method of pulmonary valvotomy since we believe that it is more accurate and therefore safer in our hands, but an awareness of this potential complication has led to modillcations in our technique of operation designed to prevent coronary air embolism. A minimum of blood is aspirated from the right ventricle while the pulmonary valve is being opened. A caval tape is released prior to completing the closure of the pulmonary arteriotomy and before the cross-clamp is removed. This allows the right heart to passively fill with bloodprior to the developmentof vigorouscontractions, which might drive air through a fistula into the coronary arteries. Finally,any large coronary vessel over the surface of the right ventricle is manually occluded brieflywhile the right heart is filling with blood. If it can be ascertained that such a vessel is, in fact, a fistula, the vessel should be ligated at the time. REFERENCES Davignon AL, Greenwold WE, DuShane JW, Edwards JE: Congenital pulmonary atresia with intact ventricular septum. Clincopathologic correlation of two anatomic types. Am Heart J 62:591-602, 1961 2 Lauer RM, Fink HP, Petry LE, Dunn MI, Diehl AM: Angiographic demonstration of intramyocardial sinusoids in pulmonary valve atresia with intact ventricular septum and hypoplastic right ventricle. N Engl J Med 271:68-72, 1964 3 Sissman NJ, Abrams HL: Bidirectional shunting in a coronary artery-right ventricular fistula associated with pulmonary atresia and an intact ventricular septum. Circulation 32:582-588, 1965
Fig. 3. The postoperative angiogram shows the catheter passing from the subclavian artery through the ductus and partitioned pulmonary artery into the ascending aorta. The dye shows the ascending aorta, partitioned pulmonary artery, and ductus arteriosus filling the descending aorta.
our case. The aortopulmonary anastomosis would appear to be the site with the least potential for growth in these patients. The diameter of this anastomosis should be as close to that of the usual adult aortic isthmus as possible.The remainder of the reconstruction would seem to have a relatively normal potential for growth, because the normal. undisturbed arterial wall constitutes approximately three fourths of the vascular circumference. REFERENCES Barratt-Boyes BG, Nicholls TT, Brandt PWT, Neutze JM: Aortic arch interrupted associated with patent ductus arteriosus, ventricular septal defect, and total anomalous pulmonary venous connection. J THORAC CARDIOVASC SURG 63:367-373, 1972 2 Ito K, Kohguchi N, Ohkawa Y, Akasaka T, Ohara H, Takarada M, Aoki H, Ogata M, Nishibatake M, Fukatsu 0, Matsushima K: Total one-stage repair of interrupted aortic arch associated with aortic septal defect and patent ductus arteriosus. J THORAC CARDIOVASC SURG 74:913917,1977
Brief communications
311
3 Tyson KRT, Harris LC, Nghiem QX: Repair of aortic arch interruption in the neonate. Surgery 67:1006-1010, 1970 4 Murphy DA, Lemire GG, Tessler I, Dunn GL: Correction of type B aortic arch interruption with ventricular and atrial septal defects in a three-day-old infant. J THORAC CARDIOVASC SURG 65:882-886, 1973 5 Bailey LL, Jacobson JG, Vyhmeister E, Petry E: Interrupted aortic arch complex. Successful total correction in the neonate. Ann Thorac Surg 25:66-70, 1978 6 Bailey LL, Jacobson JG, Doroshow RW, Merritt WH, Petry EL: Anatomic correction of interrupted aortic arch complex in neonates. Surgery 89:553-557, 1981 7 Trusler GA, Izukawa T: Interrupted aortic arch and ventricular septal defect. J THORAC CARDIOVASC SURG 69:126-131, 1975 8 Ventemiglia R, Oglietti J, Wukasch DC, Hallman GL, Cooley DA: Interruption of the aortic arch. Surgical considerations. J THORAC CARDIOVASC SURG 72:235-242, 1976 9 Kawashima Y, Oyama C, Mori T, Manabe H: Interruption of the aortic arch associated with patent ductus arteriosus and ventricular septal defect. Proposal of a new surgical technique for total correction. J Cardiovasc Surg 16:426-431,1975 10 Monro JL, Brawn W, Conway N: Correction of type B interrupted aortic arch with ventricular septal defect in infancy. J THORAC CARDIOVASC SURG 74:618-623, 1977 11 Muraoka R, Yokota M, Aoshima M, Nomoto S, Osaragi M, Kyoku I, Nakano H, Veda K, Saito A: Simplified method for total correction of interrupted aortic arch with ventricular septal defect in infancy. J THORAe CARDIOVASC SURG 78:744-749, 1979 12 Van Praagh R, Bernhard WF, Rosenthal Am, Parisi LF, Fyler DC: Interrupted aortic arch. Surgical treatment. Am J Cardiol 27:200-211, 1971 13 Fishman NH, Bronstein MH, Berman W Jr, Roe BB, Edmunds LH Jr, Robinson SJ, Rudolf AM: Surgical management of severe aortic coarctation and interrupted aortic arch in neonates. J THORAC CARDIOVASC SURG 71:35-48, 1976
Coronary artery air embolism following pulmonary valvotomy for pulmonary atresia: A note of caution Scott Stewart, M.D., J. Peter Harris, M.D., and James A. Manning, M.D., Rochester, N. Y. From the Division of Cardiothoracic Surgery and the Pediatric Cardiology Unit, University of Rochester, 601 Elmwood Ave., Rochester, N. Y. 19462.
A case of coronary artery air embolism following open pulmonary valvotomy for pulmonary atresia with intact ventricularseptum is reported. The presumptive source ofthis
3I2
Brief communications
The Journal of Thoracic and Cardiovascular Surgery
Fig. 1. Posteroanterior (Aj and lateral (Bj projections of the right ventricular cineangiogram. A large sinusoid (arrowj arises from the anterior wall of the ventricle and enters the left anterior descending coronary artery system. The infundibulum is severely hypoplastic.
complication is a fistulous communication between the coronary artery and right ventricle, and may be preventable by certain modifications in technique.
Pulmonary valvotomy and construction of a systemic-pulmonary artery shunt are complementary procedures in the management of pulmonary atresia with intact ventricular septum in the neonate. Several techniques of pulmonary valvotomy have been used, including blind instrumentation through the infundibulum and open exposure of the valve with either inflow occlusion or cardiopulmonary bypass. This communication describes the previously unrecognized potential complication of coronary artery air embolism during pulmonary valvotomy when inflow occlusion is used.
Fig. 2. The heart as visualized at autopsy. The large fistula from the right ventricle to the left anterior descending coronary artery has been exposed. Inset. An artist's rendition of air escaping from the right ventricle into the fistula and the coronary artery system.
Case report. The diagnosis of pulmonary atresia with intact ventricular septum was made at 16 hours of age. The right ventricular angiogram showed a small right ventricle with a severely hypoplastic infundibulum and an atretic pulmonary valve. Multiple myocardial sinusoids, including a particularly large one anteriorly, drained into the coronary artery system (Fig. I). The right ventricular pressure was equal to systemic pressure. An urgent right Blalock-Taussig anastomosis resulted in significant improvement in cyanosis. One week later an elective pulmonary valvotomy was performed by means of inflow occlusion. A very large, tortuous coronary vessel was noted to lie over the base of the right ventricle. The cavae were occluded with tapes, the aorta and pulmonary artery cross-clamped, and the pulmonary artery was opened. The valve was atretic. It was incised and dilated with a small
Volume 86 Number 2 August, 1983
clamp. The incision in the pulmonary artery was closed and thecaval tapes and aortic and pulmonary artery cross-clamp were released. Cardiac function appeared satisfactory initially but then deteriorated progressively. A large amount of air was noted in the coronary arterial andvenous systems. An attempt to force this air through the coronary bed with cardiac massage and epinephrine was partially successful, but a satisfactory hemodynamic state could never be sustained and the infant died 4 hours after operation. The autopsy confirmed the diagnosis of pulmonary atresia with intact ventricular septum. In addition, a very large fistulous communication between the anterior wall of the right ventricle and the coronary artery system was identified (Fig. 2). Discussion. Air presumably was introduced into the coronary artery system through the large fistulous communication arising from the right ventricle. The presence of such communications in pulmonary atresia with intact ventricular septum have been recognized for some time, but their potential clinical signillcance during pulmonary valvotomy has not been described.'? Although it is possible that air passed across the patent foramen ovale,the likelihood of this occurrence is small. It does not seem probable that enough blood would have been aspirated from the right side of the heart to permit its level to fall below that of the foramen ovale. The presenceof large right ventricle--eoronary artery fistulas may be identified from the preoperative right ventricular angiogram, and this foreknowledge should alert the surgeon to the potential for coronary artery air embolism. At operation the appearance of large, serpentine vessels over the surface of the right ventricle would strongly suggest the presence of an abnormal coronary
Brief communications
3 13
artery communication with the underlying chamber. We still prefer the open method of pulmonary valvotomy since we believe that it is more accurate and therefore safer in our hands, but an awareness of this potential complication has led to modillcations in our technique of operation designed to prevent coronary air embolism. A minimum of blood is aspirated from the right ventricle while the pulmonary valve is being opened. A caval tape is released prior to completing the closure of the pulmonary arteriotomy and before the cross-clamp is removed. This allows the right heart to passively fill with bloodprior to the developmentof vigorouscontractions, which might drive air through a fistula into the coronary arteries. Finally,any large coronary vessel over the surface of the right ventricle is manually occluded brieflywhile the right heart is filling with blood. If it can be ascertained that such a vessel is, in fact, a fistula, the vessel should be ligated at the time. REFERENCES Davignon AL, Greenwold WE, DuShane JW, Edwards JE: Congenital pulmonary atresia with intact ventricular septum. Clincopathologic correlation of two anatomic types. Am Heart J 62:591-602, 1961 2 Lauer RM, Fink HP, Petry LE, Dunn MI, Diehl AM: Angiographic demonstration of intramyocardial sinusoids in pulmonary valve atresia with intact ventricular septum and hypoplastic right ventricle. N Engl J Med 271:68-72, 1964 3 Sissman NJ, Abrams HL: Bidirectional shunting in a coronary artery-right ventricular fistula associated with pulmonary atresia and an intact ventricular septum. Circulation 32:582-588, 1965