- Email: [email protected]
Palliative Surgery for Malignant Mediastinal Tumor Invading the Superior Vena Cava and Right Atrium
720
CASE REPORT MORIMOTO ET AL MALIGNANT MEDIASTINAL TUMOR INVADING THE SVC AND RA
FEATURE ARTICLES
ervation. In addition, Hallock and colleagues [5] reported a patient who presented 6 weeks after sternal fixation with a draining tract over his hardware. This patient was treated with an extended course of intravenous antibiotics alone. In both patients, the infection recurred 2 months after completion of antibiotics, and the hardware was ultimately removed. Of note, infections involving hardware typically involve organisms producing biofilm, which is poorly penetrated by most antibiotics and commonly recur after discontinuation of therapy. However, a few novel antimicrobials, such as daptomycin, as was used in our case, have demonstrated improved biofilm penetration [6]. In the end, both of the previously described patients had a complete bony union of the sternum at the time of hardware removal, and both achieved eventual resolution of infection. These cases demonstrate the safety of conservative management in the setting of early sternal hardware infection, and they highlight the importance of using antibiotics with improved biofilm penetration. Lung transplant patients are inherently at high risk for sternal wound complications, and prevention strategies in these patients are of great importance. Completing bilateral sequential lung transplantation through anterolateral thoracotomies without sternal division is one such strategy. Meyers and colleagues [7] evaluated 50 patients treated in this way. They found no wound complications in this group compared with the 34% wound complication rate found in their historical controls. In addition, when bilateral anterolateral thoracotomies are not feasible, primary sternal plating can be considered. Early evidence demonstrated by Gandy and Moulton [8] showed primary rigid fixation after clamshell incision may reduce the occurrence of wound complication in lung transplant patients. The management of sternal wound infections involving hardware remains challenging. Multiple therapeutic options may be useful depending on the clinical scenario. Prevention strategies, including sternal sparing or primary plating, should be considered in high-risk patients, such as lung transplant recipients. Finally, this report suggests hardware preservation may be an acceptable approach to sternal wound infections if diagnosis is made early, the patient is stable without evidence of gross mediastinitis, and antibiotics with increased biofilm penetration are available.
References 1. Viol A, Pradka SP, Baumeister SP, et al. Soft-tissue defects and exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation. Plast Reconstr Surg 2009;123:1256 – 63. 2. Gaudreau G, Costache V, Houde C, et al. Recurrent sternal infection following treatment with negative pressure wound therapy and titanium transverse plate fixation. Eur J Cardiothorac Surg 2009;37:888 –92. 3. Gottlieb LJ, Pielet RW, Karp RB, Krieger LM, Smith DJ Jr, Deeb GM. Rigid internal fixation of the sternum in postoperative mediastinitis. Arch Surg 1994;129:489 –93. 4. Dickie SR, Dorafshar AH, Song DH. Definitive closure of the infected median sternotomy wound: A treatment algorithm © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
5. 6.
7.
8.
Ann Thorac Surg 2011;92:720 –2
utilizing vacuum-assisted closure followed by rigid plate fixation. Ann Plast Surg 2006;56:680 –5. Hallock GG, Szydlowski GW. Rigid fixation of the sternum using a new coupled titanium transverse plate fixation system. Ann Plast Surg 2007;58:640 – 4. Cunha BA, Eisenstein LE, Hamid NS. Pacemaker-induced staphylococcus aureus mitral valve acute bacterial endocarditis complicated by persistent bacteremia from a coronary stent: cure with prolonged/high-dose daptomycin without toxicity. Heart Lung 2006;35:207–11. Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasc Surg 1999;117:358 – 64. Gandy KL, Moulton MJ. Sternal plating to prevent malunion of transverse sternotomy in lung transplantation. Ann Thorac Surg 2008;86:1384 –5.
Palliative Surgery for Malignant Mediastinal Tumor Invading the Superior Vena Cava and Right Atrium Yoshihisa Morimoto, MD, PhD, Takaki Sugimoto, MD, PhD, Hiroko Shiozawa, MD, Makiko Hai, MD, and Yuki Yokoo, MD Division of Cardiovascular Surgery, Awaji Hospital, Hyogo, Japan
Intra-atrial extension of a superior vena cava (SVC) tumor is rare and it is associated with high mortality rates. An 80-year-old woman presented with malignant mediastinal tumor invading the superior vena cava and right atrium. The unresectable tumor caused uncontrolled SVC syndrome and led to the risk of pulmonary artery tumor thrombosis. Palliative surgery for the intracaval and atrial tumor was performed. Presently, 6 months after surgery, the patient remains free from SVC syndrome and has received effective adjuvant chemotherapy to reduce the size of the tumor. (Ann Thorac Surg 2011;92:720 –2) © 2011 by The Society of Thoracic Surgeons
W
e report a patient with malignant mediastinal tumor invading the superior vena cava (SVC) and right atrium. The huge unresectable tumor caused uncontrolled SVC syndrome and led to risk of pulmonary artery tumor thrombosis. Therefore, palliative surgery for the intracaval and atrial tumor was performed, resulting in the relief of SVC syndrome. An 80-year-old woman was admitted to our hospital with complaints of fever, appetite loss, palpitation, dyspnea on exertion, and edema of the upper extremities and face. Echocardiography and computer tomographic scanning revealed a large mass invading the SVC and right atrium,
Accepted for publication Feb 7, 2011. Address correspondence to Dr Morimoto, Department of Cardiovascular Surgery, Awaji Hospital, Hyogo, Japan, 1-6-6 Shimokamo, Sumoto, Hyogo, 656-0013 Japan; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.02.024
Ann Thorac Surg 2011;92:720 –2
CASE REPORT MORIMOTO ET AL MALIGNANT MEDIASTINAL TUMOR INVADING THE SVC AND RA
721
Fig 1. Chest computed tomographic scan demonstrating a huge mass obliterating the superior vena cava and invading the right atrium.
Fig 2. The superior vena cava junction was reconstructed using an ellipse-shaped 4 ⫻ 12 cm polytetrafluoroethylene patch (Gore-Tex [W.L. Gore & Associates, Newark, DE]).
prove survival, the quality of life, and prevention of tumor thrombosis in a select group of patients whose SVC tumor is uncontrolled. Although an SVC tumor invading to other organs is generally inoperable, the SVC tumor in the present patient caused severe symptoms, including syncope due to an elevated jugular vein pressure and risk of a tumor thrombus. We performed palliative surgery of the SVC and right atrial tumor to relieve the symptoms, prevent a tumor thrombus, and make precise histologic diagnosis. The patient has become able to walk without any symptoms of SVC syndrome, and has received a chance of effective chemotherapy after surgery.
Comment Intra-atrial extension of an SVC tumor is rare and it is associated with high mortality rates, with survival from 8 to 50 months [1, 2]. Partial resection of a malignant SVC tumor may be a life-saving procedure. Resection of the tumor can im-
Fig 3. Chest computed tomographic scan 3 months after surgery demonstrating the relief of the superior vena cava obstruction.
FEATURE ARTICLES
and the SVC was totally occluded (Fig 1). Although a biopsy was performed through a thoracoscopy, histologic confirmation of the tumor was not obtained. The symptoms improved once with steroid pulse and anticoagulant therapy, but they recurred and deteriorated with syncopic attack 6 months later. Surgery was performed for histologic confirmation of the tumor and relief of the symptoms. Mid-sternotomy imaging revealed that the tumor arose from the mediastinum and invaded anteriorly to the SVC and right atrium and posteriorly to the esophagus and trachea. Total cardiopulmonary bypass was performed through the inferior vena cava and right brachiocephalic vein to the ascending aorta. The SVC and right atrium were separately incised. The entire caval cavity was filled with a fragile gray tumor, which had a stalk growing from the posterior wall of the SVC and extended caudally to the right atrial cavity and cranially to the left innominate vein. To relieve SVC obstruction, almost all of the intracavity mass was removed and the SVC junction was reconstructed using an ellipse-shaped (4 ⫻ 12 cm) polytetrafluoroethylene patch (Gore-Tex [W.L. Gore & Associates, Newark, DE]) (Fig 2). The patient was weaned from cardiopulmonary bypass without difficulty. The jugular vein pressure decreased from 25 to 4 cm H2O with improvement of the SVC syndrome. The patient’s postoperative course was characterized by a marked recovery. Postoperative computed tomographic angiography showed the relief of SVC obstruction (Fig 3). Histologic examination of the tumor was compatible with adenocarcinoma. At present, 6 months after surgery, the patient remains free from SVC syndrome and has received effective adjuvant chemotherapy to reduce the size of the tumor.
722
CASE REPORT OSADA ET AL AORTIC DISSECTION WITH COLD AGGLUTININ
The use of cardiopulmonary bypass in oncologic surgery is still controversial because of the likelihood of hematogenous tumor dissemination [3–5]. However, it was impossible to remove the tumor thrombus without cardiopulmonary bypass because of the total occlusion and adhesion to the SVC wall. Although surgical excision does not cure SVC tumors, palliative resection might be justifiable in the presence of immediate life-threatening danger due to brain venous pressure elevation and tumor thrombosis.
References 1. Koike E, Yamashita H, Watanabe S, et al. Brachiocephalic vein thrombus of papillary thyroid cancer: report of a case. Surg Today 2002;32:59. 2. Porte H, Metois D, Finzi L, et al. Superior vena cava syndrome of malignant origin. Which surgical procedure for which diagnosis? Eur J Cardiothorac Surg 2000;17:384. 3. Hasegawa S, Otake Y, Bando T, et al. Pulmonary dissemination of tumor cells after extended resection of thyroid carcinoma with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2002;124:635. 4. Akchurin RS, Davidov MI, Partigulov SA, et al. Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery. Artif Organs 1997;21:763. 5. Mestres CA, Prabhakaran K, Adebo OA, et al. Combined resection of hepatoblastoma and intracaval right atrial extension with profound hypothermia and circulatory arrest. Eur J Cardiothorac Surg 1991;5:657. FEATURE ARTICLES
Type A Aortic Dissection With Cold Agglutinin Disease Hiroaki Osada, MD, Hiroyuki Nakajima, MD, Atsushi Shimizu, MD, Atsushi Nagasawa, MD, and Hitoshi Ogino, MD, PhD Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto; Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
Cold agglutinin disease is an uncommon condition characterized by hemagglutination and microvascular thromAccepted for publication Feb 7, 2011. Address correspondence to Dr Osada, Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragoshomachi, Nisikyo-ku, Kyoto, 606-8087 Japan; e-mail: [email protected].
Ann Thorac Surg 2011;92:722–3
bosis of red blood cells at low temperatures during cardiopulmonary bypass. We report the rare case of an ambulatory 74-year-old woman with a relatively high thermal amplitude for antibody activation. We performed aortic arch repair for type A aortic dissection using moderately hypothermic cardiopulmonary bypass and warm blood cardioplegia in a retrograde manner. This case report provides evidence that these are safe and suitable techniques for selected aortic arch repair patients with cold agglutinin disease. (Ann Thorac Surg 2011;92:722–3) © 2011 by The Society of Thoracic Surgeons
O
pen heart operations, especially aortic arch repair, often require hypothermic circulatory arrest. When patients have cold reactive protein, careful planning is required before commencement of any surgical procedures. A 74-year-old ambulatory woman was admitted to our hospital with a diagnosis of type A aortic dissection from the ascending aorta to the brachiocephalic artery, and aortic stenosis with a peak gradient of 43 mm Hg, and a calculated valve area of 0.5 cm2. She had no recent history of chest or back pain, but she had exhibited dyspnea on effort for a month. A computed tomographic scan was used to identify the cause of the dyspnea, which revealed aortic dissection. Although the patient’s ascending aorta was dilated to a diameter of 58 mm, the false lumen was not patent. After assessment of the operative risks, we decided to perform emergency surgery. Preoperative laboratory tests showed that the patient had asymptomatic cold agglutinin disease with mild hemolytic anemia of unknown cause. The titer was elevated to a ratio greater than 1:512. Prior to surgery, we tested the patient’s thermal amplitude for cold agglutination. Her serum and cross-matched type O red blood cells, contrasted with bovine albumin, reacted in the test tank. We determined the safe level of thermal amplitude for the operation by gradually lowering the temperature of the test tank from 37°C until the red blood cells coagulated in the patient’s serum at 23°C (Fig 1). At the time of the operation, we warmed anesthetic agents and fluids, including priming fluids for cardiopulmonary bypass (CPB). A body warming blanket was
Fig 1. (A) Photograph shows 300 L of the patient’s serum and 5% red blood cells. (B) Photograph of 300 L of patient’s serum and highly concentrated red blood cells. (C) Photograph of 300 L of bovine albumin and 5% red blood cells. (D) Photograph of 300 L of bovine albumin and highly concentrated red blood cells. At 23°C, the red blood cells coagulated in the patient’s serum. © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.02.019
CASE REPORT MORIMOTO ET AL MALIGNANT MEDIASTINAL TUMOR INVADING THE SVC AND RA
FEATURE ARTICLES
ervation. In addition, Hallock and colleagues [5] reported a patient who presented 6 weeks after sternal fixation with a draining tract over his hardware. This patient was treated with an extended course of intravenous antibiotics alone. In both patients, the infection recurred 2 months after completion of antibiotics, and the hardware was ultimately removed. Of note, infections involving hardware typically involve organisms producing biofilm, which is poorly penetrated by most antibiotics and commonly recur after discontinuation of therapy. However, a few novel antimicrobials, such as daptomycin, as was used in our case, have demonstrated improved biofilm penetration [6]. In the end, both of the previously described patients had a complete bony union of the sternum at the time of hardware removal, and both achieved eventual resolution of infection. These cases demonstrate the safety of conservative management in the setting of early sternal hardware infection, and they highlight the importance of using antibiotics with improved biofilm penetration. Lung transplant patients are inherently at high risk for sternal wound complications, and prevention strategies in these patients are of great importance. Completing bilateral sequential lung transplantation through anterolateral thoracotomies without sternal division is one such strategy. Meyers and colleagues [7] evaluated 50 patients treated in this way. They found no wound complications in this group compared with the 34% wound complication rate found in their historical controls. In addition, when bilateral anterolateral thoracotomies are not feasible, primary sternal plating can be considered. Early evidence demonstrated by Gandy and Moulton [8] showed primary rigid fixation after clamshell incision may reduce the occurrence of wound complication in lung transplant patients. The management of sternal wound infections involving hardware remains challenging. Multiple therapeutic options may be useful depending on the clinical scenario. Prevention strategies, including sternal sparing or primary plating, should be considered in high-risk patients, such as lung transplant recipients. Finally, this report suggests hardware preservation may be an acceptable approach to sternal wound infections if diagnosis is made early, the patient is stable without evidence of gross mediastinitis, and antibiotics with increased biofilm penetration are available.
References 1. Viol A, Pradka SP, Baumeister SP, et al. Soft-tissue defects and exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation. Plast Reconstr Surg 2009;123:1256 – 63. 2. Gaudreau G, Costache V, Houde C, et al. Recurrent sternal infection following treatment with negative pressure wound therapy and titanium transverse plate fixation. Eur J Cardiothorac Surg 2009;37:888 –92. 3. Gottlieb LJ, Pielet RW, Karp RB, Krieger LM, Smith DJ Jr, Deeb GM. Rigid internal fixation of the sternum in postoperative mediastinitis. Arch Surg 1994;129:489 –93. 4. Dickie SR, Dorafshar AH, Song DH. Definitive closure of the infected median sternotomy wound: A treatment algorithm © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
5. 6.
7.
8.
Ann Thorac Surg 2011;92:720 –2
utilizing vacuum-assisted closure followed by rigid plate fixation. Ann Plast Surg 2006;56:680 –5. Hallock GG, Szydlowski GW. Rigid fixation of the sternum using a new coupled titanium transverse plate fixation system. Ann Plast Surg 2007;58:640 – 4. Cunha BA, Eisenstein LE, Hamid NS. Pacemaker-induced staphylococcus aureus mitral valve acute bacterial endocarditis complicated by persistent bacteremia from a coronary stent: cure with prolonged/high-dose daptomycin without toxicity. Heart Lung 2006;35:207–11. Meyers BF, Sundaresan RS, Guthrie T, Cooper JD, Patterson GA. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasc Surg 1999;117:358 – 64. Gandy KL, Moulton MJ. Sternal plating to prevent malunion of transverse sternotomy in lung transplantation. Ann Thorac Surg 2008;86:1384 –5.
Palliative Surgery for Malignant Mediastinal Tumor Invading the Superior Vena Cava and Right Atrium Yoshihisa Morimoto, MD, PhD, Takaki Sugimoto, MD, PhD, Hiroko Shiozawa, MD, Makiko Hai, MD, and Yuki Yokoo, MD Division of Cardiovascular Surgery, Awaji Hospital, Hyogo, Japan
Intra-atrial extension of a superior vena cava (SVC) tumor is rare and it is associated with high mortality rates. An 80-year-old woman presented with malignant mediastinal tumor invading the superior vena cava and right atrium. The unresectable tumor caused uncontrolled SVC syndrome and led to the risk of pulmonary artery tumor thrombosis. Palliative surgery for the intracaval and atrial tumor was performed. Presently, 6 months after surgery, the patient remains free from SVC syndrome and has received effective adjuvant chemotherapy to reduce the size of the tumor. (Ann Thorac Surg 2011;92:720 –2) © 2011 by The Society of Thoracic Surgeons
W
e report a patient with malignant mediastinal tumor invading the superior vena cava (SVC) and right atrium. The huge unresectable tumor caused uncontrolled SVC syndrome and led to risk of pulmonary artery tumor thrombosis. Therefore, palliative surgery for the intracaval and atrial tumor was performed, resulting in the relief of SVC syndrome. An 80-year-old woman was admitted to our hospital with complaints of fever, appetite loss, palpitation, dyspnea on exertion, and edema of the upper extremities and face. Echocardiography and computer tomographic scanning revealed a large mass invading the SVC and right atrium,
Accepted for publication Feb 7, 2011. Address correspondence to Dr Morimoto, Department of Cardiovascular Surgery, Awaji Hospital, Hyogo, Japan, 1-6-6 Shimokamo, Sumoto, Hyogo, 656-0013 Japan; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.02.024
Ann Thorac Surg 2011;92:720 –2
CASE REPORT MORIMOTO ET AL MALIGNANT MEDIASTINAL TUMOR INVADING THE SVC AND RA
721
Fig 1. Chest computed tomographic scan demonstrating a huge mass obliterating the superior vena cava and invading the right atrium.
Fig 2. The superior vena cava junction was reconstructed using an ellipse-shaped 4 ⫻ 12 cm polytetrafluoroethylene patch (Gore-Tex [W.L. Gore & Associates, Newark, DE]).
prove survival, the quality of life, and prevention of tumor thrombosis in a select group of patients whose SVC tumor is uncontrolled. Although an SVC tumor invading to other organs is generally inoperable, the SVC tumor in the present patient caused severe symptoms, including syncope due to an elevated jugular vein pressure and risk of a tumor thrombus. We performed palliative surgery of the SVC and right atrial tumor to relieve the symptoms, prevent a tumor thrombus, and make precise histologic diagnosis. The patient has become able to walk without any symptoms of SVC syndrome, and has received a chance of effective chemotherapy after surgery.
Comment Intra-atrial extension of an SVC tumor is rare and it is associated with high mortality rates, with survival from 8 to 50 months [1, 2]. Partial resection of a malignant SVC tumor may be a life-saving procedure. Resection of the tumor can im-
Fig 3. Chest computed tomographic scan 3 months after surgery demonstrating the relief of the superior vena cava obstruction.
FEATURE ARTICLES
and the SVC was totally occluded (Fig 1). Although a biopsy was performed through a thoracoscopy, histologic confirmation of the tumor was not obtained. The symptoms improved once with steroid pulse and anticoagulant therapy, but they recurred and deteriorated with syncopic attack 6 months later. Surgery was performed for histologic confirmation of the tumor and relief of the symptoms. Mid-sternotomy imaging revealed that the tumor arose from the mediastinum and invaded anteriorly to the SVC and right atrium and posteriorly to the esophagus and trachea. Total cardiopulmonary bypass was performed through the inferior vena cava and right brachiocephalic vein to the ascending aorta. The SVC and right atrium were separately incised. The entire caval cavity was filled with a fragile gray tumor, which had a stalk growing from the posterior wall of the SVC and extended caudally to the right atrial cavity and cranially to the left innominate vein. To relieve SVC obstruction, almost all of the intracavity mass was removed and the SVC junction was reconstructed using an ellipse-shaped (4 ⫻ 12 cm) polytetrafluoroethylene patch (Gore-Tex [W.L. Gore & Associates, Newark, DE]) (Fig 2). The patient was weaned from cardiopulmonary bypass without difficulty. The jugular vein pressure decreased from 25 to 4 cm H2O with improvement of the SVC syndrome. The patient’s postoperative course was characterized by a marked recovery. Postoperative computed tomographic angiography showed the relief of SVC obstruction (Fig 3). Histologic examination of the tumor was compatible with adenocarcinoma. At present, 6 months after surgery, the patient remains free from SVC syndrome and has received effective adjuvant chemotherapy to reduce the size of the tumor.
722
CASE REPORT OSADA ET AL AORTIC DISSECTION WITH COLD AGGLUTININ
The use of cardiopulmonary bypass in oncologic surgery is still controversial because of the likelihood of hematogenous tumor dissemination [3–5]. However, it was impossible to remove the tumor thrombus without cardiopulmonary bypass because of the total occlusion and adhesion to the SVC wall. Although surgical excision does not cure SVC tumors, palliative resection might be justifiable in the presence of immediate life-threatening danger due to brain venous pressure elevation and tumor thrombosis.
References 1. Koike E, Yamashita H, Watanabe S, et al. Brachiocephalic vein thrombus of papillary thyroid cancer: report of a case. Surg Today 2002;32:59. 2. Porte H, Metois D, Finzi L, et al. Superior vena cava syndrome of malignant origin. Which surgical procedure for which diagnosis? Eur J Cardiothorac Surg 2000;17:384. 3. Hasegawa S, Otake Y, Bando T, et al. Pulmonary dissemination of tumor cells after extended resection of thyroid carcinoma with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2002;124:635. 4. Akchurin RS, Davidov MI, Partigulov SA, et al. Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery. Artif Organs 1997;21:763. 5. Mestres CA, Prabhakaran K, Adebo OA, et al. Combined resection of hepatoblastoma and intracaval right atrial extension with profound hypothermia and circulatory arrest. Eur J Cardiothorac Surg 1991;5:657. FEATURE ARTICLES
Type A Aortic Dissection With Cold Agglutinin Disease Hiroaki Osada, MD, Hiroyuki Nakajima, MD, Atsushi Shimizu, MD, Atsushi Nagasawa, MD, and Hitoshi Ogino, MD, PhD Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Kyoto; Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
Cold agglutinin disease is an uncommon condition characterized by hemagglutination and microvascular thromAccepted for publication Feb 7, 2011. Address correspondence to Dr Osada, Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragoshomachi, Nisikyo-ku, Kyoto, 606-8087 Japan; e-mail: [email protected].
Ann Thorac Surg 2011;92:722–3
bosis of red blood cells at low temperatures during cardiopulmonary bypass. We report the rare case of an ambulatory 74-year-old woman with a relatively high thermal amplitude for antibody activation. We performed aortic arch repair for type A aortic dissection using moderately hypothermic cardiopulmonary bypass and warm blood cardioplegia in a retrograde manner. This case report provides evidence that these are safe and suitable techniques for selected aortic arch repair patients with cold agglutinin disease. (Ann Thorac Surg 2011;92:722–3) © 2011 by The Society of Thoracic Surgeons
O
pen heart operations, especially aortic arch repair, often require hypothermic circulatory arrest. When patients have cold reactive protein, careful planning is required before commencement of any surgical procedures. A 74-year-old ambulatory woman was admitted to our hospital with a diagnosis of type A aortic dissection from the ascending aorta to the brachiocephalic artery, and aortic stenosis with a peak gradient of 43 mm Hg, and a calculated valve area of 0.5 cm2. She had no recent history of chest or back pain, but she had exhibited dyspnea on effort for a month. A computed tomographic scan was used to identify the cause of the dyspnea, which revealed aortic dissection. Although the patient’s ascending aorta was dilated to a diameter of 58 mm, the false lumen was not patent. After assessment of the operative risks, we decided to perform emergency surgery. Preoperative laboratory tests showed that the patient had asymptomatic cold agglutinin disease with mild hemolytic anemia of unknown cause. The titer was elevated to a ratio greater than 1:512. Prior to surgery, we tested the patient’s thermal amplitude for cold agglutination. Her serum and cross-matched type O red blood cells, contrasted with bovine albumin, reacted in the test tank. We determined the safe level of thermal amplitude for the operation by gradually lowering the temperature of the test tank from 37°C until the red blood cells coagulated in the patient’s serum at 23°C (Fig 1). At the time of the operation, we warmed anesthetic agents and fluids, including priming fluids for cardiopulmonary bypass (CPB). A body warming blanket was
Fig 1. (A) Photograph shows 300 L of the patient’s serum and 5% red blood cells. (B) Photograph of 300 L of patient’s serum and highly concentrated red blood cells. (C) Photograph of 300 L of bovine albumin and 5% red blood cells. (D) Photograph of 300 L of bovine albumin and highly concentrated red blood cells. At 23°C, the red blood cells coagulated in the patient’s serum. © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.02.019