- Email: [email protected]
Intraoperative Diagnosis of Unroofed Coronary Sinus After Aortic Valve Replacement
296
CASE REPORT PAYNE ET AL INTRAOPERATIVE UNROOFED CORONARY SINUS
4. Kotelis D, Geisbusch P, Hinz U, et al. Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg 2009;50:1285–1292. 5. Cooper DG, Walsh SR, Sadat U, et al. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and metaanalysis. J Vasc Surg 2009;49:1594 – 601. 6. Woo EY, Carpenter JP, Jackson BM, et al. Left subclavian artery coverage during thoracic endovascular aortic repair: a single center experience. J Vasc Surg 2008;48:555– 60. 7. Reece TB, Gazoni LM, Cherry KJ, et al. Reevaluating the need for left subclavian artery revascularization with thoracic endovascular aortic repair. Ann Thorac Surg 2007;84: 1201–5.
Intraoperative Diagnosis of Unroofed Coronary Sinus After Aortic Valve Replacement Darrin M. Payne, MD, Andrew Hamilton, MD, Brian Milne, MD, Robert Tanzola, MD, and Michael O’Reilly, MD Department of Surgery, Division of Cardiac Surgery, Department of Anesthesiology and Perioperative Medicine, and Department of Medicine, Division of Cardiology, Kingston General Hospital, Queens University, Kingston, Ontario, Canada
FEATURE ARTICLES
A patient with combined aortic insufficiency and stenosis underwent aortic valve replacement. After weaning off cardiopulmonary bypass, a new shunt into the left atrium was noted that had not been apparent on multiple previous echocardiographs. Using an agitated saline test, we confirmed a shunt between the coronary sinus and left atrium. The assumption was made that there had been an iatrogenic fistula created with placement of the retrograde catheter; however, upon opening the left atrium it was realized that the patient had a previously undiagnosed, congenitally unroofed coronary sinus. It was repaired primarily and the patient had an uneventful recovery. (Ann Thorac Surg 2012;93:296 –7) © 2012 by The Society of Thoracic Surgeons
Ann Thorac Surg 2012;93:296 –7
symptoms, a repeated echocardiograph was performed and revealed severe AS (mean and peak gradients of 58 mm Hg and 94 mm Hg, respectively) and severe AI. Left ventricular function was preserved. The remainder of the echocardiograph was unremarkable. A coronary angiogram was completed, displaying normal coronary anatomy with no significant disease. He was taken to the operating room to undergo aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) was performed, confirming severe AS and AI. No other significant findings were observed throughout the complete TEE study. Median sternotomy was performed and the aorta and right atrium were cannulated routinely. A retrograde coronary sinus catheter was placed. The aorta was cross-clamped and retrograde cardioplegia was delivered. While delivering cardioplegia, the coronary sinus (CS) pressure tended to be low, and flow rates tended to be higher than normally observed. Arrest was achieved after approximately 800 mL of retrograde cardioplegia was given. The aorta was opened and an additional dose of 600 mL of antegrade cardioplegia was delivered directly down the right and left coronaries because of concerns regarding the adequacy of our retrograde protection. Aortic valve replacement was performed uneventfully and a no. 27 St. Jude Epic bioprosthetic valve (St. Jude Medical, St. Paul, MN) was implanted. Throughout implantation, retrograde coronary cardioplegia was delivered and good return was noted from both the left and right coronary ostia. Transesophageal echocardiography was performed after uneventful weaning from cardiopulmonary bypass (CPB), revealing normal left ventricular and prosthetic valvular function. However, a systolic shunt was observed entering the left atrium (LA) between the atrial appendage and the mitral annulus which had not been identified before CPB (Fig 1). The source of the inflow was not clear despite real-time review by multiple trained echocardiographers. It was suggested that the inflow could be arising from the CS. A small amount of agitated saline was injected through the CS catheter, and
U
nroofed coronary sinus is a rare congenital defect in which there is a complete or partial lack of the partition separating the coronary sinus and the left atrium; it is often associated with other congenital abnormalities. Patients may be completely asymptomatic or present with dyspnea, cyanosis, hypoxia, paradoxical embolus, cerebral abscess, or right-sided heart failure [1, 2]. We present a case of a patient in whom we discovered an unroofed coronary sinus intraoperatively after a routine aortic valve replacement. A 53-year-old man had been followed for moderate aortic stenosis (AS) and aortic insufficiency (AI). With onset of
Accepted for publication June 13, 2011. Address correspondence to Dr Payne, Kingston General Hospital, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Intraoperative transesophageal echocardiograph showing shunt between the coronary sinus and left atrium. (AVR ⫽ aortic valve replacement; CS ⫽ coronary sinus; LA ⫽ left atrium.) 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.06.076
Ann Thorac Surg 2012;93:297–9
CASE REPORT SELZMAN ET AL EBSTEIN’S ANOMALY AND LVADS
297
Fig 2. (A) Intraoperative transesophageal echocardiograph showing communication between coronary sinus (CS) and left atrium (LA) (pre– bubble test). (B) Intraoperative transesophageal echocardiograph of bubble test showing communication between the coronary sinus and left atrium. (AVR ⫽ aortic valve replacement.)
Comment An unroofed CS is a rare lesion in which the CS communicates directly with the LA because of a congenital defect in the tissue separating the LA and the CS. These lesions the rarest type of atrial septal defect and are often associated with other congenital cardiac defects, particularly a persistent left superior vena cava [1, 2]. They are most commonly diagnosed and dealt with in childhood. Common diagnostic modalities include echocardiography, computed tomography, and magnetic resonance imaging. Interestingly, our patient had undergone multiple previous echocardiographies, none of which had revealed the lesion. Echocardiography, particularly TEE, is typically reliable in detecting an unroofed CS, which can be best observed in midesophageal long-axis views [3]. It is possible that the presence of the retrograde CS catheter was functioning as a buttress to hold the CS open and amplify the shunt. Because TEE was unreliable in determining the precise origin of the shunt, the intraoperative bubble test was instrumental in confirming the cause. In retrospect, the low CS pressures and high flow rates noted with our delivery of CS cardioplegia could be explained by the communication with the LA. Although © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
rare, the presence of a previously undiagnosed unroofed CS should be considered in the setting of a new-onset, poorly explained LA shunt following cardiac surgery.
References 1. Thangaroopan M, Truong QA, Kalra MK, Yared K, Abbara S. Rare case of an unroofed coronary sinus diagnosis by multidetector computed tomography. Circulation 2009;119: e518 –20. 2. Ootaki Y, Yamaguchi M, Yoshimura N, Oka S, Yoshida M, Hasegawa T. Unroofed coronary sinus syndrome: diagnosis, classification, and surgical treatment. J Thorac Cardiovasc Surg 2003;126:1655– 6. 3. Joffe DC, Rivo J, Oxorn DC. Coronary sinus atrial septal defect. Anesth Analg 2008:107;1163–5.
Complications Associated With the Use of Left Ventricular Assist Device Therapy in an Adult Patient With Ebstein’s Anomaly Craig H. Selzman, MD, Georges Desjardins, MD, Amit N. Patel, MD, Erin Davis, RN, Sara Dick, RN, and Josef Stehlik, MD Departments of Cardiothoracic Surgery, Anesthesia, and Cardiology, University of Utah, Salt Lake City, Utah
This case describes issues related to left ventricular assist device placement in an adult with ischemic heart disease with well-compensated Ebstein’s anomaly who subsequently developed severe right heart dysfunction. We discuss strategies for dealing with this rare but structurally important congenital heart defect. (Ann Thorac Surg 2012;93:297–9) © 2012 by The Society of Thoracic Surgeons
T
he use of left ventricular assist devices (LVADs) for bridging ill patients to transplant has become a standard operation at most transplant centers. We report on an adult patient with end-stage heart disease from
Accepted for publication June 16, 2011. Address correspondence to Dr Selzman, Division of Cardiothoracic Surgery, University of Utah, 30 N 1900 E, SOM 3C 127, Salt Lake City, UT 84132; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.06.063
FEATURE ARTICLES
shunting into the LA was confirmed with TEE (Figs 2A, 2B). The assumption was made that an iatrogenic fistula between the CS and the LA was created by placement of the retrograde catheter. CPB was resumed and the aorta was reclamped. Attempted repair on the arrested heart was made by placing a large pledgeted 3-0 prolene suture from the left ventricle, underneath the left circumflex coronary into the base of the left atrial appendage. The patient was again weaned uneventfully from CPB, but the shunt remained. The decision was made to repair the defect from inside the LA. The heart was again arrested and the LA was entered directly. The defect was identified at the base of the left atrial appendage, measuring approximately 8 mm in diameter. It was clear that this defect was not iatrogenic, because the opening was well endothelialized with no evidence of trauma. The diagnosis of a congenital unroofed CS was made, and it was easily repaired primarily with a 4-0 prolene suture. No other anatomic abnormalities were observed. The patient was subsequently weaned from CPB, and TEE confirmed no residual shunt. The patient had an unremarkable postoperative course and was discharged home on postoperative day 4.
CASE REPORT PAYNE ET AL INTRAOPERATIVE UNROOFED CORONARY SINUS
4. Kotelis D, Geisbusch P, Hinz U, et al. Short and midterm results after left subclavian artery coverage during endovascular repair of the thoracic aorta. J Vasc Surg 2009;50:1285–1292. 5. Cooper DG, Walsh SR, Sadat U, et al. Neurological complications after left subclavian artery coverage during thoracic endovascular aortic repair: a systematic review and metaanalysis. J Vasc Surg 2009;49:1594 – 601. 6. Woo EY, Carpenter JP, Jackson BM, et al. Left subclavian artery coverage during thoracic endovascular aortic repair: a single center experience. J Vasc Surg 2008;48:555– 60. 7. Reece TB, Gazoni LM, Cherry KJ, et al. Reevaluating the need for left subclavian artery revascularization with thoracic endovascular aortic repair. Ann Thorac Surg 2007;84: 1201–5.
Intraoperative Diagnosis of Unroofed Coronary Sinus After Aortic Valve Replacement Darrin M. Payne, MD, Andrew Hamilton, MD, Brian Milne, MD, Robert Tanzola, MD, and Michael O’Reilly, MD Department of Surgery, Division of Cardiac Surgery, Department of Anesthesiology and Perioperative Medicine, and Department of Medicine, Division of Cardiology, Kingston General Hospital, Queens University, Kingston, Ontario, Canada
FEATURE ARTICLES
A patient with combined aortic insufficiency and stenosis underwent aortic valve replacement. After weaning off cardiopulmonary bypass, a new shunt into the left atrium was noted that had not been apparent on multiple previous echocardiographs. Using an agitated saline test, we confirmed a shunt between the coronary sinus and left atrium. The assumption was made that there had been an iatrogenic fistula created with placement of the retrograde catheter; however, upon opening the left atrium it was realized that the patient had a previously undiagnosed, congenitally unroofed coronary sinus. It was repaired primarily and the patient had an uneventful recovery. (Ann Thorac Surg 2012;93:296 –7) © 2012 by The Society of Thoracic Surgeons
Ann Thorac Surg 2012;93:296 –7
symptoms, a repeated echocardiograph was performed and revealed severe AS (mean and peak gradients of 58 mm Hg and 94 mm Hg, respectively) and severe AI. Left ventricular function was preserved. The remainder of the echocardiograph was unremarkable. A coronary angiogram was completed, displaying normal coronary anatomy with no significant disease. He was taken to the operating room to undergo aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) was performed, confirming severe AS and AI. No other significant findings were observed throughout the complete TEE study. Median sternotomy was performed and the aorta and right atrium were cannulated routinely. A retrograde coronary sinus catheter was placed. The aorta was cross-clamped and retrograde cardioplegia was delivered. While delivering cardioplegia, the coronary sinus (CS) pressure tended to be low, and flow rates tended to be higher than normally observed. Arrest was achieved after approximately 800 mL of retrograde cardioplegia was given. The aorta was opened and an additional dose of 600 mL of antegrade cardioplegia was delivered directly down the right and left coronaries because of concerns regarding the adequacy of our retrograde protection. Aortic valve replacement was performed uneventfully and a no. 27 St. Jude Epic bioprosthetic valve (St. Jude Medical, St. Paul, MN) was implanted. Throughout implantation, retrograde coronary cardioplegia was delivered and good return was noted from both the left and right coronary ostia. Transesophageal echocardiography was performed after uneventful weaning from cardiopulmonary bypass (CPB), revealing normal left ventricular and prosthetic valvular function. However, a systolic shunt was observed entering the left atrium (LA) between the atrial appendage and the mitral annulus which had not been identified before CPB (Fig 1). The source of the inflow was not clear despite real-time review by multiple trained echocardiographers. It was suggested that the inflow could be arising from the CS. A small amount of agitated saline was injected through the CS catheter, and
U
nroofed coronary sinus is a rare congenital defect in which there is a complete or partial lack of the partition separating the coronary sinus and the left atrium; it is often associated with other congenital abnormalities. Patients may be completely asymptomatic or present with dyspnea, cyanosis, hypoxia, paradoxical embolus, cerebral abscess, or right-sided heart failure [1, 2]. We present a case of a patient in whom we discovered an unroofed coronary sinus intraoperatively after a routine aortic valve replacement. A 53-year-old man had been followed for moderate aortic stenosis (AS) and aortic insufficiency (AI). With onset of
Accepted for publication June 13, 2011. Address correspondence to Dr Payne, Kingston General Hospital, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Intraoperative transesophageal echocardiograph showing shunt between the coronary sinus and left atrium. (AVR ⫽ aortic valve replacement; CS ⫽ coronary sinus; LA ⫽ left atrium.) 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.06.076
Ann Thorac Surg 2012;93:297–9
CASE REPORT SELZMAN ET AL EBSTEIN’S ANOMALY AND LVADS
297
Fig 2. (A) Intraoperative transesophageal echocardiograph showing communication between coronary sinus (CS) and left atrium (LA) (pre– bubble test). (B) Intraoperative transesophageal echocardiograph of bubble test showing communication between the coronary sinus and left atrium. (AVR ⫽ aortic valve replacement.)
Comment An unroofed CS is a rare lesion in which the CS communicates directly with the LA because of a congenital defect in the tissue separating the LA and the CS. These lesions the rarest type of atrial septal defect and are often associated with other congenital cardiac defects, particularly a persistent left superior vena cava [1, 2]. They are most commonly diagnosed and dealt with in childhood. Common diagnostic modalities include echocardiography, computed tomography, and magnetic resonance imaging. Interestingly, our patient had undergone multiple previous echocardiographies, none of which had revealed the lesion. Echocardiography, particularly TEE, is typically reliable in detecting an unroofed CS, which can be best observed in midesophageal long-axis views [3]. It is possible that the presence of the retrograde CS catheter was functioning as a buttress to hold the CS open and amplify the shunt. Because TEE was unreliable in determining the precise origin of the shunt, the intraoperative bubble test was instrumental in confirming the cause. In retrospect, the low CS pressures and high flow rates noted with our delivery of CS cardioplegia could be explained by the communication with the LA. Although © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
rare, the presence of a previously undiagnosed unroofed CS should be considered in the setting of a new-onset, poorly explained LA shunt following cardiac surgery.
References 1. Thangaroopan M, Truong QA, Kalra MK, Yared K, Abbara S. Rare case of an unroofed coronary sinus diagnosis by multidetector computed tomography. Circulation 2009;119: e518 –20. 2. Ootaki Y, Yamaguchi M, Yoshimura N, Oka S, Yoshida M, Hasegawa T. Unroofed coronary sinus syndrome: diagnosis, classification, and surgical treatment. J Thorac Cardiovasc Surg 2003;126:1655– 6. 3. Joffe DC, Rivo J, Oxorn DC. Coronary sinus atrial septal defect. Anesth Analg 2008:107;1163–5.
Complications Associated With the Use of Left Ventricular Assist Device Therapy in an Adult Patient With Ebstein’s Anomaly Craig H. Selzman, MD, Georges Desjardins, MD, Amit N. Patel, MD, Erin Davis, RN, Sara Dick, RN, and Josef Stehlik, MD Departments of Cardiothoracic Surgery, Anesthesia, and Cardiology, University of Utah, Salt Lake City, Utah
This case describes issues related to left ventricular assist device placement in an adult with ischemic heart disease with well-compensated Ebstein’s anomaly who subsequently developed severe right heart dysfunction. We discuss strategies for dealing with this rare but structurally important congenital heart defect. (Ann Thorac Surg 2012;93:297–9) © 2012 by The Society of Thoracic Surgeons
T
he use of left ventricular assist devices (LVADs) for bridging ill patients to transplant has become a standard operation at most transplant centers. We report on an adult patient with end-stage heart disease from
Accepted for publication June 16, 2011. Address correspondence to Dr Selzman, Division of Cardiothoracic Surgery, University of Utah, 30 N 1900 E, SOM 3C 127, Salt Lake City, UT 84132; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.06.063
FEATURE ARTICLES
shunting into the LA was confirmed with TEE (Figs 2A, 2B). The assumption was made that an iatrogenic fistula between the CS and the LA was created by placement of the retrograde catheter. CPB was resumed and the aorta was reclamped. Attempted repair on the arrested heart was made by placing a large pledgeted 3-0 prolene suture from the left ventricle, underneath the left circumflex coronary into the base of the left atrial appendage. The patient was again weaned uneventfully from CPB, but the shunt remained. The decision was made to repair the defect from inside the LA. The heart was again arrested and the LA was entered directly. The defect was identified at the base of the left atrial appendage, measuring approximately 8 mm in diameter. It was clear that this defect was not iatrogenic, because the opening was well endothelialized with no evidence of trauma. The diagnosis of a congenital unroofed CS was made, and it was easily repaired primarily with a 4-0 prolene suture. No other anatomic abnormalities were observed. The patient was subsequently weaned from CPB, and TEE confirmed no residual shunt. The patient had an unremarkable postoperative course and was discharged home on postoperative day 4.