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Free Wall Rupture After Arterial Switch Operation
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CASE REPORT GIL-JAURENA ET AL WALL RUPTURE AFTER SWITCH
Ann Thorac Surg 2014;98:2230–1
Free Wall Rupture After Arterial Switch Operation
Juan-Miguel Gil-Jaurena, MD, Angel Aroca, MD, Ram on P erez-Caballero, MD, PhD, and Ana Pita, MD n, and Pediatric Cardiac Surgery, Hospital Gregorio Mara~ no Pediatric Cardiac Surgery, Hospital La Paz, Madrid, Spain
A neonate underwent arterial switch operation, supported on extracorporeal membrane oxygenation for 3 days. Two weeks later, a pseudoaneurysm was seen on an echocardiogram, and a free wall rupture was suggested. Prompt surgery was performed, a free wall rupture assessed, and a patch with BioGlue was applied successfully. One year later, the child is in good condition. (Ann Thorac Surg 2014;98:2230–1) Ó 2014 by The Society of Thoracic Surgeons
A
FEATURE ARTICLES
rterial switch operation (ASO) for transposition of the great arteries (TGA) is a well-known procedure with excellent surgical results nowadays. Several stepwise conditions, such as a particular coronary pattern plus a hypocoagulability setting because of extracorporeal membrane oxygenation (ECMO) support, led to an unexpected complication in the case reported. A high degree of suspicion followed by a prompt surgical revision, closer to a postischemic event in the adult population, yields a good result in the short and midterm. A child delivered by caesarean section at 37 weeks’ gestation, weighing 2,600 kg, received a diagnosis of TGA and small ventricular septal defect. Because of a restrictive atrial septal defect, a Rashkind septostomy was performed 2 days later and, once stabilized, the patient was electively scheduled for surgery. Standard switch procedure with arterial return and bicaval cannulation was performed on day 7, including closure of atrial septal defect and ventricular septal defect (the latter, with a single stitch). The anterior descending coronary artery came from sinus one, and the right coronary artery from sinus two. The circumflex vessel came from the right artery (so-called type D). The Lecompte maneuver was performed, and the neopulmonary root was fashioned with a glutaraldehyde-treated patch of autologous pericardium. Off bypass, the right coronary artery was dissected further to become tension-free. Despite this maneuver, a second pump run was conducted and eventually supported with ECMO because of moderate dysfunction. Three days later, the ventricular function was restored and the child was weaned off ECMO. Recovery was seamless thereafter. In a regular echocardiographic study on day 22, an image suggesting a pseudoaneurysm in the left ventricle with pericardial
Fig 1. Subcostal four-chamber view. Pericardial effusion close to the left ventricle free-wall. The arrow indicates the pseudoaneurysm.
effusion (Fig 1) and blood exiting the ventricle toward the pericardial well (Fig 2) was captured. On an emergent basis, the patient was brought back to the operating room and placed on bypass, cannulating the ascending aorta and the right atrial appendage. After gently lifting the left ventricle, some oozing was observed in the lateral wall between the first and second marginal branches, and a free wall rupture was suggested. Several epicardial stitches proved ineffective, and a Dacron patch with BioGlue was applied. Bypass was discontinued and the chest was closed, with a straightforward recovery except for a shunt that was implanted because of hydrocephaly before discharge. One year later, the child is in good condition, weighs 8 kg, shows good biventricular function on an echocardiogram with no evidence of wall rupture, and is drug free.
Accepted for publication Jan 14, 2014. Address correspondence to Dr Gil-Jaurena, Pediatric Cardiac Surgery, n, C/O’Donnell 50, Hospital General Universitario Gregorio Mara~ no 28009, Madrid, Spain; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 2. Subcostal short axis. Doppler showing communication between the left ventricle and the pseudoaneurysm (free-wall rupture), indicated by an arrow. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.072
Ann Thorac Surg 2014;98:2230–1
References 1. Reardon MJ, Carr CL, Diamond A, et al. Ischemic left ventricular free wall rupture: prediction, diagnosis, and treatment. Ann Thorac Surg 1997;64:1509–13. 2. Iemura J, Oku H, Otaki M, Kitayama H, Inoue T, Kaneda T. Surgical strategy for left ventricular free wall rupture after acute myocardial infarction. Ann Thorac Surg 2001;71:201–4. 3. Stiegel M, Zimmern SH, Robicsek F. Left ventricular rupture following coronary occlusion treated by streptokinase infusion: successful surgical repair. Ann Thorac Surg 1987;44: 413–5. 4. Padr o JM, Caralps JM, Montoya JD, C amara ML, Garcia Picart J, Arís A. Sutureless repair of postinfarction cardiac rupture. J Card Surg 1988;3:491–3. 5. Carnero-Alc azar M, Alswies A, Perez-Isla L, et al. Short-term and mid-term follow-up of sutureless surgery for postinfarction subacute free wall rupture. Interact CardioVasc Thorac Surg 2009;8:619–23. 6. Raffa GM, Tarelli G, Patrini D, Settepani F. Sutureless repair for postinfarction cardiac rupture: a simple approach with a tissue-adhering patch. J Thorac Cardiovasc Surg 2013;145: 598–9. 7. Kadner A, Fasnatch M, Krestchmar O, Pretre R. Traumatic free wall and ventricular septal rupture -“hybrid” management in a child. Eur J Cardiothorac Surg 2007;31:949–51. 8. Belli E, Basaran M. Left ventricular pseudoaneurysm in children following subaortic muscular resection. World J Pediatr Congenit Heart Surg 2010;1:386–8.
FEATURE ARTICLES
Although rare, mechanical complications after myocardial infarction are well known: acute mitral regurgitation, ventricular septal defect, and free wall rupture. They usually spring beyond 3 days after the ischemic event and might be enhanced by a fibrinolytic state [1–3]. A high degree of suspicion is needed for the diagnosis of these otherwise dreadful side effects. ASO for TGA carries gentle dissection of the coronary arteries and their transfer to a new position, which implies a risk of ischemic events. Growing experience with this technique has yielded good results, and electrical changes which might need surgical revision of the coronary arteries are exceptional. On the other hand, ECMO support for global dysfunction can hide any subtle impairment once it is overcome. Our case report shows a neonate undergoing ASO for TGA, with ECMO support during 3 days and a subacute free wall rupture with a successful outcome following surgery. We hypothesize that any stretch or kink in the circumflex artery, coming off the right one, might have played a role in putting the lateral wall of the left ventricle at risk. Although a prompt revision of the coronary artery was attempted, an ischemic event could have happened in that particular area and gone unnoticed by the ECMO support. The self-contained rupture was first realized on discovering the pseudoaneurysm 15 days later. There was no hesitation in revisiting the patient and, under extracorporeal circulation, fixing the friable wall with a patch on glue as previously published. Several reports have been published about free wall rupture in adults, addressing the pros and cons of extracorporeal circulation, exclusion of the infarcted area with or without stitches, and a range of glues and patches [4–6]. If an acute event in a neonate is resolved, there is a lifespan of follow-up, as opposed to older patients. To our knowledge, this is the first report of a free wall rupture in a child after surgical repair. Two related
2231
reports have been found: one case of a traumatic rupture [7] and a case depicting two patients with a pseudoaneurysm after subaortic resection [8]. Uneven epicardial detachment of a coronary artery followed by a status of hypocoagulability on ECMO might have triggered the wall rupture (mimicking what we know from adults). In such a setting, a low threshold for mechanical side effects after ischemic events must be considered. Prompt surgery, performed the same way as reported in the literature (but on pump), proved successful. Because the child is in good cardiac condition 1 year later, coronarography has not been deemed necessary thus far.
ˇ
Comment
CASE REPORT GIL-JAURENA ET AL WALL RUPTURE AFTER SWITCH
CASE REPORT GIL-JAURENA ET AL WALL RUPTURE AFTER SWITCH
Ann Thorac Surg 2014;98:2230–1
Free Wall Rupture After Arterial Switch Operation
Juan-Miguel Gil-Jaurena, MD, Angel Aroca, MD, Ram on P erez-Caballero, MD, PhD, and Ana Pita, MD n, and Pediatric Cardiac Surgery, Hospital Gregorio Mara~ no Pediatric Cardiac Surgery, Hospital La Paz, Madrid, Spain
A neonate underwent arterial switch operation, supported on extracorporeal membrane oxygenation for 3 days. Two weeks later, a pseudoaneurysm was seen on an echocardiogram, and a free wall rupture was suggested. Prompt surgery was performed, a free wall rupture assessed, and a patch with BioGlue was applied successfully. One year later, the child is in good condition. (Ann Thorac Surg 2014;98:2230–1) Ó 2014 by The Society of Thoracic Surgeons
A
FEATURE ARTICLES
rterial switch operation (ASO) for transposition of the great arteries (TGA) is a well-known procedure with excellent surgical results nowadays. Several stepwise conditions, such as a particular coronary pattern plus a hypocoagulability setting because of extracorporeal membrane oxygenation (ECMO) support, led to an unexpected complication in the case reported. A high degree of suspicion followed by a prompt surgical revision, closer to a postischemic event in the adult population, yields a good result in the short and midterm. A child delivered by caesarean section at 37 weeks’ gestation, weighing 2,600 kg, received a diagnosis of TGA and small ventricular septal defect. Because of a restrictive atrial septal defect, a Rashkind septostomy was performed 2 days later and, once stabilized, the patient was electively scheduled for surgery. Standard switch procedure with arterial return and bicaval cannulation was performed on day 7, including closure of atrial septal defect and ventricular septal defect (the latter, with a single stitch). The anterior descending coronary artery came from sinus one, and the right coronary artery from sinus two. The circumflex vessel came from the right artery (so-called type D). The Lecompte maneuver was performed, and the neopulmonary root was fashioned with a glutaraldehyde-treated patch of autologous pericardium. Off bypass, the right coronary artery was dissected further to become tension-free. Despite this maneuver, a second pump run was conducted and eventually supported with ECMO because of moderate dysfunction. Three days later, the ventricular function was restored and the child was weaned off ECMO. Recovery was seamless thereafter. In a regular echocardiographic study on day 22, an image suggesting a pseudoaneurysm in the left ventricle with pericardial
Fig 1. Subcostal four-chamber view. Pericardial effusion close to the left ventricle free-wall. The arrow indicates the pseudoaneurysm.
effusion (Fig 1) and blood exiting the ventricle toward the pericardial well (Fig 2) was captured. On an emergent basis, the patient was brought back to the operating room and placed on bypass, cannulating the ascending aorta and the right atrial appendage. After gently lifting the left ventricle, some oozing was observed in the lateral wall between the first and second marginal branches, and a free wall rupture was suggested. Several epicardial stitches proved ineffective, and a Dacron patch with BioGlue was applied. Bypass was discontinued and the chest was closed, with a straightforward recovery except for a shunt that was implanted because of hydrocephaly before discharge. One year later, the child is in good condition, weighs 8 kg, shows good biventricular function on an echocardiogram with no evidence of wall rupture, and is drug free.
Accepted for publication Jan 14, 2014. Address correspondence to Dr Gil-Jaurena, Pediatric Cardiac Surgery, n, C/O’Donnell 50, Hospital General Universitario Gregorio Mara~ no 28009, Madrid, Spain; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 2. Subcostal short axis. Doppler showing communication between the left ventricle and the pseudoaneurysm (free-wall rupture), indicated by an arrow. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.072
Ann Thorac Surg 2014;98:2230–1
References 1. Reardon MJ, Carr CL, Diamond A, et al. Ischemic left ventricular free wall rupture: prediction, diagnosis, and treatment. Ann Thorac Surg 1997;64:1509–13. 2. Iemura J, Oku H, Otaki M, Kitayama H, Inoue T, Kaneda T. Surgical strategy for left ventricular free wall rupture after acute myocardial infarction. Ann Thorac Surg 2001;71:201–4. 3. Stiegel M, Zimmern SH, Robicsek F. Left ventricular rupture following coronary occlusion treated by streptokinase infusion: successful surgical repair. Ann Thorac Surg 1987;44: 413–5. 4. Padr o JM, Caralps JM, Montoya JD, C amara ML, Garcia Picart J, Arís A. Sutureless repair of postinfarction cardiac rupture. J Card Surg 1988;3:491–3. 5. Carnero-Alc azar M, Alswies A, Perez-Isla L, et al. Short-term and mid-term follow-up of sutureless surgery for postinfarction subacute free wall rupture. Interact CardioVasc Thorac Surg 2009;8:619–23. 6. Raffa GM, Tarelli G, Patrini D, Settepani F. Sutureless repair for postinfarction cardiac rupture: a simple approach with a tissue-adhering patch. J Thorac Cardiovasc Surg 2013;145: 598–9. 7. Kadner A, Fasnatch M, Krestchmar O, Pretre R. Traumatic free wall and ventricular septal rupture -“hybrid” management in a child. Eur J Cardiothorac Surg 2007;31:949–51. 8. Belli E, Basaran M. Left ventricular pseudoaneurysm in children following subaortic muscular resection. World J Pediatr Congenit Heart Surg 2010;1:386–8.
FEATURE ARTICLES
Although rare, mechanical complications after myocardial infarction are well known: acute mitral regurgitation, ventricular septal defect, and free wall rupture. They usually spring beyond 3 days after the ischemic event and might be enhanced by a fibrinolytic state [1–3]. A high degree of suspicion is needed for the diagnosis of these otherwise dreadful side effects. ASO for TGA carries gentle dissection of the coronary arteries and their transfer to a new position, which implies a risk of ischemic events. Growing experience with this technique has yielded good results, and electrical changes which might need surgical revision of the coronary arteries are exceptional. On the other hand, ECMO support for global dysfunction can hide any subtle impairment once it is overcome. Our case report shows a neonate undergoing ASO for TGA, with ECMO support during 3 days and a subacute free wall rupture with a successful outcome following surgery. We hypothesize that any stretch or kink in the circumflex artery, coming off the right one, might have played a role in putting the lateral wall of the left ventricle at risk. Although a prompt revision of the coronary artery was attempted, an ischemic event could have happened in that particular area and gone unnoticed by the ECMO support. The self-contained rupture was first realized on discovering the pseudoaneurysm 15 days later. There was no hesitation in revisiting the patient and, under extracorporeal circulation, fixing the friable wall with a patch on glue as previously published. Several reports have been published about free wall rupture in adults, addressing the pros and cons of extracorporeal circulation, exclusion of the infarcted area with or without stitches, and a range of glues and patches [4–6]. If an acute event in a neonate is resolved, there is a lifespan of follow-up, as opposed to older patients. To our knowledge, this is the first report of a free wall rupture in a child after surgical repair. Two related
2231
reports have been found: one case of a traumatic rupture [7] and a case depicting two patients with a pseudoaneurysm after subaortic resection [8]. Uneven epicardial detachment of a coronary artery followed by a status of hypocoagulability on ECMO might have triggered the wall rupture (mimicking what we know from adults). In such a setting, a low threshold for mechanical side effects after ischemic events must be considered. Prompt surgery, performed the same way as reported in the literature (but on pump), proved successful. Because the child is in good cardiac condition 1 year later, coronarography has not been deemed necessary thus far.
ˇ
Comment
CASE REPORT GIL-JAURENA ET AL WALL RUPTURE AFTER SWITCH