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Partial Aortic Root Remodelling for Fistula Between the Non-Coronary Sinus and the Right Atrium
Right-sided valve replacement is preferred treatment for refractory right heart failure due to severe valvular incompetence in patients with CHD. However, it remains controversial whether a mechanical or bioprosthetic valve should be used. One potential hazard of valve replacement for CHD is extension of the fibrous degeneration onto the biological prosthesis. One would expect that a mechanical valve would be less vulnerable to such progression, and this was the reason for use of such valves in our patient. However, the potential for anticoagulantrelated complications must be considered if patients have compromised liver function due to extensive liver metastases. In summary, we describe a patient with CHD who developed severe hypoxia due to a right-to-left shunt through a PFO associated with severe right ventricular dysfunction. Urgent transcatheter PFO closure is a useful means of correcting the acute haemodynamic derangement prior to definitive right-sided valve surgery. Patients with CHD should routinely be assessed for the presence of a PFO in order not to miss the safe and suitable timing of cardiac interventions.
References 1. Fox DJ, Khattar RS. Carcinoid heart disease: presentation, diagnosis, and management. Heart 2004;90:1224–8.
Case Reports
261
2. Simula DV, Edwards WD, Tazelaar HD, Connolly HM, Schafgf HV. Surgical pathology of carcinoid heart disease: a study of 139 valves from 75 patients spanning 20 years. Mayo Clin Proc 2002;77:139–47. 3. Moller JE, Connolly HM, Rubin J, Seward JB, Modesto K, Pellikka PA. Factors associated with progression of carcinoid heart disease. N Engl J Med 2003;348:1005–15. 4. Mansencal N, Mitry E, Forissier JF, Martin F, Redheuil A, Lepere C, Farcot JC, Joseph T, Lacombe P, Rougier P, Dubourg O. Assessment of patent foramen ovale in carcinoid heart disease. Am Heart J 2006;151(1129):e1–6. 5. Boglioli LR, Gardiner J, Gerstenblith G, Taff ML, Cameron DE. Carcinoid heart disease with severe hypoxia due to interatrial shunt through patent foramen ovale. Tex Heart Inst J 1997;24:125–8. 6. Marenco J, Naimi S, Hijazi Z, Patel A, Pandian N. Nonsurgical closure of a patent foramen ovale in a patient with carcinoid heart disease and severe hypoxia from interatrial shunting. Cathet Cardiovasc Intervent 2000;51:210–3. 7. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20. 8. Chessa M, Carminati M, Butera G, Bini RM, Drago M, Rosti L, Giamberti A, Pome G, Bossone E, Frigiola A. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol 2002;39:1061–5. 9. Schwerzmann M, Salehian O. Hazards of percutaneous PFO closure. Eur J Echocardiogr 2005;6:393–5.
Partial Aortic Root Remodelling for Fistula Between the Non-Coronary Sinus and the Right Atrium Manabu Itoh, MD, Yukio Okazaki, MD ∗ , Kazuyuki Ikeda, MD, Koujirou Furukawa, MD, Satoshi Ohtsubo, MD and Tsuyoshi Itoh, MD Department of Thoracic and Cardiovascular Surgery, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, Japan
This report describes a rare case of the fistula between the non-coronary sinus and the right atrium (RA) after ascending aortic replacement for chronic aortic dissection. A 67-year-old lady had been suddenly suffering from severe dyspnoea with general fatigue for a couple of days. Trans-thoracic echocardiogram in the emergency room demonstrated massive shunt flow from the non-coronary sinus to the RA with remarkable dilatation of the RA, right ventricle (RV) and inferior vena cava, similar to the rupture of sinus of Valsalva (Konno-type IV). The fistula was successfully treated by partial remodelling of the aortic root in an emergency basis because of her life-threatening illness. Some remaining diseased aortic root, which may be related to initial dissection or inappropriate use of gelatin–resorcin–formalin glue at the previous ascending aortic replacement, may cause this kind of serious events. Modified aortic root remodelling method with only diseased sinus resected was successfully applied to the localised aortic root disorder. (Heart, Lung and Circulation 2008;17:243–263) © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Aortic root reconstruction; Valve sparing operation; Aortic dissection; Aorta-right atrium fistula; Reoperation; Biologic glue Received 5 January 2007; received in revised form 25 January 2007; accepted 30 January 2007; available online 9 April 2007 ∗
Corresponding author. Tel.: +81 952 34 2345; fax: +81 952 34 2061. E-mail address: [email protected] (Y. Okazaki).
Introduction
F
istula between the non-coronary sinus and the right atrium (RA) was one of the rare complications after replacement of the ascending aorta for aortic dissection.
© 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.01.012
CASE REPORT
Heart, Lung and Circulation 2008;17:243–263
262
Case Reports
Heart, Lung and Circulation 2008;17:243–263
CASE REPORT
Inappropriate use of gelatin–resorcin–formalin (GRF) glue or some remaining diseased aortic wall related to the previous dissection might have induced this kind of serious situation. Trans-thoracic echocardiogram demonstrated massive shunt flow from the non-coronary sinus to RA, similar to the rupture of sinus of Valsalva (Konno-type IV). Because of life-threatening illness, emergency valvesparing root reconstruction using partial remodelling method was successfully applied.
Case Report A 67-year-old lady had been suddenly suffering from severe dyspnoea with general fatigue for a couple of days. Continuous heart murmur was obviously detected around the right sternal border with remarkable dilatation of the jugular vein. Trans-thoracic echocardiogram in the emergency room demonstrated massive shunt flow from the non-coronary sinus to the right atrium with remarkable dilatation of the RA, right ventricle (RV) and inferior vena cava, similar to the rupture of sinus of Valsalva (Konno-type IV). Laboratory data showed severe hepatic congestion with collapsed coagulation system (PTINR more than 5), which was treated with transfusion of fresh frozen plasma before cardiopulmonary bypass (CPB) established, renal failure with anuria and metabolic acidosis (base excess: −15.3). She previously underwent ascending aortic replacement for chronic aortic dissection (DeBakey type II) with stump reinforcement using felt strips and GRF glue six years ago. An emergency operation was decided due to her critical condition based on the acute severe right heart failure. She underwent partial remodelling of the aortic root in an emergency basis. The chest was entered through the previous median sternotomy incision with the left femoral artery and vein exposed for potential crash cannulation in case of massive bleeding due to stiff adhesions. Surprisingly, the femoral vein had pulsations similar to the femoral artery, possibly due to massive L–R shunt through the fistula. The RA and RV were markedly enlarged. Epi-aortic echo demonstrated a large fistula between the aortic root and the RA through the non-coronary sinus. On the contrary, the other sinuses appeared normal by the epi-aortic echo. CPB was established with bi-caval venous drainage and left femoral arterial return. Just after starting the CPB, her arterial blood pressure was remarkably decreased even with high flow arterial return of CPB. The venous blood reservoir was immediately filled with oxygenated blood through the fistula between the non-coronary sinus and the RA. The ascending aortic prosthetic graft, replaced previously, was immediately cross-clamped to maintain haemodynamics. The proximal ascending prosthetic graft was incised to observe the aortic root and to perfuse cardioplegic solutions selectively. The wall of the non-coronary sinus had a large penetration, 2 cm × 1 cm in size, to the RA with necrotic tissue (Fig. 1). At first, patch repair of the fistula was attempted, but failed due to fragile tissues around the fistula. The fistula with a small pseudo-aneurysm was incised longitudinally to obtain better surgical view (Fig. 2). The diseased wall
Figure 1. A surgical probe was passed through the fistula between the non-coronary sinus and the right atrium.
of the non-coronary sinus was completely debrided. The other sinuses appeared normal without any discolouration or deformation macroscopically. The new tube graft (Hemashield Gold 26 mm, Boston Scientific Medi-tech, Wayne, NJ) was trimmed to make a non-coronary sinus. The trimmed proximal stump of the graft was anastomosed to the non-coronary sinus just above the cusp attachment using 4-0 Prolene (Ethicon, Inc., Piscataway, NJ) continuous sutures. The other site of the proximal stump was anastomosed to the healthy native sino-tubular junction of the right and left coronary sinuses, where no abnormal walls were detected, using 4-0 Prolene continuous sutures. The distal stump of the graft was anastomosed with 3-0 Prolene continuous sutures to the distal aortic stump. CPB was weaned smoothly. Adequate haemostasis was achieved after administration of fresh frozen plasma and platelets. Her general condition improved immediately after surgery. No aortic regurgitation was detected by UCG or AOG. She has been doing well after surgery until this moment for more than 12 months.
Figure 2. The roof of the fistula was removed. The wall of the non-coronary sinus particularly around the commissure between non-coronary and right coronary sinuses was defected.
Discussion A fistula between the ascending aorta and RA related to aortic dissection has been rarely reported.1–3 Its haemodynamic status and configurations of the fistula were similar to the rupture of the sinus of Valsalva (Konno-type IV) in this case. As a differential diagnosis for heart murmur around the sternum after the ascending aortic replacement for dissection, some type of fistula between the aorta and a cardiac chamber should be listed. A diastolic murmur may lead to a misdiagnosis of aortic regurgitation related to dissection. Partial remodelling of the aortic root was performed on an emergency basis for the fistula between the noncoronary sinus and the RA for the patient with poor general conditions related to right heart failure due to massive shunt flow through the fistula. Total root replacement or valve-sparing root reconstruction4 could also be indicated for this kind of situations. In our case, native aortic cusps and the right and left coronary sinuses were intact. Therefore, limited partial remodelling of the aortic root was indicated to save operation time and to minimise surgical invasiveness. At the previous ascending replacement, the dissected non-coronary sinus was preserved using GRF glue and felt strips in this case. Inappropriate use of GRF glue at the previous operation might cause some necrosis of the non-coronary sinus wall.5 In our institute, GRF glue has
Case Reports
263
been used to reinforce aortic stumps with felt strips both of outer and inner sides in more than 100 cases of the aortic dissection. This is the first case of the complications potentially related to GRF glue in our institute. Appropriate use of GRF glue without excess use of formalin is essential. Additional use of felt strips is also recommended. Furthermore, aggressive resection of dissected aortic wall may be encouraged to decrease this kind of late complication in aortic surgery.
References 1. Russo C, Chiara FD, Bruschi G, Ciliberto GR, Vitali E. Aortoatrial fistula through the septaum in recurrent aortic dissection. Ann Thorac Surg 2001;72:921–2. 2. Matsushita H, Obo H, Nakagiri K, Mukohara N, Shida T. Aortoright atrial fistula caused by type A aortic dissection. Ann Thorac Surg 2004;78:2173–5. 3. Chung DA, Page AJF, Coulden RA, Nashef SAM. Aorto-atrial fistula after operated type A dissection. Eur J Cardiothorac Surg 2000;17:617–9. 4. Leyh RG, Fisher S, Ruhparwar A, Karck M, Harringer W, Harverich A. Valve-sparing aortic root replacement in patients after a previous operation for acute type A aortic dissection. J Thorac Cardiovasc Surg 2002;123:377–8. 5. Yoshitatsu M, Nomura F, Katayama A, Tamura K, Katayama K, Ihara K, Nakashima Y. Pathologic findings of aortic redissection after glue repair of proximal aorta. J Thorac Cardiovasc Surg 2004;127:593–5.
CASE REPORT
Heart, Lung and Circulation 2008;17:243–263
References 1. Fox DJ, Khattar RS. Carcinoid heart disease: presentation, diagnosis, and management. Heart 2004;90:1224–8.
Case Reports
261
2. Simula DV, Edwards WD, Tazelaar HD, Connolly HM, Schafgf HV. Surgical pathology of carcinoid heart disease: a study of 139 valves from 75 patients spanning 20 years. Mayo Clin Proc 2002;77:139–47. 3. Moller JE, Connolly HM, Rubin J, Seward JB, Modesto K, Pellikka PA. Factors associated with progression of carcinoid heart disease. N Engl J Med 2003;348:1005–15. 4. Mansencal N, Mitry E, Forissier JF, Martin F, Redheuil A, Lepere C, Farcot JC, Joseph T, Lacombe P, Rougier P, Dubourg O. Assessment of patent foramen ovale in carcinoid heart disease. Am Heart J 2006;151(1129):e1–6. 5. Boglioli LR, Gardiner J, Gerstenblith G, Taff ML, Cameron DE. Carcinoid heart disease with severe hypoxia due to interatrial shunt through patent foramen ovale. Tex Heart Inst J 1997;24:125–8. 6. Marenco J, Naimi S, Hijazi Z, Patel A, Pandian N. Nonsurgical closure of a patent foramen ovale in a patient with carcinoid heart disease and severe hypoxia from interatrial shunting. Cathet Cardiovasc Intervent 2000;51:210–3. 7. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20. 8. Chessa M, Carminati M, Butera G, Bini RM, Drago M, Rosti L, Giamberti A, Pome G, Bossone E, Frigiola A. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol 2002;39:1061–5. 9. Schwerzmann M, Salehian O. Hazards of percutaneous PFO closure. Eur J Echocardiogr 2005;6:393–5.
Partial Aortic Root Remodelling for Fistula Between the Non-Coronary Sinus and the Right Atrium Manabu Itoh, MD, Yukio Okazaki, MD ∗ , Kazuyuki Ikeda, MD, Koujirou Furukawa, MD, Satoshi Ohtsubo, MD and Tsuyoshi Itoh, MD Department of Thoracic and Cardiovascular Surgery, Saga University Hospital, 5-1-1 Nabeshima, Saga 849-8501, Japan
This report describes a rare case of the fistula between the non-coronary sinus and the right atrium (RA) after ascending aortic replacement for chronic aortic dissection. A 67-year-old lady had been suddenly suffering from severe dyspnoea with general fatigue for a couple of days. Trans-thoracic echocardiogram in the emergency room demonstrated massive shunt flow from the non-coronary sinus to the RA with remarkable dilatation of the RA, right ventricle (RV) and inferior vena cava, similar to the rupture of sinus of Valsalva (Konno-type IV). The fistula was successfully treated by partial remodelling of the aortic root in an emergency basis because of her life-threatening illness. Some remaining diseased aortic root, which may be related to initial dissection or inappropriate use of gelatin–resorcin–formalin glue at the previous ascending aortic replacement, may cause this kind of serious events. Modified aortic root remodelling method with only diseased sinus resected was successfully applied to the localised aortic root disorder. (Heart, Lung and Circulation 2008;17:243–263) © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Aortic root reconstruction; Valve sparing operation; Aortic dissection; Aorta-right atrium fistula; Reoperation; Biologic glue Received 5 January 2007; received in revised form 25 January 2007; accepted 30 January 2007; available online 9 April 2007 ∗
Corresponding author. Tel.: +81 952 34 2345; fax: +81 952 34 2061. E-mail address: [email protected] (Y. Okazaki).
Introduction
F
istula between the non-coronary sinus and the right atrium (RA) was one of the rare complications after replacement of the ascending aorta for aortic dissection.
© 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.01.012
CASE REPORT
Heart, Lung and Circulation 2008;17:243–263
262
Case Reports
Heart, Lung and Circulation 2008;17:243–263
CASE REPORT
Inappropriate use of gelatin–resorcin–formalin (GRF) glue or some remaining diseased aortic wall related to the previous dissection might have induced this kind of serious situation. Trans-thoracic echocardiogram demonstrated massive shunt flow from the non-coronary sinus to RA, similar to the rupture of sinus of Valsalva (Konno-type IV). Because of life-threatening illness, emergency valvesparing root reconstruction using partial remodelling method was successfully applied.
Case Report A 67-year-old lady had been suddenly suffering from severe dyspnoea with general fatigue for a couple of days. Continuous heart murmur was obviously detected around the right sternal border with remarkable dilatation of the jugular vein. Trans-thoracic echocardiogram in the emergency room demonstrated massive shunt flow from the non-coronary sinus to the right atrium with remarkable dilatation of the RA, right ventricle (RV) and inferior vena cava, similar to the rupture of sinus of Valsalva (Konno-type IV). Laboratory data showed severe hepatic congestion with collapsed coagulation system (PTINR more than 5), which was treated with transfusion of fresh frozen plasma before cardiopulmonary bypass (CPB) established, renal failure with anuria and metabolic acidosis (base excess: −15.3). She previously underwent ascending aortic replacement for chronic aortic dissection (DeBakey type II) with stump reinforcement using felt strips and GRF glue six years ago. An emergency operation was decided due to her critical condition based on the acute severe right heart failure. She underwent partial remodelling of the aortic root in an emergency basis. The chest was entered through the previous median sternotomy incision with the left femoral artery and vein exposed for potential crash cannulation in case of massive bleeding due to stiff adhesions. Surprisingly, the femoral vein had pulsations similar to the femoral artery, possibly due to massive L–R shunt through the fistula. The RA and RV were markedly enlarged. Epi-aortic echo demonstrated a large fistula between the aortic root and the RA through the non-coronary sinus. On the contrary, the other sinuses appeared normal by the epi-aortic echo. CPB was established with bi-caval venous drainage and left femoral arterial return. Just after starting the CPB, her arterial blood pressure was remarkably decreased even with high flow arterial return of CPB. The venous blood reservoir was immediately filled with oxygenated blood through the fistula between the non-coronary sinus and the RA. The ascending aortic prosthetic graft, replaced previously, was immediately cross-clamped to maintain haemodynamics. The proximal ascending prosthetic graft was incised to observe the aortic root and to perfuse cardioplegic solutions selectively. The wall of the non-coronary sinus had a large penetration, 2 cm × 1 cm in size, to the RA with necrotic tissue (Fig. 1). At first, patch repair of the fistula was attempted, but failed due to fragile tissues around the fistula. The fistula with a small pseudo-aneurysm was incised longitudinally to obtain better surgical view (Fig. 2). The diseased wall
Figure 1. A surgical probe was passed through the fistula between the non-coronary sinus and the right atrium.
of the non-coronary sinus was completely debrided. The other sinuses appeared normal without any discolouration or deformation macroscopically. The new tube graft (Hemashield Gold 26 mm, Boston Scientific Medi-tech, Wayne, NJ) was trimmed to make a non-coronary sinus. The trimmed proximal stump of the graft was anastomosed to the non-coronary sinus just above the cusp attachment using 4-0 Prolene (Ethicon, Inc., Piscataway, NJ) continuous sutures. The other site of the proximal stump was anastomosed to the healthy native sino-tubular junction of the right and left coronary sinuses, where no abnormal walls were detected, using 4-0 Prolene continuous sutures. The distal stump of the graft was anastomosed with 3-0 Prolene continuous sutures to the distal aortic stump. CPB was weaned smoothly. Adequate haemostasis was achieved after administration of fresh frozen plasma and platelets. Her general condition improved immediately after surgery. No aortic regurgitation was detected by UCG or AOG. She has been doing well after surgery until this moment for more than 12 months.
Figure 2. The roof of the fistula was removed. The wall of the non-coronary sinus particularly around the commissure between non-coronary and right coronary sinuses was defected.
Discussion A fistula between the ascending aorta and RA related to aortic dissection has been rarely reported.1–3 Its haemodynamic status and configurations of the fistula were similar to the rupture of the sinus of Valsalva (Konno-type IV) in this case. As a differential diagnosis for heart murmur around the sternum after the ascending aortic replacement for dissection, some type of fistula between the aorta and a cardiac chamber should be listed. A diastolic murmur may lead to a misdiagnosis of aortic regurgitation related to dissection. Partial remodelling of the aortic root was performed on an emergency basis for the fistula between the noncoronary sinus and the RA for the patient with poor general conditions related to right heart failure due to massive shunt flow through the fistula. Total root replacement or valve-sparing root reconstruction4 could also be indicated for this kind of situations. In our case, native aortic cusps and the right and left coronary sinuses were intact. Therefore, limited partial remodelling of the aortic root was indicated to save operation time and to minimise surgical invasiveness. At the previous ascending replacement, the dissected non-coronary sinus was preserved using GRF glue and felt strips in this case. Inappropriate use of GRF glue at the previous operation might cause some necrosis of the non-coronary sinus wall.5 In our institute, GRF glue has
Case Reports
263
been used to reinforce aortic stumps with felt strips both of outer and inner sides in more than 100 cases of the aortic dissection. This is the first case of the complications potentially related to GRF glue in our institute. Appropriate use of GRF glue without excess use of formalin is essential. Additional use of felt strips is also recommended. Furthermore, aggressive resection of dissected aortic wall may be encouraged to decrease this kind of late complication in aortic surgery.
References 1. Russo C, Chiara FD, Bruschi G, Ciliberto GR, Vitali E. Aortoatrial fistula through the septaum in recurrent aortic dissection. Ann Thorac Surg 2001;72:921–2. 2. Matsushita H, Obo H, Nakagiri K, Mukohara N, Shida T. Aortoright atrial fistula caused by type A aortic dissection. Ann Thorac Surg 2004;78:2173–5. 3. Chung DA, Page AJF, Coulden RA, Nashef SAM. Aorto-atrial fistula after operated type A dissection. Eur J Cardiothorac Surg 2000;17:617–9. 4. Leyh RG, Fisher S, Ruhparwar A, Karck M, Harringer W, Harverich A. Valve-sparing aortic root replacement in patients after a previous operation for acute type A aortic dissection. J Thorac Cardiovasc Surg 2002;123:377–8. 5. Yoshitatsu M, Nomura F, Katayama A, Tamura K, Katayama K, Ihara K, Nakashima Y. Pathologic findings of aortic redissection after glue repair of proximal aorta. J Thorac Cardiovasc Surg 2004;127:593–5.
CASE REPORT
Heart, Lung and Circulation 2008;17:243–263