- Email: [email protected]
Pulmonary Valve Replacement Through a Left Thoracotomy Approach
306
CASE REPORT BARNARD ET AL LEFT THORACOTOMY PULMONARY VALVE REPLACEMENT
Ann Thorac Surg 2012;93:306 – 8
Pulmonary Valve Replacement Through a Left Thoracotomy Approach James Barnard, MD, FRCS (CTh), Andreas Hoschtitzky, MS, FRCSEd-CTh, and Ragheb Hasan, MBCHB, FRCS(CTh) Manchester Royal Infirmary, Wythenshawe Hospital, Manchester, United Kingdom
Fig 4. Papillary fibroelastoma composed of fibroelastic fronds. Central avascular collagen core (*), elastic fibers (arrow). Inset: superficial endothelial layer (arrowhead). (Hematoxylin and eosin [saffron coloring], ⫻25.)
FEATURE ARTICLES
embolization and thrombi formation on the tumor has been suggested [3]. This fibrin or thrombus originating from the tumor surface is probably related to local trauma and endothelial damage of the papillary fronds, composed of collagen and elastin covered by superficial endothelial cells [4]. Although there is no clear guideline, anticoagulation has been recommended in the management of such tumors. Our case presents a typical aspect of multiple deposition of thrombotic material on the tumor that can potentially be responsible for microembolization. Although, in our case the thrombi were very small, significant changes in tumor size for a short interval have been reported [5]. Despite a relationship between size and mobility, and the risk of systemic thromboembolism, it has been suggested that tumors with a low risk of emboli could be managed conservatively with anticoagulation [1], at least while the patient is awaiting surgery or when surgery is contraindicated. We thank Cécile Luc-Pupat, Romain Vitte, Franck Ferrer, and Laurent Billard for supporting this work.
References 1. Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases. Am Heart J 2003;146:404 –10. 2. Ngaage DL, Mullany CJ, Daly RC, et al. Surgical treatment of cardiac papillary fibroelastoma: a single center experience with eighty-eight patients. Ann Thorac Surg 2005;80:1712– 8. 3. Grandmougin D, Fayad G, Moukassa D, et al. Cardiac valve papillary fibroelastomas: clinical, histological and immunohistochemical studies and a physiopathogenic hypothesis. J Heart Valve Dis 2000;9:832– 41. 4. Veinot JP. Fibroelastoma and embolic stroke. Circulation 1999;99:2709 –12. 5. Joffe II II, Jacobs LE, Owen AN, Ioli A, Kotler MN. Rapid development of a papillary fibroelastoma with associated thrombus: the role of transthoracic and transesophageal echocardiography. Echocardiography 1997;14:287–92. © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
We report here the first case, to our knowledge, of pulmonary valve replacement being performed via a left thoracotomy approach in a patient with pectus excavatum who had 3 previous sternotomies. The merit of this approach and its feasibility are discussed. (Ann Thorac Surg 2012;93:306 – 8) © 2012 by The Society of Thoracic Surgeons
P
ulmonary valve replacement is an increasingly performed operation in adults who have undergone surgery for right ventricular outflow tract obstruction in their earlier years and have been left with residual pulmonary regurgitation. If left unchecked, pulmonary regurgitation leads to progressive right ventricular dilatation and, with time, to right ventricular dysfunction, exercise intolerance, ventricular arrhythmias, and sudden death. There is evidence that in patients with severe pulmonary valve regurgitation, pulmonary valve replacement can reduce right ventricular overload and the development of arrhythmias. The operation of pulmonary valve replacement is most frequently performed through a repeat sternotomy and can be performed electively with a reported perioperative mortality of 1% to 4% and a 10-year survival of 86% to 95% [1]. Our patient presented postnatally with pulmonary atresia (Fallot-type) with intact ventricular septum. She was initially treated with prostaglandin, after which a Waterston’s shunt was created in the neonatal period. At the age of 4 months, she underwent a right ventricular outflow tract reconstruction by means of a homograft monocusp patch. Subsequent to this, at the age of 9 months, her Waterston’s shunt was disconnected, the muscular obstruction in the right ventricular infundibulum was resected, and the patent foramen ovale was closed. She did well for a long while, until at the age of 19 years old, she started to have mild dyspnoea which progressed over time and was also troubled by occasional retrosternal chest pains. She also developed a pectus excavatum (Fig 1). Transthoracic echocardiography demonstrated reversed interventricular septal motion with good left ventricular function, and left-sided ejection fraction of 60%. Her left ventricular end diastolic, end systolic, and interventricular septal dimensions were respectively 3.7, 2.7, and 0.9 cm.
Accepted for publication May 13, 2011. Address correspondence to Mr Hasan, Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, United Kingdom; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.05.064
Ann Thorac Surg 2012;93:306 – 8
CASE REPORT BARNARD ET AL LEFT THORACOTOMY PULMONARY VALVE REPLACEMENT
307
Fig 1. Magnetic resonance imaging scans showing the degree of pectus excavatum and close proximity of the heart to the anterior chest wall.
ular outflow tract. The cross clamp was removed after 83 minutes. Cardiopulmonary bypass was discontinued without difficulty after 116 minutes and the heart returned to sinus rhythm without difficulty. Two ventricular pacing wires were placed and 2 24F intercostal drains were inserted into the left chest and the thoracotomy was closed in layers. The patient did well after surgery and was discharged home after 7 days. She continues to do well 14 months after surgery.
Comment Whereas pulmonary valve replacement is a not an uncommonly performed procedure for patients who have pulmonary valve regurgitation [2], this case represents the first reported case that we are aware of, where a left thoracotomy approach has been used. This approach represented the safest access to the heart in view of the adherence of the right atrium to the posterior table of the sternum and the pectus excavatum. Left thoracotomy performed with the patient under general anesthesia was first described in 1910 [3] and was first described in a large series of mitral valve surgery in 1952 [4]. The first case of pulmonary valve replacement was performed in 1965 [5]. Left thoracotomy has an established role in re-do mitral valve surgery in some centers [6, 7] and has also been described for aortic valve replacement [8]. Left thoracotomy approach has also been used as a form of minimal access approach for mitral valve surgery [9]. In performing a repeat sternotomy, the benefits of establishing access for cardiopulmonary bypass before sternotomy are well described. In this case, the small caliber of the femoral arteries and the quality of the vessels after previous cannulation made this approach unattractive and, hence, an alternative approach was considered. In addition to creating a safe entry into the thorax, this approach also allowed access to the aorta for cannulation, allowed conduct of cardiopulmonary bypass without any difficulties, and provided a good surgical exposure. We feel that this approach to sometimes challenging repeat pulmonary valve surgery, where vascular access via the groin or subclavian vessels is not feasible and entry through the median sternotomy approach is unappealing, should be considered as a surgical option.
References 1. Oechslin EN, Harrison DA, Harris L, et al. Reoperation in adults with repair of tetralogy of fallot: indications and outcomes. J Thorac Cardiovasc Surg 1999;118:245–51.
FEATURE ARTICLES
There was severe regurgitation of the pulmonary valve with a pressure half time of 74 meters per second. There was moderate to severe tricuspid regurgitation. Maximum velocity across the tricuspid valve was 2.6 meters per second. Right ventricular systolic function appeared to be mild to moderately reduced, with a tricuspid annular plane systolic excursion of 0.9 cm. Cardiopulmonary stress testing revealed a VO2 maximum of 29.7 mL/Kg/minute which was 72% of predicted. Cardiac magnetic resonance imaging confirmed the echo findings and right ventricular analysis indicated an end diastolic volume of 150 mls with an end systolic volume of 80 mls, giving a stroke volume of 70 mls and an estimated ejection fraction of 47%. In view of her 3 previous sternotomies, the adherence of the right atrium to the back of her sternum, and her pectus excavatum, it was decided to establish femoral artery to femoral vein cardiopulmonary bypass. The left femoral artery was exposed and found to be very small and not useable. The right vessel was scanned and found to be even smaller ⬍0.5 cm. In view of the difficulty in proceeding, it was decided to wake the patient up and discuss other therapeutic options. Two days later, the patient was returned to the operating theater for another approach to her surgery. The patient had a size 17F venous cannula inserted percutaneously through the right jugular vein to use as a superior vena cava cannula. After the patient was prepared and draped, the left femoral vessels that were explored previously were exposed again. The left femoral vein was of adequate caliber for insertion of a long venous cannula. A left submammary incision was fashioned and the chest was entered via a left antero-lateral thoracotomy through the fourth intercostal space. The lung was dissected off the mediastinum. Tedious dissection of the ascending aorta and arch was carried out as there was no peripheral artery for arterial access. The aortic cannula was inserted into the arch and the patient was fully heparinized and cardiopulmonary bypass was established with cooling down to 32°C. The ascending aorta was cross clamped, cardioplegia was infused into the aortic root, and the heart arrested easily. A longitudinal arteriotomy was performed through the middle of the main pulmonary artery. The area where the previous patch was inserted was heavily calcified and this was excised. A size 21-mm Perimount Magna bioprosthesis was fixed to the posterior pulmonary annulus with multiple pledgeted interrupted 2/0 ethibond sutures. A bovine pericardial patch was fashioned and was sutured to the edges of the pulmonary arteriotomy at the level of the valve. It was sutured to the valve using continuous 3/0 prolene sutures in double layered fashion. Rewarming was then instituted. The edges of the patch were sutured to the edges of the right ventric-
308
CASE REPORT KARIMI ET AL ANOMALOUS SINGLE CORONARY ARTERY
2. Boudjemline Y. Pulmonary valve replacement: extending the indications to the whole spectrum of pulmonary valve disease. Future Cardiol 2007;3:35– 41. 3. Lilienthal H. IV. The first case of thoracotomy in a human being under anaesthesia by intratracheal insufflation. Ann Surg 1910;52:30 –3. 4. Baker C, Brock RC, Campbell M, Wood P. Valvotomy for mitral stenosis; a further report, on 100 cases. Br Med J 1952; 1:1043–55. 5. Fuller DN, Marchand P, Zion MM, Zwi S. Homograft replacement of the pulmonary valve. Thorax 1966;21:337– 42. 6. Suzuki Y, Pagani FD, Bolling SF. Left thoracotomy for multiple-time redo mitral valve surgery using on-pump beating heart technique. Ann Thorac Surg 2008;86:466 –71. 7. Crooke GA, Schwartz CF, Ribakove GH, et al. Retrograde arterial perfusion, not incision location, significantly increases the risk of stroke in reoperative mitral valve procedures. Ann Thorac Surg 2010;89:723–30. 8. Barreda T, Laali M, Dorent R, Acar C. Left thoracotomy for aortic and mitral valve surgery in a case of mediastinal displacement due to pneumonectomy. J Heart Valve Dis 2008;17:239 – 42. 9. Saunders PC, Grossi EA, Sharony R, et al. Minimally invasive technology for mitral valve surgery via left thoracotomy: experience with forty cases. J Thorac Cardiovasc Surg 2004;127:1026 –32.
FEATURE ARTICLES
Reimplantation of Anomalous Single Coronary Artery From Pulmonary Artery: Diagnosis and Surgical Management Mohsen Karimi, MD, Elise Hulsebus, PA, and William Lutin, MD Department of Surgery, Division of Pediatric Cardiothoracic Surgery, and Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Georgia, Children’s Medical Center, Augusta, Georgia
A newborn presented in cardiogenic shock with the diagnosis of anomalous single coronary artery from pulmonary artery and was successfully revived with prostaglandin (PGE1) infusion. She underwent surgical implantation of her coronary arteries while receiving PGE1 infusion to maintain high oxygen tension for the coronaries during cardiopulmonary bypass. She was discharged in 2 weeks with good biventricular function and moderate mitral regurgitation. At 2 months follow-up, she was gaining weight with preserved ventricular function and moderate mitral regurgitation. (Ann Thorac Surg 2012;93:308 –10) © 2012 by The Society of Thoracic Surgeons
A
nomalous left coronary artery from pulmonary artery (ALCAPA) is a rare disease with an incidence of 1 in 300,000 live births and a reported mortality of 90% by 1 year of age in untreated patients [1]. Anomalous
Accepted for publication June 22, 2011. Address correspondence to Dr Karimi, Division of Pediatric Cardiothoracic Surgery, Medical College of Georgia, Children’s Medical Center, 1446 Harper St, BP-3107, Augusta, GA 30912; e-mail: mkarimi@georgiahealth. edu.
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2012;93:308 –10
single coronary artery from pulmonary artery (ASCAPA) is even more rare and lethal as the result of ductal closure shortly after birth [2]. We report a case of a neonate with ASCAPA who was revived with PGE1 infusion and underwent successful reimplantation of her common coronary trunk. This is a case of a 1-week old girl, weighing 3.5 kg, who presented to a local hospital in cardiogenic shock that required aggressive fluid and inotropic resuscitation. She was transferred to our facility because of echocardiographic findings of dilated and hypocontractile right and left ventricles with severe mitral and tricuspid valve regurgitation. She was given prostaglandin (PGE1) infusion for presumed critical coarctation of aorta and intubated before transport. Her repeated echocardiogram confirmed these findings with no evidence of coarctation of aorta, a small to moderately sized patent ductus arteriosus with left to right shunting, and a patent foramen ovale. There was a questionable anomalous right coronary artery origin from the pulmonary artery, and the left coronary artery could not be identified (Fig 1A). The following day, she had a repeated echocardiogram that revealed improved biventricular function with resolution of tricuspid regurgitation, but with moderate to severe mitral regurgitation and papillary muscle hyperdensity. She had a cardiac catheterization that revealed the presence of an anomalous single coronary artery from the pulmonary artery, originating from the anterior sinus of Valsalva (Fig 1B). PGE1 infusion and inotropic support was maintained, and the patient was taken to the operating room for repair of her anomalous coronary arteries. Anesthesia induction was carefully administered to avoid hypotension and coronary hypoperfusion during PGE1 infusion. A midline sternotomy was performed and a piece of pericardium was harvested and tanned in glutaraldehyde solution. The heart appeared somewhat enlarged but well perfused and mildly cyanotic. The coronary anatomy was inspected and appeared to be a single-trunk coronary system arising from the anterior and rightward aspect of the pulmonary artery sinus (Fig 2). A cardiopulmonary bypass was performed via single arterial cannulation into the aorta and bicaval venous cannulation. Perfusion pressure was maintained high with a beating heart while controlling the pulmonary artery branches to avoid run-off and coronary steal. The heart was vented through the right superior pulmonary vein and arrested in antegrade fashion by placing a cardioplegia needle in the main pulmonary artery just at the bifurcation. The PGE1 infusion was continued to keep the ductus open while on bypass to perfuse the coronary arteries with high oxygen tension. The ductus was ligated and divided upon initiation of cardioplegia administration. The ascending aorta and the main pulmonary artery (MPA) were completely dissected, and the course of the coronary arteries was identified. They appeared to be originating as a common trunk from the anterior and rightward aspect of the pulmonary artery sinus 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.06.075
CASE REPORT BARNARD ET AL LEFT THORACOTOMY PULMONARY VALVE REPLACEMENT
Ann Thorac Surg 2012;93:306 – 8
Pulmonary Valve Replacement Through a Left Thoracotomy Approach James Barnard, MD, FRCS (CTh), Andreas Hoschtitzky, MS, FRCSEd-CTh, and Ragheb Hasan, MBCHB, FRCS(CTh) Manchester Royal Infirmary, Wythenshawe Hospital, Manchester, United Kingdom
Fig 4. Papillary fibroelastoma composed of fibroelastic fronds. Central avascular collagen core (*), elastic fibers (arrow). Inset: superficial endothelial layer (arrowhead). (Hematoxylin and eosin [saffron coloring], ⫻25.)
FEATURE ARTICLES
embolization and thrombi formation on the tumor has been suggested [3]. This fibrin or thrombus originating from the tumor surface is probably related to local trauma and endothelial damage of the papillary fronds, composed of collagen and elastin covered by superficial endothelial cells [4]. Although there is no clear guideline, anticoagulation has been recommended in the management of such tumors. Our case presents a typical aspect of multiple deposition of thrombotic material on the tumor that can potentially be responsible for microembolization. Although, in our case the thrombi were very small, significant changes in tumor size for a short interval have been reported [5]. Despite a relationship between size and mobility, and the risk of systemic thromboembolism, it has been suggested that tumors with a low risk of emboli could be managed conservatively with anticoagulation [1], at least while the patient is awaiting surgery or when surgery is contraindicated. We thank Cécile Luc-Pupat, Romain Vitte, Franck Ferrer, and Laurent Billard for supporting this work.
References 1. Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases. Am Heart J 2003;146:404 –10. 2. Ngaage DL, Mullany CJ, Daly RC, et al. Surgical treatment of cardiac papillary fibroelastoma: a single center experience with eighty-eight patients. Ann Thorac Surg 2005;80:1712– 8. 3. Grandmougin D, Fayad G, Moukassa D, et al. Cardiac valve papillary fibroelastomas: clinical, histological and immunohistochemical studies and a physiopathogenic hypothesis. J Heart Valve Dis 2000;9:832– 41. 4. Veinot JP. Fibroelastoma and embolic stroke. Circulation 1999;99:2709 –12. 5. Joffe II II, Jacobs LE, Owen AN, Ioli A, Kotler MN. Rapid development of a papillary fibroelastoma with associated thrombus: the role of transthoracic and transesophageal echocardiography. Echocardiography 1997;14:287–92. © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
We report here the first case, to our knowledge, of pulmonary valve replacement being performed via a left thoracotomy approach in a patient with pectus excavatum who had 3 previous sternotomies. The merit of this approach and its feasibility are discussed. (Ann Thorac Surg 2012;93:306 – 8) © 2012 by The Society of Thoracic Surgeons
P
ulmonary valve replacement is an increasingly performed operation in adults who have undergone surgery for right ventricular outflow tract obstruction in their earlier years and have been left with residual pulmonary regurgitation. If left unchecked, pulmonary regurgitation leads to progressive right ventricular dilatation and, with time, to right ventricular dysfunction, exercise intolerance, ventricular arrhythmias, and sudden death. There is evidence that in patients with severe pulmonary valve regurgitation, pulmonary valve replacement can reduce right ventricular overload and the development of arrhythmias. The operation of pulmonary valve replacement is most frequently performed through a repeat sternotomy and can be performed electively with a reported perioperative mortality of 1% to 4% and a 10-year survival of 86% to 95% [1]. Our patient presented postnatally with pulmonary atresia (Fallot-type) with intact ventricular septum. She was initially treated with prostaglandin, after which a Waterston’s shunt was created in the neonatal period. At the age of 4 months, she underwent a right ventricular outflow tract reconstruction by means of a homograft monocusp patch. Subsequent to this, at the age of 9 months, her Waterston’s shunt was disconnected, the muscular obstruction in the right ventricular infundibulum was resected, and the patent foramen ovale was closed. She did well for a long while, until at the age of 19 years old, she started to have mild dyspnoea which progressed over time and was also troubled by occasional retrosternal chest pains. She also developed a pectus excavatum (Fig 1). Transthoracic echocardiography demonstrated reversed interventricular septal motion with good left ventricular function, and left-sided ejection fraction of 60%. Her left ventricular end diastolic, end systolic, and interventricular septal dimensions were respectively 3.7, 2.7, and 0.9 cm.
Accepted for publication May 13, 2011. Address correspondence to Mr Hasan, Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, United Kingdom; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.05.064
Ann Thorac Surg 2012;93:306 – 8
CASE REPORT BARNARD ET AL LEFT THORACOTOMY PULMONARY VALVE REPLACEMENT
307
Fig 1. Magnetic resonance imaging scans showing the degree of pectus excavatum and close proximity of the heart to the anterior chest wall.
ular outflow tract. The cross clamp was removed after 83 minutes. Cardiopulmonary bypass was discontinued without difficulty after 116 minutes and the heart returned to sinus rhythm without difficulty. Two ventricular pacing wires were placed and 2 24F intercostal drains were inserted into the left chest and the thoracotomy was closed in layers. The patient did well after surgery and was discharged home after 7 days. She continues to do well 14 months after surgery.
Comment Whereas pulmonary valve replacement is a not an uncommonly performed procedure for patients who have pulmonary valve regurgitation [2], this case represents the first reported case that we are aware of, where a left thoracotomy approach has been used. This approach represented the safest access to the heart in view of the adherence of the right atrium to the posterior table of the sternum and the pectus excavatum. Left thoracotomy performed with the patient under general anesthesia was first described in 1910 [3] and was first described in a large series of mitral valve surgery in 1952 [4]. The first case of pulmonary valve replacement was performed in 1965 [5]. Left thoracotomy has an established role in re-do mitral valve surgery in some centers [6, 7] and has also been described for aortic valve replacement [8]. Left thoracotomy approach has also been used as a form of minimal access approach for mitral valve surgery [9]. In performing a repeat sternotomy, the benefits of establishing access for cardiopulmonary bypass before sternotomy are well described. In this case, the small caliber of the femoral arteries and the quality of the vessels after previous cannulation made this approach unattractive and, hence, an alternative approach was considered. In addition to creating a safe entry into the thorax, this approach also allowed access to the aorta for cannulation, allowed conduct of cardiopulmonary bypass without any difficulties, and provided a good surgical exposure. We feel that this approach to sometimes challenging repeat pulmonary valve surgery, where vascular access via the groin or subclavian vessels is not feasible and entry through the median sternotomy approach is unappealing, should be considered as a surgical option.
References 1. Oechslin EN, Harrison DA, Harris L, et al. Reoperation in adults with repair of tetralogy of fallot: indications and outcomes. J Thorac Cardiovasc Surg 1999;118:245–51.
FEATURE ARTICLES
There was severe regurgitation of the pulmonary valve with a pressure half time of 74 meters per second. There was moderate to severe tricuspid regurgitation. Maximum velocity across the tricuspid valve was 2.6 meters per second. Right ventricular systolic function appeared to be mild to moderately reduced, with a tricuspid annular plane systolic excursion of 0.9 cm. Cardiopulmonary stress testing revealed a VO2 maximum of 29.7 mL/Kg/minute which was 72% of predicted. Cardiac magnetic resonance imaging confirmed the echo findings and right ventricular analysis indicated an end diastolic volume of 150 mls with an end systolic volume of 80 mls, giving a stroke volume of 70 mls and an estimated ejection fraction of 47%. In view of her 3 previous sternotomies, the adherence of the right atrium to the back of her sternum, and her pectus excavatum, it was decided to establish femoral artery to femoral vein cardiopulmonary bypass. The left femoral artery was exposed and found to be very small and not useable. The right vessel was scanned and found to be even smaller ⬍0.5 cm. In view of the difficulty in proceeding, it was decided to wake the patient up and discuss other therapeutic options. Two days later, the patient was returned to the operating theater for another approach to her surgery. The patient had a size 17F venous cannula inserted percutaneously through the right jugular vein to use as a superior vena cava cannula. After the patient was prepared and draped, the left femoral vessels that were explored previously were exposed again. The left femoral vein was of adequate caliber for insertion of a long venous cannula. A left submammary incision was fashioned and the chest was entered via a left antero-lateral thoracotomy through the fourth intercostal space. The lung was dissected off the mediastinum. Tedious dissection of the ascending aorta and arch was carried out as there was no peripheral artery for arterial access. The aortic cannula was inserted into the arch and the patient was fully heparinized and cardiopulmonary bypass was established with cooling down to 32°C. The ascending aorta was cross clamped, cardioplegia was infused into the aortic root, and the heart arrested easily. A longitudinal arteriotomy was performed through the middle of the main pulmonary artery. The area where the previous patch was inserted was heavily calcified and this was excised. A size 21-mm Perimount Magna bioprosthesis was fixed to the posterior pulmonary annulus with multiple pledgeted interrupted 2/0 ethibond sutures. A bovine pericardial patch was fashioned and was sutured to the edges of the pulmonary arteriotomy at the level of the valve. It was sutured to the valve using continuous 3/0 prolene sutures in double layered fashion. Rewarming was then instituted. The edges of the patch were sutured to the edges of the right ventric-
308
CASE REPORT KARIMI ET AL ANOMALOUS SINGLE CORONARY ARTERY
2. Boudjemline Y. Pulmonary valve replacement: extending the indications to the whole spectrum of pulmonary valve disease. Future Cardiol 2007;3:35– 41. 3. Lilienthal H. IV. The first case of thoracotomy in a human being under anaesthesia by intratracheal insufflation. Ann Surg 1910;52:30 –3. 4. Baker C, Brock RC, Campbell M, Wood P. Valvotomy for mitral stenosis; a further report, on 100 cases. Br Med J 1952; 1:1043–55. 5. Fuller DN, Marchand P, Zion MM, Zwi S. Homograft replacement of the pulmonary valve. Thorax 1966;21:337– 42. 6. Suzuki Y, Pagani FD, Bolling SF. Left thoracotomy for multiple-time redo mitral valve surgery using on-pump beating heart technique. Ann Thorac Surg 2008;86:466 –71. 7. Crooke GA, Schwartz CF, Ribakove GH, et al. Retrograde arterial perfusion, not incision location, significantly increases the risk of stroke in reoperative mitral valve procedures. Ann Thorac Surg 2010;89:723–30. 8. Barreda T, Laali M, Dorent R, Acar C. Left thoracotomy for aortic and mitral valve surgery in a case of mediastinal displacement due to pneumonectomy. J Heart Valve Dis 2008;17:239 – 42. 9. Saunders PC, Grossi EA, Sharony R, et al. Minimally invasive technology for mitral valve surgery via left thoracotomy: experience with forty cases. J Thorac Cardiovasc Surg 2004;127:1026 –32.
FEATURE ARTICLES
Reimplantation of Anomalous Single Coronary Artery From Pulmonary Artery: Diagnosis and Surgical Management Mohsen Karimi, MD, Elise Hulsebus, PA, and William Lutin, MD Department of Surgery, Division of Pediatric Cardiothoracic Surgery, and Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Georgia, Children’s Medical Center, Augusta, Georgia
A newborn presented in cardiogenic shock with the diagnosis of anomalous single coronary artery from pulmonary artery and was successfully revived with prostaglandin (PGE1) infusion. She underwent surgical implantation of her coronary arteries while receiving PGE1 infusion to maintain high oxygen tension for the coronaries during cardiopulmonary bypass. She was discharged in 2 weeks with good biventricular function and moderate mitral regurgitation. At 2 months follow-up, she was gaining weight with preserved ventricular function and moderate mitral regurgitation. (Ann Thorac Surg 2012;93:308 –10) © 2012 by The Society of Thoracic Surgeons
A
nomalous left coronary artery from pulmonary artery (ALCAPA) is a rare disease with an incidence of 1 in 300,000 live births and a reported mortality of 90% by 1 year of age in untreated patients [1]. Anomalous
Accepted for publication June 22, 2011. Address correspondence to Dr Karimi, Division of Pediatric Cardiothoracic Surgery, Medical College of Georgia, Children’s Medical Center, 1446 Harper St, BP-3107, Augusta, GA 30912; e-mail: mkarimi@georgiahealth. edu.
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2012;93:308 –10
single coronary artery from pulmonary artery (ASCAPA) is even more rare and lethal as the result of ductal closure shortly after birth [2]. We report a case of a neonate with ASCAPA who was revived with PGE1 infusion and underwent successful reimplantation of her common coronary trunk. This is a case of a 1-week old girl, weighing 3.5 kg, who presented to a local hospital in cardiogenic shock that required aggressive fluid and inotropic resuscitation. She was transferred to our facility because of echocardiographic findings of dilated and hypocontractile right and left ventricles with severe mitral and tricuspid valve regurgitation. She was given prostaglandin (PGE1) infusion for presumed critical coarctation of aorta and intubated before transport. Her repeated echocardiogram confirmed these findings with no evidence of coarctation of aorta, a small to moderately sized patent ductus arteriosus with left to right shunting, and a patent foramen ovale. There was a questionable anomalous right coronary artery origin from the pulmonary artery, and the left coronary artery could not be identified (Fig 1A). The following day, she had a repeated echocardiogram that revealed improved biventricular function with resolution of tricuspid regurgitation, but with moderate to severe mitral regurgitation and papillary muscle hyperdensity. She had a cardiac catheterization that revealed the presence of an anomalous single coronary artery from the pulmonary artery, originating from the anterior sinus of Valsalva (Fig 1B). PGE1 infusion and inotropic support was maintained, and the patient was taken to the operating room for repair of her anomalous coronary arteries. Anesthesia induction was carefully administered to avoid hypotension and coronary hypoperfusion during PGE1 infusion. A midline sternotomy was performed and a piece of pericardium was harvested and tanned in glutaraldehyde solution. The heart appeared somewhat enlarged but well perfused and mildly cyanotic. The coronary anatomy was inspected and appeared to be a single-trunk coronary system arising from the anterior and rightward aspect of the pulmonary artery sinus (Fig 2). A cardiopulmonary bypass was performed via single arterial cannulation into the aorta and bicaval venous cannulation. Perfusion pressure was maintained high with a beating heart while controlling the pulmonary artery branches to avoid run-off and coronary steal. The heart was vented through the right superior pulmonary vein and arrested in antegrade fashion by placing a cardioplegia needle in the main pulmonary artery just at the bifurcation. The PGE1 infusion was continued to keep the ductus open while on bypass to perfuse the coronary arteries with high oxygen tension. The ductus was ligated and divided upon initiation of cardioplegia administration. The ascending aorta and the main pulmonary artery (MPA) were completely dissected, and the course of the coronary arteries was identified. They appeared to be originating as a common trunk from the anterior and rightward aspect of the pulmonary artery sinus 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.06.075