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CORONARY ARTERY DISSECTION: A COMPLICATION OF CANNULATION
CORONARY ARTERY DISSECTION: A COMPLICATION OF CANNULATION Alfred Heilbrunn, M.D., and Jack M. Zimmerman,
M.D.
Kansas City, Mo., and Kansas City, Kans.
D
coronary artery perfusion has been generally accepted as the best means of myocardial protection during open-heart operations on the aortic valve. The techniques of coronary perfusion have differed in detail with a variety of perfusates, flows, pressures, and temperatures being used. Several different types of coronary perfusion cannulas have been described.1'10> 1 2 > 2 3 We have been using the coronary perfusion catheter manufactured by Abbott Laboratories (Fig. 1). We selected this particular cannula because of its low cost, flexibility, and disposability. In addition, it can be easily secured with a stitch and does not require an assistant to hold it. Recently we encountered a fatal complication during use of this cannula. With the hope that others may avoid this situation, it was our opinion that a brief report was justified. IRECT
CASE REPORT A 45-year-old white man was first seen a t the Kansas City Veterans Administration Hospital in 1958 for treatment of aortic insufficiency and subacute bacterial endocarditis. In subsequent years he was followed as an outpatient, with two admissions for unrelated problems. Complete cardiac evaluation was carried out early in 1964. This demonstrated moderately severe left ventricular hypertrophy and a 25 mm. H g systolie gradient across the aortic valve. Dye dilution curves made by injection of dye at various levels in the thoracic aorta and sampling at the left brachial artery revealed regurgitation from as low as the level of the tenth thoracic vertebra. Progressive disability as well as increasing cardiomegaly demonstrated by x-ray studies led to readmission in September. Operation was performed on Sept. 22, 1964, through a sternal splitting approach. With the use of a single % inch, line in the right atrium and return via the right common femoral artery, cardiopulmonary bypass was initiated and the patient was cooled to 30° C. Exposure of the aortic valve revealed marked calcification of the right and left coronary cusps with obliteration of the commissure between them. The noncoronary cusp was prolapsed into the ventricle and contained a 6 by 4 mm. perforation (Fig. 2 ) . Perfusion of the left coronary artery was begun with the use of cold blood. Because of the extensive calcification involving the annulus, resection of the valve was difficult. The From the Departments of Surgery of the Veterans Administration Hospital, Kansas City, Mo., and the University of Kansas School of Medicine, Kansas City, Kans. Received for publication Dec. 7, 1964. 767
768
HEILBEUNN
AND ZIMMERMAN
J. Thoracic and Cardiovas. Surg.
Fig. 1.—Abbott coronary perfusion catheter. Proximal end made to fit directly to % inch line. Enlarged view of left coronary tip in inset.
LEFT CORONARY CUSP
RIGHT CORONARY CUSP
NON-CORONARY CUSP
whmm in
Fig. 2.—Resected aortic valve. Note perforation of noncoronary cusp and calcific obliteration of commissure between left and right coronary cusps.
Vol. 49, No. 5 May, 1965
CORONARY ARTERY DISSECTION
769
left coronary cannula was removed briefly during excision of the valve and, when reinserted, was not resutured. Subsequently it became dislodged several times. A Starr-Edwards prosthesis was sutured in place. After the patient was rewarmed and the aortotomy was closed, it was noted that the right ventricle was fibrillating vigorously, but the left side had very little activity. With direct current countershoek, the right ventricle quickly resumed an apparently effective beat but, in spite of repeated attempts over a 2 hour period, the left ventricle remained in a slow, weak fibrillation. At autopsy, pertinent findings were limited to the heart. The prosthesis was secure and in excellent position. The orifices of both coronary arteries were unimpaired and there was only minimal evidence of coronary atherosclerosis. A hematoma surrounded the area of the bifurcation of the left coronary artery into its anterior descending and circumflex branches. When the vessel was opened, an obviously recent intimal tear, with a distal flap that obstructed the two branches, was seen (Fig. 3 ) . DISCUSSION
The successful conduct of open-heart surgery demands careful attention to numerous details of technique. The complexities of aortic valve surgery are in creased by the need for coronary perfusion. In the case presented, it appears that an intimal tear was probably produced in the left coronary artery by the
Fig. 3.—Posterior view of base of the heart and root of the aorta shows opened left coronary artery. Artist's diagram shows more clearly the extent of intimal tear and the flap produced.
770
HEILBRUNN
AND ZIMMERMAN
J. Thoracic and Cardiovas. Surg.
tip of the perfusion catheter. This led to the formation of an intimal flap and mural hematoma which occluded the major branches of the left coronary artery. As a result, perfusion to the hypertrophied myocardium was ineffective, and irreversible damage ensued. We have encountered no other difficulty with this cannula and have continued to use it. Possibly the tear which occurred was a consequence of the repeated insertion of the cannula; in retrospect, the time should have been taken to resuture it in place after removal during excision of the valve. Also we have suggested to the manufacturer that the tips be made more rounded. Similar complications could occur with other cannulas in current use. A brief review of the recent literature 1 8 ' " ' 13~21'2* reveals only a few com plications of coronary artery perfusion, although the occurrence of intimal tears and dissection after femoral artery cannulation has been described. 8,2i Bjork 3 reported instances of perforation of the sinus of Valsalva on two separate occasions by hand-held coronary perfusion cannulas. In another report of patients undergoing prosthetic aortic valve replace ment, 14 three deaths were attributed to inadequate coronary perfusion because of anomalies of the coronary artery distribution. In this series, one additional death occurred as a result of a laceration of the left coronary artery. Roe,22 reviewing the current status of aortic valve replacement, mentions the possi bilities of difficulties in this area. No other reports of death or significant com plications attributed directly to coronary artery perfusion were found. One wonders if an unrecognized dissection resulting from coronary perfusion may account for some of the other reported failures of resuscitation of the left ventricle following aortic valve surgery. SUMMARY
A case of coronary artery intimal tear with dissection, as a complication of coronary perfusion, is described. This serves to re-emphasize the need for care in handling of coronary perfusion and the demanding attention to detail that is vital in open-heart surgery. REFERENCES 1. Balmson, H . T., Spencer, F . C , Busse, E . F . G., and Davis, F . W., J r . ; Cusp Replace ment and Coronary Artery Perfusion in Open Operations on the Aortic Valve, Ann. Surg. 152: 494, 1960. 2. Barrett-Boyes, B . G.: Homograft Aortic Valve Replacement in Aortie Incompetence and Stenosis, Thorax 19: 131, 1964. 3. Bjork, V. O.: Aortic Value Replacement, Thorax 19: 369, 1964. 4. Davis, M. V., Mitchell, B . F . , and Adam, M . : Further Experiences With Open Surgery on the Aortic Valve, Am. J . Surg. 106: 641, 1963. 5. Dong, E., Hurley, E. J., Hancock, E . W., Stofer, R. C , and Shumway, N . E . : Surgical Treatment of Aortic Stenosis, Surgery 52: 720, 1962. 6. Effler, D. B., and Groves, L. K . : Open-Heart Surgery for Acquired Valvular Heart Disease, Arch. Surg. 84: 155, 1962. 7. Effler, D. B., Groves, L. K., and Favalaro, R.: Aortic and Mitral Valve Replacement, Arch. Surg. 88: 145, 1964. 8. Glotzer, D. G., Shaw, R. S., and Scannell, J . G.: Calcine Coronary Emboli Following Open Valvuloplasty for Aortie Stenosis, J . THORACIC & CARDIOVAS SURG. 4 3 : 434,
1962. 9. Jones, T. W. Netto, R. R., Winterscheid, L. C , Dillard, D. H., and Merendino, K. A . :
Vol. 49, No. S May, 1965
CORONARY ARTERY DISSECTION
771
Arterial Complications Incident to Cannulations in Open Heart Surgery, Ann. Surg. 152: 969, 1960. 10. Kay, E. B., Head, L. R., and Nogueira, C.: Direct Coronary Artery Perfusion for Aortic Stenosis, J . A. M. A. 168: 1767, 1958. 11. Kay, E. B., Suzuki, A., and Mendelsohn, D.: Operative Results in Aortic Valve Surgery, Circulation 26: 484, 1962. 12. King, B. J., An Improved Coronary Artery Perfusion Cannula, J . THORACIC & CARDIOVAS. SURG. 45:
667,
1963.
13. Larson, R. E., and Kirklin, J . W.: Early and Late Results of Partial and Total Re placement of the Aortic Valve With Individual Teflon Cusps, J . THORACIC & CARDIOVS. SURG. 47:
720,
1964.
14. Lillehei, C. W., Bonnabeau, R. C , and Levy, M. J . : Surgical Correction of Aortic and Mitral Valve Disease by Total Valve Replacement, Geriatrics 19: 240, 1964. 15. McGoon, D. W.: Acquired Aortic Value Disease, Surgery 53: 372, 1963. 16. McGoon, D. C , Mankin, H. T., and Kirklin, J . W.: Results of Open-Heart Operation for Acquired Aortic Valve Disease, J . THORACIC & CARDIOVAS. SURG. 45: 47, 1963. 17. McGoon, D. C , and Moffitt, E. A.: Total Prosthetic Reconstruction of the Aortic Valve, J . THORACIC & CARDIOVAS. SURG. 46:
162,
1963.
18. Morrow, A. G., Austen, W. G., and Braunwald, E.: The Surgical Treatment of Calcine Aortic Stenosis: Operative Methods and Results of Pre- and Post-operative Hemodynamic Assessment, Ann. Surg. 158: 936, 1963. 19. Mulder, D. H., Kattus, A. A., Fonkalsrud, E. W., and Longmire, W. P . : The Surgical Treatment of Acquired Aortic Stenosis, J . THORACIC & CARDIOVAS. SURG. 46: 468, 1963. 20. Muller, W. H., Blank, R. H., and Warren, W. D.: Current Concepts of the Surgical Treatment of Aortic Stenosis, Ann. Surg. 153: 815, 1961. 21. Nelson, T. G., and Coolley, D. A.: Prosthetic Replacement of the Mitral or Aortic Valves, Am. J . Cardiol. 14: 148, 1964. 22. Roe, B . : Prosthetic Aortic Valve: Current Status, Dis. Chest 46: 480, 1964. 23. Sayed, H. E., and Melrose, D. G.: Perfusion Technique in Aortic Valve Surgery, Lancet 1: 551, 1962. 24. Starr, A., Edwards, M. L., McCord, C. W., and Griswold, H. E . : Aortic Replacement: Clinical Experience With a Semirigid Ball Valve Prosthesis, Circulation 27: 779, 1963. 25. Williams, K. R., and Johnson, J . : Aortic Dissection After Femoral Artery Cannulation, Arch. Surg. 89: 663, 1964.
M.D.
Kansas City, Mo., and Kansas City, Kans.
D
coronary artery perfusion has been generally accepted as the best means of myocardial protection during open-heart operations on the aortic valve. The techniques of coronary perfusion have differed in detail with a variety of perfusates, flows, pressures, and temperatures being used. Several different types of coronary perfusion cannulas have been described.1'10> 1 2 > 2 3 We have been using the coronary perfusion catheter manufactured by Abbott Laboratories (Fig. 1). We selected this particular cannula because of its low cost, flexibility, and disposability. In addition, it can be easily secured with a stitch and does not require an assistant to hold it. Recently we encountered a fatal complication during use of this cannula. With the hope that others may avoid this situation, it was our opinion that a brief report was justified. IRECT
CASE REPORT A 45-year-old white man was first seen a t the Kansas City Veterans Administration Hospital in 1958 for treatment of aortic insufficiency and subacute bacterial endocarditis. In subsequent years he was followed as an outpatient, with two admissions for unrelated problems. Complete cardiac evaluation was carried out early in 1964. This demonstrated moderately severe left ventricular hypertrophy and a 25 mm. H g systolie gradient across the aortic valve. Dye dilution curves made by injection of dye at various levels in the thoracic aorta and sampling at the left brachial artery revealed regurgitation from as low as the level of the tenth thoracic vertebra. Progressive disability as well as increasing cardiomegaly demonstrated by x-ray studies led to readmission in September. Operation was performed on Sept. 22, 1964, through a sternal splitting approach. With the use of a single % inch, line in the right atrium and return via the right common femoral artery, cardiopulmonary bypass was initiated and the patient was cooled to 30° C. Exposure of the aortic valve revealed marked calcification of the right and left coronary cusps with obliteration of the commissure between them. The noncoronary cusp was prolapsed into the ventricle and contained a 6 by 4 mm. perforation (Fig. 2 ) . Perfusion of the left coronary artery was begun with the use of cold blood. Because of the extensive calcification involving the annulus, resection of the valve was difficult. The From the Departments of Surgery of the Veterans Administration Hospital, Kansas City, Mo., and the University of Kansas School of Medicine, Kansas City, Kans. Received for publication Dec. 7, 1964. 767
768
HEILBEUNN
AND ZIMMERMAN
J. Thoracic and Cardiovas. Surg.
Fig. 1.—Abbott coronary perfusion catheter. Proximal end made to fit directly to % inch line. Enlarged view of left coronary tip in inset.
LEFT CORONARY CUSP
RIGHT CORONARY CUSP
NON-CORONARY CUSP
whmm in
Fig. 2.—Resected aortic valve. Note perforation of noncoronary cusp and calcific obliteration of commissure between left and right coronary cusps.
Vol. 49, No. 5 May, 1965
CORONARY ARTERY DISSECTION
769
left coronary cannula was removed briefly during excision of the valve and, when reinserted, was not resutured. Subsequently it became dislodged several times. A Starr-Edwards prosthesis was sutured in place. After the patient was rewarmed and the aortotomy was closed, it was noted that the right ventricle was fibrillating vigorously, but the left side had very little activity. With direct current countershoek, the right ventricle quickly resumed an apparently effective beat but, in spite of repeated attempts over a 2 hour period, the left ventricle remained in a slow, weak fibrillation. At autopsy, pertinent findings were limited to the heart. The prosthesis was secure and in excellent position. The orifices of both coronary arteries were unimpaired and there was only minimal evidence of coronary atherosclerosis. A hematoma surrounded the area of the bifurcation of the left coronary artery into its anterior descending and circumflex branches. When the vessel was opened, an obviously recent intimal tear, with a distal flap that obstructed the two branches, was seen (Fig. 3 ) . DISCUSSION
The successful conduct of open-heart surgery demands careful attention to numerous details of technique. The complexities of aortic valve surgery are in creased by the need for coronary perfusion. In the case presented, it appears that an intimal tear was probably produced in the left coronary artery by the
Fig. 3.—Posterior view of base of the heart and root of the aorta shows opened left coronary artery. Artist's diagram shows more clearly the extent of intimal tear and the flap produced.
770
HEILBRUNN
AND ZIMMERMAN
J. Thoracic and Cardiovas. Surg.
tip of the perfusion catheter. This led to the formation of an intimal flap and mural hematoma which occluded the major branches of the left coronary artery. As a result, perfusion to the hypertrophied myocardium was ineffective, and irreversible damage ensued. We have encountered no other difficulty with this cannula and have continued to use it. Possibly the tear which occurred was a consequence of the repeated insertion of the cannula; in retrospect, the time should have been taken to resuture it in place after removal during excision of the valve. Also we have suggested to the manufacturer that the tips be made more rounded. Similar complications could occur with other cannulas in current use. A brief review of the recent literature 1 8 ' " ' 13~21'2* reveals only a few com plications of coronary artery perfusion, although the occurrence of intimal tears and dissection after femoral artery cannulation has been described. 8,2i Bjork 3 reported instances of perforation of the sinus of Valsalva on two separate occasions by hand-held coronary perfusion cannulas. In another report of patients undergoing prosthetic aortic valve replace ment, 14 three deaths were attributed to inadequate coronary perfusion because of anomalies of the coronary artery distribution. In this series, one additional death occurred as a result of a laceration of the left coronary artery. Roe,22 reviewing the current status of aortic valve replacement, mentions the possi bilities of difficulties in this area. No other reports of death or significant com plications attributed directly to coronary artery perfusion were found. One wonders if an unrecognized dissection resulting from coronary perfusion may account for some of the other reported failures of resuscitation of the left ventricle following aortic valve surgery. SUMMARY
A case of coronary artery intimal tear with dissection, as a complication of coronary perfusion, is described. This serves to re-emphasize the need for care in handling of coronary perfusion and the demanding attention to detail that is vital in open-heart surgery. REFERENCES 1. Balmson, H . T., Spencer, F . C , Busse, E . F . G., and Davis, F . W., J r . ; Cusp Replace ment and Coronary Artery Perfusion in Open Operations on the Aortic Valve, Ann. Surg. 152: 494, 1960. 2. Barrett-Boyes, B . G.: Homograft Aortic Valve Replacement in Aortie Incompetence and Stenosis, Thorax 19: 131, 1964. 3. Bjork, V. O.: Aortic Value Replacement, Thorax 19: 369, 1964. 4. Davis, M. V., Mitchell, B . F . , and Adam, M . : Further Experiences With Open Surgery on the Aortic Valve, Am. J . Surg. 106: 641, 1963. 5. Dong, E., Hurley, E. J., Hancock, E . W., Stofer, R. C , and Shumway, N . E . : Surgical Treatment of Aortic Stenosis, Surgery 52: 720, 1962. 6. Effler, D. B., and Groves, L. K . : Open-Heart Surgery for Acquired Valvular Heart Disease, Arch. Surg. 84: 155, 1962. 7. Effler, D. B., Groves, L. K., and Favalaro, R.: Aortic and Mitral Valve Replacement, Arch. Surg. 88: 145, 1964. 8. Glotzer, D. G., Shaw, R. S., and Scannell, J . G.: Calcine Coronary Emboli Following Open Valvuloplasty for Aortie Stenosis, J . THORACIC & CARDIOVAS SURG. 4 3 : 434,
1962. 9. Jones, T. W. Netto, R. R., Winterscheid, L. C , Dillard, D. H., and Merendino, K. A . :
Vol. 49, No. S May, 1965
CORONARY ARTERY DISSECTION
771
Arterial Complications Incident to Cannulations in Open Heart Surgery, Ann. Surg. 152: 969, 1960. 10. Kay, E. B., Head, L. R., and Nogueira, C.: Direct Coronary Artery Perfusion for Aortic Stenosis, J . A. M. A. 168: 1767, 1958. 11. Kay, E. B., Suzuki, A., and Mendelsohn, D.: Operative Results in Aortic Valve Surgery, Circulation 26: 484, 1962. 12. King, B. J., An Improved Coronary Artery Perfusion Cannula, J . THORACIC & CARDIOVAS. SURG. 45:
667,
1963.
13. Larson, R. E., and Kirklin, J . W.: Early and Late Results of Partial and Total Re placement of the Aortic Valve With Individual Teflon Cusps, J . THORACIC & CARDIOVS. SURG. 47:
720,
1964.
14. Lillehei, C. W., Bonnabeau, R. C , and Levy, M. J . : Surgical Correction of Aortic and Mitral Valve Disease by Total Valve Replacement, Geriatrics 19: 240, 1964. 15. McGoon, D. W.: Acquired Aortic Value Disease, Surgery 53: 372, 1963. 16. McGoon, D. C , Mankin, H. T., and Kirklin, J . W.: Results of Open-Heart Operation for Acquired Aortic Valve Disease, J . THORACIC & CARDIOVAS. SURG. 45: 47, 1963. 17. McGoon, D. C , and Moffitt, E. A.: Total Prosthetic Reconstruction of the Aortic Valve, J . THORACIC & CARDIOVAS. SURG. 46:
162,
1963.
18. Morrow, A. G., Austen, W. G., and Braunwald, E.: The Surgical Treatment of Calcine Aortic Stenosis: Operative Methods and Results of Pre- and Post-operative Hemodynamic Assessment, Ann. Surg. 158: 936, 1963. 19. Mulder, D. H., Kattus, A. A., Fonkalsrud, E. W., and Longmire, W. P . : The Surgical Treatment of Acquired Aortic Stenosis, J . THORACIC & CARDIOVAS. SURG. 46: 468, 1963. 20. Muller, W. H., Blank, R. H., and Warren, W. D.: Current Concepts of the Surgical Treatment of Aortic Stenosis, Ann. Surg. 153: 815, 1961. 21. Nelson, T. G., and Coolley, D. A.: Prosthetic Replacement of the Mitral or Aortic Valves, Am. J . Cardiol. 14: 148, 1964. 22. Roe, B . : Prosthetic Aortic Valve: Current Status, Dis. Chest 46: 480, 1964. 23. Sayed, H. E., and Melrose, D. G.: Perfusion Technique in Aortic Valve Surgery, Lancet 1: 551, 1962. 24. Starr, A., Edwards, M. L., McCord, C. W., and Griswold, H. E . : Aortic Replacement: Clinical Experience With a Semirigid Ball Valve Prosthesis, Circulation 27: 779, 1963. 25. Williams, K. R., and Johnson, J . : Aortic Dissection After Femoral Artery Cannulation, Arch. Surg. 89: 663, 1964.