- Email: [email protected]
Novel Repair for Late Posttraumatic Aortic Valve Injury and Root Pseudoaneurysm
350
CASE REPORT VENTURINI ET AL STENTLESS VALVE FOR ROOT PSEUDOANEURYSM
FEATURE ARTICLES
the present case, is highly suggestive of subclavian artery trauma, aortography is the imaging modality of choice to confirm the diagnosis [6]. However, since trauma centers provide computed tomography on a 24-hour basis, in the setting of acute trauma, computed tomographic scanning is quicker, simpler, cost-effective, and an equally sensitive evaluation of aortic and great vessel injuries with a reported diagnostic accuracy of 88% to 100% [8]. Also in this case, transesophageal echocardiography proved very useful as a portable intraoperative monitoring examination. Transesophageal echocardiography is the only imaging modality that can be performed on very unstable patients, thus it can be very helpful for diagnosis, monitoring, and decision making in acute situations [8]. A full median sternotomy was performed to allow maximum exposure. Given the location of injury, hypothermic cardiopulmonary bypass and circulatory arrest was instituted to ensure adequate proximal hemostatic control of the great vessels and to provide cerebral and distal spinal cord protection. Proximal control of the subclavian artery could not be achieved with tangential clamping, and complete aortic occlusion was used instead. In this case the patient recovered without any neurologic deficits or paraplegia. Therapeutic approaches for traumatic subclavian artery repair described in the literature include ligation of the artery, end-to-end anastomosis with or without excision of the traumatized vessel parts or insertion of a saphenous vein or prosthetic graft to bridge the defect after retraction of the traumatized vessel segments [4]. Anatomical repair is clearly the most desirable surgical option, especially in older patients in which ligation is not as well tolerated. Whether or not one uses some type of vascular substitute, vein or synthetic prosthetic graft material does not seem to affect outcome [4]. The results from subclavian artery surgery are very satisfactory with morbidity and mortality rates reported at 14.3% and 4.8%, respectively [2, 6]. Improvements in diagnosis, surgical techniques, and cardiopulmonary bypass utilization contribute to this favorable outcome. In conclusion, we describe the successful surgical management of a patient with traumatic avulsion of a single right subclavian artery. Improved diagnostic and surgical repair principles produced an excellent postoperative outcome and recovery.
We would like to thank David Hayes for his descriptive illustrations.
References 1. Moes CAF, Benson LN, Barrows PE, et al. The subclavian artery as the first branch of the aortic arch. Pediatr Cardiol 1991;12:39. 2. Strum JT, Dorsey JS, Olson FR, et al. The management of subclavian artery injuries following blunt thoracic trauma. Ann Thorac Surg 1984;38:188 –91. 3. Zelenock GB, Kazmers A, Graham LM, et al. Non-penetrating subclavian artery injuries. Arch Surg 1985;120:685–92. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2006;81:350 –2
4. Posner MP, Deitrick J, McGrath P, et al. Nonpenetrating vascular injury to the subclavian artery. J Vasc Surg 1988;8: 611–7. 5. Hougen TJ. Congenital anomalies of the aortic arch. In: Lindsay J, ed. Diseases of the aorta. Philadelphia: Lea & Febiger, 1994:19 –53. 6. Anastasiadis K, Channon KM, Ratnatunga C. Traumatic innominate artery injury. J Cardiovasc Surg 2002;43:697–700. 7. Stark P. Traumatic rupture of the aorta: a review. CRC Crit Rev Diagn Imag 1984;31:547–50. 8. Dolmatch BL, Gray RJ, Horton KM, Rundback JH. Diagnostic imaging of aortic disease. In: Lindsay J, ed. Diseases of the aorta. Philadelphia: Lea & Febiger, 1994:197–250.
Novel Repair for Late Posttraumatic Aortic Valve Injury and Root Pseudoaneurysm Andrea Venturini, MD, PhD, Raimondo Ascione, MD, MCh, Franco Ciulli, MD, Elvio Polesel, MD, Roberto Moretti, MD, Gianni D. Angelini, MD, MCh, and Claudio Zussa, MD, PhD Department of Cardiac Surgery, Ospedale Civile Umberto I, Venezia Mestre, Italy; Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
We report a case of posttraumatic aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after a road traffic accident. The surgical treatment consisted of exclusion of the pseudoaneurysm with direct closure of the entry tear in the right coronary sinus followed by insertion of a Toronto stentless prosthesis (St. Jude Medical, St. Paul, MN). This surgical approach aimed to cover the repaired entry tear ensuring exclusion of the site. Recovery was uneventful and 12 month follow-up was unremarkable. (Ann Thorac Surg 2006;81:350 –2) © 2006 by The Society of Thoracic Surgeons
T
raumatic aortic valve regurgitation and pseudoaneurysm of the aortic root are rare complications of road traffic accidents [1]. There is very little in the literature on simultaneous occurrence of traumatic pseudoaneurysm of the aortic root and aortic valve insufficiency [1]. We report a case of concomitant severe aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after road traffic accidents treated with direct closure of the pseudoaneurysm neck and subsequent insertion of a stentless aortic valve. An otherwise healthy 26-year-old man sustained blunt trauma caused by rapid deceleration in a motorbike road accident. The patient was taken to the accident and emergency department and blood pressure, heart rate, electrocardiogram, and chest roentgenogram were unreAccepted for publication Sept 3, 2004. Address correspondence to Dr Venturini, Unità Operativa di Cardiochirurgia, Ospedale Civile Umberto I, Via Circonvallazione 50, Venezia Mestre, 30174 Italy; e-mail: [email protected].
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.09.018
Ann Thorac Surg 2006;81:350 –2
CASE REPORT VENTURINI ET AL STENTLESS VALVE FOR ROOT PSEUDOANEURYSM
351
show well functioning stentless valve and no recurrence of the pseudoaneurysm.
Fig 1. Aortography showing the saccular pseudoaneurysm and severe aortic regurgitation.
markable on examination. Transthoracic echocardiogram showed mild aortic regurgitation and no pericardial effusion. The patient suffered several injuries to his face requiring multiple staged corrective surgery. Nine months after the road traffic accidents the patient complained of moderate shortness of breath on exercise. A transthoracic echocardiogram showed moderate aortic regurgitation and moderate dilatation of the aortic root. The findings were not considered to be an indication for surgery at that stage. One year later the patient’s condition deteriorated. Cardiac catheterization and echocardiogram showed severe aortic regurgitation and a saccular aneurysm of the aortic root requiring operation (Fig 1). After median sternotomy, cardiopulmonary bypass was established and the aortic valve and root were explored through a transverse aortotomy. There was a 20-mm pseudoaneurysm of the aortic root originating from a tear in the right sinus of Valsalva below the ostium of the right coronary artery. There was also a circular shaped tear (7 to 8 mm) in the right coronary cusp with thickened edges, suggestive of chronic fibrotic degeneration (Fig 2). The diameters of the aortic annulus and of the sinotubular junction were 24 and 25 mm, respectively. These findings excluded the possibility of aortic valve repair. Therefore the native aortic valve was excised and the neck of the pseudoaneurysm was closed with two 4-0 Prolene pericardial pledgeted mattress-stitches (Ethicon, Somerville, NJ). Next, a size 25-mm Toronto stentless valve (St. Jude Medical, St. Paul, MN) was inserted with the aim of excluding the entry of the pseudoaneurysm (Fig 3). The aortotomy was then closed and the patient was easily weaned off the cardiopulmonary bypass. Intraoperative transesophageal echocardiography showed no blood flow in the pseudoaneurysm and a well functioning and competent stentless valve. Recovery was unremarkable and the patient was discharged home on postoperative day 6. Transthoracic echocardiogram performed at 3 and 12 months after the surgery continued to
Deceleration injuries of the aorta may result in tears that can potentially lead to catastrophic hemorrhage. The tear site is most often at the aortic isthmus with injuries of the aortic root being rare [2]. It has been postulated that the mechanism of aortic valve injury may be due to a sudden increase of pressure during the beginning of diastole. Although the pressure is low in the empty left ventricle, the high aortic pressure may induce an abnormal damaging stress if the valve is competent [3]. This increase of pressure is a consequence of blunt trauma or deceleration in high-speed accidents [3]. However, little is known about the true mechanism leading to aortic root pseudoaneurysms. Our case presented 22 months after a road traffic accident with a combined aortic valve and aortic root lesion. We speculate that the road traffic accident initially determined a minimal degree of localized injuries that extended with time, leading to late severe aortic regurgitation and pseudoaneurysm formation because the patient only presented with a moderate degree of aortic regurgitation and moderate dilatation of the aortic root at 9 months. Consideration should be given to the choice of operation for a ruptured aortic valve (ie, repair or replacement). After an extensive review of the literature, Meunier [2] concluded that the indications for conservative surgery include a simple tear, avulsion of one cusp, or one avulsed commissure, whereas prosthetic valve replacements should be limited to complex or multiple lesions in which most of the attempted repairs have been unsuccessful in the short-term or mid-term. Our solution of replacing the aortic valve with a stentless bioprosthesis was determined by a personal prefer-
Fig 2. Intraoperative view of the large tear in the right coronary leaflet (blue arrow) and the rupture in the right sinus of Valsalva (black arrow).
FEATURE ARTICLES
Comment
352
CASE REPORT FIRSTENBERG ET AL PERICARDIAL HYPOPLASIA
Ann Thorac Surg 2006;81:352– 4
Fig 3. Schematic operative technique: (A and B) closure of the ostium of the pseudoaneurysm with two 4-0 Prolene interrupted pericardial pledgeted mattress stitches (Ethicon, Somerville, NJ). (C) Insertion of the stentless valve covering the origin of the pseudoaneurysm to ensure its exclusion.
FEATURE ARTICLES
ence of the patient preoperatively and by the favorable intraoperative findings. The position of the pseudoaneurysm neck was such that after direct repair it was possible to ensure its exclusion by covering it with the bioprosthesis itself. Aortic root pseudoaneurysms have usually been approached either with a patch repair [4] or with root replacement [5]. However, the technique reported herein is much simpler and is as effective as an aortic root replacement. We would like to stress that our surgical solution has been possible both because of favorable anatomy and because the direct closure of the aortic tear was considered safe due to good tissue quality. More conventional surgical approaches consisting of aortic root replacement with either a tissue root or a composite prosthesis should otherwise be considered. In conclusion, we report a novel way of repairing concomitant aortic valve injury and sinus of Valsalva pseudoaneurysms by using a stentless aortic valve. This solution may be an effective and simple surgical option in the presence of favorable surgical presentation.
References 1. Penderleath D. Cause of death from rupture of one of semilunar valves of the aorta. London Medical Gazette 1830;7:109. 2. Meunier J-P, Berkane N, Lopez S, et al. Traumatic aortic regurgitation: aortic valvuloplasty controlled by aortoscopy. J Heart Valve Dis 2001;10:784 – 8. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
3. Bright EF, Beck CS. Nonpenetrating wounds of the heart: clinical and experimental studies. Am Heart J 1935;10:293–7. 4. Murray EG, Minami K, Kortke H, et al. Traumatic sinus of Valsalva fistula and aortic valve rupture. Ann Thorac Surg 1993;55:760 –1. 5. Tamura K, Nakahara H, Furukawa H, et al. Traumatic aortic regurgitation with ascending aortic aneurysm: report of a case. Kyobu Geka 2003;56(3):225–7.
Technical Considerations for Myocardial Revascularization in Congenital Bilateral Hypoplasia of the Pericardium Michael S. Firstenberg, MD, Chittoor B. Sai-Sudhakar, MBBS, Subha V. Raman, MD, and Robert E. Michler, MD Department of Cardiothoracic Surgery, Ohio State University, Columbus, Ohio
Congenital hypoplasia of the pericardium is a rare clinical condition that is typically encountered as an incidental finding during routine thoracic imaging or cardiothoAccepted for publication Aug 23, 2004. Address correspondence to Dr Michler, Department of Cardiothoracic Surgery, North Doan Hall, 8th Floor, Ohio State University, Columbus, OH 43210; e-mail: [email protected].
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.08.085
CASE REPORT VENTURINI ET AL STENTLESS VALVE FOR ROOT PSEUDOANEURYSM
FEATURE ARTICLES
the present case, is highly suggestive of subclavian artery trauma, aortography is the imaging modality of choice to confirm the diagnosis [6]. However, since trauma centers provide computed tomography on a 24-hour basis, in the setting of acute trauma, computed tomographic scanning is quicker, simpler, cost-effective, and an equally sensitive evaluation of aortic and great vessel injuries with a reported diagnostic accuracy of 88% to 100% [8]. Also in this case, transesophageal echocardiography proved very useful as a portable intraoperative monitoring examination. Transesophageal echocardiography is the only imaging modality that can be performed on very unstable patients, thus it can be very helpful for diagnosis, monitoring, and decision making in acute situations [8]. A full median sternotomy was performed to allow maximum exposure. Given the location of injury, hypothermic cardiopulmonary bypass and circulatory arrest was instituted to ensure adequate proximal hemostatic control of the great vessels and to provide cerebral and distal spinal cord protection. Proximal control of the subclavian artery could not be achieved with tangential clamping, and complete aortic occlusion was used instead. In this case the patient recovered without any neurologic deficits or paraplegia. Therapeutic approaches for traumatic subclavian artery repair described in the literature include ligation of the artery, end-to-end anastomosis with or without excision of the traumatized vessel parts or insertion of a saphenous vein or prosthetic graft to bridge the defect after retraction of the traumatized vessel segments [4]. Anatomical repair is clearly the most desirable surgical option, especially in older patients in which ligation is not as well tolerated. Whether or not one uses some type of vascular substitute, vein or synthetic prosthetic graft material does not seem to affect outcome [4]. The results from subclavian artery surgery are very satisfactory with morbidity and mortality rates reported at 14.3% and 4.8%, respectively [2, 6]. Improvements in diagnosis, surgical techniques, and cardiopulmonary bypass utilization contribute to this favorable outcome. In conclusion, we describe the successful surgical management of a patient with traumatic avulsion of a single right subclavian artery. Improved diagnostic and surgical repair principles produced an excellent postoperative outcome and recovery.
We would like to thank David Hayes for his descriptive illustrations.
References 1. Moes CAF, Benson LN, Barrows PE, et al. The subclavian artery as the first branch of the aortic arch. Pediatr Cardiol 1991;12:39. 2. Strum JT, Dorsey JS, Olson FR, et al. The management of subclavian artery injuries following blunt thoracic trauma. Ann Thorac Surg 1984;38:188 –91. 3. Zelenock GB, Kazmers A, Graham LM, et al. Non-penetrating subclavian artery injuries. Arch Surg 1985;120:685–92. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2006;81:350 –2
4. Posner MP, Deitrick J, McGrath P, et al. Nonpenetrating vascular injury to the subclavian artery. J Vasc Surg 1988;8: 611–7. 5. Hougen TJ. Congenital anomalies of the aortic arch. In: Lindsay J, ed. Diseases of the aorta. Philadelphia: Lea & Febiger, 1994:19 –53. 6. Anastasiadis K, Channon KM, Ratnatunga C. Traumatic innominate artery injury. J Cardiovasc Surg 2002;43:697–700. 7. Stark P. Traumatic rupture of the aorta: a review. CRC Crit Rev Diagn Imag 1984;31:547–50. 8. Dolmatch BL, Gray RJ, Horton KM, Rundback JH. Diagnostic imaging of aortic disease. In: Lindsay J, ed. Diseases of the aorta. Philadelphia: Lea & Febiger, 1994:197–250.
Novel Repair for Late Posttraumatic Aortic Valve Injury and Root Pseudoaneurysm Andrea Venturini, MD, PhD, Raimondo Ascione, MD, MCh, Franco Ciulli, MD, Elvio Polesel, MD, Roberto Moretti, MD, Gianni D. Angelini, MD, MCh, and Claudio Zussa, MD, PhD Department of Cardiac Surgery, Ospedale Civile Umberto I, Venezia Mestre, Italy; Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
We report a case of posttraumatic aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after a road traffic accident. The surgical treatment consisted of exclusion of the pseudoaneurysm with direct closure of the entry tear in the right coronary sinus followed by insertion of a Toronto stentless prosthesis (St. Jude Medical, St. Paul, MN). This surgical approach aimed to cover the repaired entry tear ensuring exclusion of the site. Recovery was uneventful and 12 month follow-up was unremarkable. (Ann Thorac Surg 2006;81:350 –2) © 2006 by The Society of Thoracic Surgeons
T
raumatic aortic valve regurgitation and pseudoaneurysm of the aortic root are rare complications of road traffic accidents [1]. There is very little in the literature on simultaneous occurrence of traumatic pseudoaneurysm of the aortic root and aortic valve insufficiency [1]. We report a case of concomitant severe aortic valve regurgitation and pseudoaneurysm of the aortic root diagnosed 22 months after road traffic accidents treated with direct closure of the pseudoaneurysm neck and subsequent insertion of a stentless aortic valve. An otherwise healthy 26-year-old man sustained blunt trauma caused by rapid deceleration in a motorbike road accident. The patient was taken to the accident and emergency department and blood pressure, heart rate, electrocardiogram, and chest roentgenogram were unreAccepted for publication Sept 3, 2004. Address correspondence to Dr Venturini, Unità Operativa di Cardiochirurgia, Ospedale Civile Umberto I, Via Circonvallazione 50, Venezia Mestre, 30174 Italy; e-mail: [email protected].
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.09.018
Ann Thorac Surg 2006;81:350 –2
CASE REPORT VENTURINI ET AL STENTLESS VALVE FOR ROOT PSEUDOANEURYSM
351
show well functioning stentless valve and no recurrence of the pseudoaneurysm.
Fig 1. Aortography showing the saccular pseudoaneurysm and severe aortic regurgitation.
markable on examination. Transthoracic echocardiogram showed mild aortic regurgitation and no pericardial effusion. The patient suffered several injuries to his face requiring multiple staged corrective surgery. Nine months after the road traffic accidents the patient complained of moderate shortness of breath on exercise. A transthoracic echocardiogram showed moderate aortic regurgitation and moderate dilatation of the aortic root. The findings were not considered to be an indication for surgery at that stage. One year later the patient’s condition deteriorated. Cardiac catheterization and echocardiogram showed severe aortic regurgitation and a saccular aneurysm of the aortic root requiring operation (Fig 1). After median sternotomy, cardiopulmonary bypass was established and the aortic valve and root were explored through a transverse aortotomy. There was a 20-mm pseudoaneurysm of the aortic root originating from a tear in the right sinus of Valsalva below the ostium of the right coronary artery. There was also a circular shaped tear (7 to 8 mm) in the right coronary cusp with thickened edges, suggestive of chronic fibrotic degeneration (Fig 2). The diameters of the aortic annulus and of the sinotubular junction were 24 and 25 mm, respectively. These findings excluded the possibility of aortic valve repair. Therefore the native aortic valve was excised and the neck of the pseudoaneurysm was closed with two 4-0 Prolene pericardial pledgeted mattress-stitches (Ethicon, Somerville, NJ). Next, a size 25-mm Toronto stentless valve (St. Jude Medical, St. Paul, MN) was inserted with the aim of excluding the entry of the pseudoaneurysm (Fig 3). The aortotomy was then closed and the patient was easily weaned off the cardiopulmonary bypass. Intraoperative transesophageal echocardiography showed no blood flow in the pseudoaneurysm and a well functioning and competent stentless valve. Recovery was unremarkable and the patient was discharged home on postoperative day 6. Transthoracic echocardiogram performed at 3 and 12 months after the surgery continued to
Deceleration injuries of the aorta may result in tears that can potentially lead to catastrophic hemorrhage. The tear site is most often at the aortic isthmus with injuries of the aortic root being rare [2]. It has been postulated that the mechanism of aortic valve injury may be due to a sudden increase of pressure during the beginning of diastole. Although the pressure is low in the empty left ventricle, the high aortic pressure may induce an abnormal damaging stress if the valve is competent [3]. This increase of pressure is a consequence of blunt trauma or deceleration in high-speed accidents [3]. However, little is known about the true mechanism leading to aortic root pseudoaneurysms. Our case presented 22 months after a road traffic accident with a combined aortic valve and aortic root lesion. We speculate that the road traffic accident initially determined a minimal degree of localized injuries that extended with time, leading to late severe aortic regurgitation and pseudoaneurysm formation because the patient only presented with a moderate degree of aortic regurgitation and moderate dilatation of the aortic root at 9 months. Consideration should be given to the choice of operation for a ruptured aortic valve (ie, repair or replacement). After an extensive review of the literature, Meunier [2] concluded that the indications for conservative surgery include a simple tear, avulsion of one cusp, or one avulsed commissure, whereas prosthetic valve replacements should be limited to complex or multiple lesions in which most of the attempted repairs have been unsuccessful in the short-term or mid-term. Our solution of replacing the aortic valve with a stentless bioprosthesis was determined by a personal prefer-
Fig 2. Intraoperative view of the large tear in the right coronary leaflet (blue arrow) and the rupture in the right sinus of Valsalva (black arrow).
FEATURE ARTICLES
Comment
352
CASE REPORT FIRSTENBERG ET AL PERICARDIAL HYPOPLASIA
Ann Thorac Surg 2006;81:352– 4
Fig 3. Schematic operative technique: (A and B) closure of the ostium of the pseudoaneurysm with two 4-0 Prolene interrupted pericardial pledgeted mattress stitches (Ethicon, Somerville, NJ). (C) Insertion of the stentless valve covering the origin of the pseudoaneurysm to ensure its exclusion.
FEATURE ARTICLES
ence of the patient preoperatively and by the favorable intraoperative findings. The position of the pseudoaneurysm neck was such that after direct repair it was possible to ensure its exclusion by covering it with the bioprosthesis itself. Aortic root pseudoaneurysms have usually been approached either with a patch repair [4] or with root replacement [5]. However, the technique reported herein is much simpler and is as effective as an aortic root replacement. We would like to stress that our surgical solution has been possible both because of favorable anatomy and because the direct closure of the aortic tear was considered safe due to good tissue quality. More conventional surgical approaches consisting of aortic root replacement with either a tissue root or a composite prosthesis should otherwise be considered. In conclusion, we report a novel way of repairing concomitant aortic valve injury and sinus of Valsalva pseudoaneurysms by using a stentless aortic valve. This solution may be an effective and simple surgical option in the presence of favorable surgical presentation.
References 1. Penderleath D. Cause of death from rupture of one of semilunar valves of the aorta. London Medical Gazette 1830;7:109. 2. Meunier J-P, Berkane N, Lopez S, et al. Traumatic aortic regurgitation: aortic valvuloplasty controlled by aortoscopy. J Heart Valve Dis 2001;10:784 – 8. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
3. Bright EF, Beck CS. Nonpenetrating wounds of the heart: clinical and experimental studies. Am Heart J 1935;10:293–7. 4. Murray EG, Minami K, Kortke H, et al. Traumatic sinus of Valsalva fistula and aortic valve rupture. Ann Thorac Surg 1993;55:760 –1. 5. Tamura K, Nakahara H, Furukawa H, et al. Traumatic aortic regurgitation with ascending aortic aneurysm: report of a case. Kyobu Geka 2003;56(3):225–7.
Technical Considerations for Myocardial Revascularization in Congenital Bilateral Hypoplasia of the Pericardium Michael S. Firstenberg, MD, Chittoor B. Sai-Sudhakar, MBBS, Subha V. Raman, MD, and Robert E. Michler, MD Department of Cardiothoracic Surgery, Ohio State University, Columbus, Ohio
Congenital hypoplasia of the pericardium is a rare clinical condition that is typically encountered as an incidental finding during routine thoracic imaging or cardiothoAccepted for publication Aug 23, 2004. Address correspondence to Dr Michler, Department of Cardiothoracic Surgery, North Doan Hall, 8th Floor, Ohio State University, Columbus, OH 43210; e-mail: [email protected].
0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2004.08.085