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Right Video-Assisted Thoracoscopy Ligation of the Thoracic Duct as Treatment for a Case of Chyloptysis
[2] Chung DA, Sharples LD, Nashef SA. A case-control analysis of readmissions to the cardiac surgical intensive care unit. Eur J Cardiothorac Surg 2002;22(August (2)):282–6. [3] Liu H, Ang CS, Liu L, Zhuang YM, Yang XM, Zhang Y. Predicotrs and reasons for readmission into cardiac intensive care unit. Zhonghua Yi Xue Za Zhi 2012;92(January (4)):272–5 (Article in Chinese).
2012 ANZSCTS Annual Scientific Meeting
485
optimisation, satisfactory fluid management, and minimising surgical time, are imperative. http://dx.doi.org/10.1016/j.hlc.2013.03.062 2012 Poster Presentation/Panel 37
http://dx.doi.org/10.1016/j.hlc.2013.03.061
Right Video-Assisted Thoracoscopy Ligation of the Thoracic Duct as Treatment for a Case of Chyloptysis
2012 Poster Presentation/Panel 36
Robert Xu ∗ , Gareth Crouch, Kan Nawata, Craig Jurisevic, Robert Stuklis
Cardiac Surgery in Jehovah’s Witness Patients – A Local Perspective
D’Arcy Sutherland Cardiothoracic Surgery Unit, Royal Adelaide Hospital, South Australia, Australia
Robert Xu ∗ , Kan Nawata, Michael Worthington, Robert Stuklis
Introduction: Chyloptysis is a rare phenomenon that has had minimal exposure in the medical literature. We describe a case of chyloptysis as a consequence of thoracic duct injury following aortic arch surgery, and subsequent management. Methods: A 71 year-old gentleman presents with ongoing expectoration of milky, foul-tasting sputum, while denying any systemic symptoms. He first presented in 2007 with a Type B dissection with an aneurysmal complex. This had been monitored with serial imaging and managed with medical antihypertensive therapy for six years. He underwent distal aortic arch repair: the distal aortic arch was transected and a 26 mm graft was sutured, with a distal anastomosis formed below the pulmonary hilum to the distal descending thoracic aorta. At Day 14, a progressive left pleural effusion was confirmed on CT and tapped using needle thoracostomy. Biochemistry of the specimen confirmed a diagnosis of chylothorax. After a trial of conservative therapy the chyle leak persisted and the patient was taken for surgical intervention via redo thoracotomy. Post discharge the patient was noted to have a reaccumulation of fluid in his left pleural cavity, likely due to a persistent chylothorax. Although this was slow-leaking and showed little progression in size on serial imaging, it was compounded by a frequent irritating productive cough, prompting re-referral for cardiothoracic surgical opinion. The diagnosis was a chylous pleural effusion complicated by a bronchopleural fistula. Results: The patient proceeded to right video assisted thoracoscopy and ligation of the thoracic duct. The thoracic duct originates from the cistern chylii which sits atop the second lumbar vertebral body. It rises anterior to the vertebral bodies, typically on the right side, entering the chest through the aortic hiatus before crossing to the left side at the level of the fourth or fifth thoracic vertebra. The duct was identified and clipped. At follow-up, he was well with no reaccumulation of pleural fluid on imaging or recurrence of productive cough (Fig. 1). Discussion: Chyloptysis is a rare condition, which has been reported to occur spontaneously on a background of mediastinal lymphatic disorders including lymphangioleiomyomatosis, or thoracic lympangiectasis.3 However, iatrogenic injury can also be a cause, as in this case where injury to the thoracic duct leading to chylous pleural
D’Arcy Sutherland Cardiothoracic Surgery Unit, Royal Adelaide Hospital, South Australia, Australia Introduction: Cardiac surgery is associated with a high number of blood product transfusions, making up nearly 20% of all transfusions in Australasia. Patients who adhere to the Jehovah’s Witness faith are banned from accepting blood transfusions, even in life-threatening situations, and have a variable acceptance of other components or substitutes. As such, they pose a special challenge for the cardiac surgeon. We report the clinical outcomes and operative mortality for such patients in a large cardiac center. Methods: Data was prospectively collected for all patients who identified as Jehovah’s Witnesses who underwent cardiac surgery at the Royal Adelaide from the January 2009 to September 2012 and retrospectively analysed. Fourteen patients were identified, with a mean age of 65 ± 9 years. The surgical procedures included eight coronary artery bypass grafts (CABG), three combined aortic valve replacement (AVR) and CABG, one Bentall’s procedure, two minimally-invasive mitral valve operations. One patient underwent a redo AVR in the given timeframe. There were three urgent procedures, the ejection fraction was 64 ± 11%, and 11/14 had NYHA IIIIV functional symptoms. Preoperative haemoglobin was 140 ± 12 g/L, 10 patients took aspirin within 24 h of surgery, and four received preoperative erythropoietin and/or iron supplementation. Four patients accepted albumix as a transfusion product. Results: Cardiopulmonary bypass time was 97 ± 45 min, aortic cross-clamp time was 60 ± 39 min. The lowest measured haemoglobin during admission was 89 ± 21 g/L, and the total volume of Day 1 bleeding through drains was 805 ± 543 mL. One patient had to return to theatre for reopening for bleeding, and there was one operative mortality. Two patients experienced strokes, and one required a prolonged ventilator wean necessitating a tracheostomy. Haemoglobin at discharge was 100 ± 19 g/L. Discussion: In our limited study series, the early surgical results of Jehovah’s Witness patients were acceptable. Nevertheless, suitable measures in order to minimise morbidity and mortality, including the use of preoperative
ABSTRACTS
Heart, Lung and Circulation 2013;22:455–489
486
2012 ANZSCTS Annual Scientific Meeting
Heart, Lung and Circulation 2013;22:455–489
ABSTRACTS
carditis. The aortic root was replaced with a 27 mm Freestyle prosthesis.
Fig. 1. Lymphoscintigram not conclusive for chylothorax due to slow leak of nuclear tracer.
effusion with coexisting bronchopleural fistula facilitating chyloptysis, one of the accepted mechanisms.4 Iatrogenic injury to the thoracic duct is a not uncommon consequence of thoracic cavity surgery. We present a case of such an injury following distal aortic arch repair, with persistent chylothorax and chyloptysis as a consequence. Right assisted video-assisted thoracoscopy luct digation has been used as a successful treatment modality. http://dx.doi.org/10.1016/j.hlc.2013.03.063 2012 Poster Presentation/Panel 38 Extra Anatomical Repair of Coarctation of Aorta Following Multiple Previous Interventions Robert Xu ∗ , Ritwick Bhuyan, James Edwards, Robert Stuklis D’Arcy Sutherland Cardiothoracic Surgery Unit, Royal Adelaide Hospital, South Australia, Australia Introduction: Coarctation of the aorta is one of the most common congenital anomalies to need multiple interventions. This is partly because of the complex natural history of the disease and association with other cardiac pathologies. Persistence and recurrence of stenosis is a complication of coarctation repair and is associated with major long-term morbidity. Methods: A 30-year male presented with a very complex history of coaractation repair. At the age of four years, he underwent surgical correction with resection and end-to-end anastomosis through a left thoracotomy. He subsequently underwent two balloon dilatation procedures in 1990 and 1997, and a dilatation and stenting in 2001. He subsequently had an episode of aortic valve endocarditis in 2002, and progressed towards a leaking aortic valve, presenting in early 2011 with NYHA functional class III symptoms. Echocardiogram revealed diffuse restenosis of his previously stented coarctation and severe aortic regurgitation with an ejection fraction of 58%. The ascending aorta was 3.8 cm in diameter and aortic root was also 3.8 cm in diameter. Results: He underwent an aortic root replacement as the first stage of the procedure. The aortic valve was bicuspid, heavily calcified and stenotic and had definite erosion from the previous endo-
He was subsequently planned for the second stage of the procedure–an extra anatomical bypass to relieve his recurrent coarctation of aorta. This was performed eight months following his aortic root replacement. The arch of the aorta was narrowed down distal to the origin of the left common carotid artery with a significantly dilated left subclavian artery (about 15 mm in diameter) and the stent took off immediately distal to the subclavian artery and that segment of the aorta was very narrow. A 16 mm straight Dacron Graft was first anastomosed to the undersuface of the left subclavian artery. The distal end of this graft was then anastomosed to the distal descending aorta in an end to side fashion. Discussion: Management options for combined aortic valve disease and recurrent coarctation of aorta in the adult population have not been well described. The obvious problem for the surgeon is which management option to select: one-stage correction of both lesions simultaneously through a median sternotomy with valve replacement and an extraanatomic bypass graft from the ascending to the descending aorta or a two stage approach. The two stage approach has the advantage of correction of the valvular lesion before the coarctation. To the best of our knowledge sixth cardiac intervention with a two stage Bentalls procedure and extra-anatomical bypass has not been described previously. http://dx.doi.org/10.1016/j.hlc.2013.03.064
2012 ANZSCTS Annual Scientific Meeting
485
optimisation, satisfactory fluid management, and minimising surgical time, are imperative. http://dx.doi.org/10.1016/j.hlc.2013.03.062 2012 Poster Presentation/Panel 37
http://dx.doi.org/10.1016/j.hlc.2013.03.061
Right Video-Assisted Thoracoscopy Ligation of the Thoracic Duct as Treatment for a Case of Chyloptysis
2012 Poster Presentation/Panel 36
Robert Xu ∗ , Gareth Crouch, Kan Nawata, Craig Jurisevic, Robert Stuklis
Cardiac Surgery in Jehovah’s Witness Patients – A Local Perspective
D’Arcy Sutherland Cardiothoracic Surgery Unit, Royal Adelaide Hospital, South Australia, Australia
Robert Xu ∗ , Kan Nawata, Michael Worthington, Robert Stuklis
Introduction: Chyloptysis is a rare phenomenon that has had minimal exposure in the medical literature. We describe a case of chyloptysis as a consequence of thoracic duct injury following aortic arch surgery, and subsequent management. Methods: A 71 year-old gentleman presents with ongoing expectoration of milky, foul-tasting sputum, while denying any systemic symptoms. He first presented in 2007 with a Type B dissection with an aneurysmal complex. This had been monitored with serial imaging and managed with medical antihypertensive therapy for six years. He underwent distal aortic arch repair: the distal aortic arch was transected and a 26 mm graft was sutured, with a distal anastomosis formed below the pulmonary hilum to the distal descending thoracic aorta. At Day 14, a progressive left pleural effusion was confirmed on CT and tapped using needle thoracostomy. Biochemistry of the specimen confirmed a diagnosis of chylothorax. After a trial of conservative therapy the chyle leak persisted and the patient was taken for surgical intervention via redo thoracotomy. Post discharge the patient was noted to have a reaccumulation of fluid in his left pleural cavity, likely due to a persistent chylothorax. Although this was slow-leaking and showed little progression in size on serial imaging, it was compounded by a frequent irritating productive cough, prompting re-referral for cardiothoracic surgical opinion. The diagnosis was a chylous pleural effusion complicated by a bronchopleural fistula. Results: The patient proceeded to right video assisted thoracoscopy and ligation of the thoracic duct. The thoracic duct originates from the cistern chylii which sits atop the second lumbar vertebral body. It rises anterior to the vertebral bodies, typically on the right side, entering the chest through the aortic hiatus before crossing to the left side at the level of the fourth or fifth thoracic vertebra. The duct was identified and clipped. At follow-up, he was well with no reaccumulation of pleural fluid on imaging or recurrence of productive cough (Fig. 1). Discussion: Chyloptysis is a rare condition, which has been reported to occur spontaneously on a background of mediastinal lymphatic disorders including lymphangioleiomyomatosis, or thoracic lympangiectasis.3 However, iatrogenic injury can also be a cause, as in this case where injury to the thoracic duct leading to chylous pleural
D’Arcy Sutherland Cardiothoracic Surgery Unit, Royal Adelaide Hospital, South Australia, Australia Introduction: Cardiac surgery is associated with a high number of blood product transfusions, making up nearly 20% of all transfusions in Australasia. Patients who adhere to the Jehovah’s Witness faith are banned from accepting blood transfusions, even in life-threatening situations, and have a variable acceptance of other components or substitutes. As such, they pose a special challenge for the cardiac surgeon. We report the clinical outcomes and operative mortality for such patients in a large cardiac center. Methods: Data was prospectively collected for all patients who identified as Jehovah’s Witnesses who underwent cardiac surgery at the Royal Adelaide from the January 2009 to September 2012 and retrospectively analysed. Fourteen patients were identified, with a mean age of 65 ± 9 years. The surgical procedures included eight coronary artery bypass grafts (CABG), three combined aortic valve replacement (AVR) and CABG, one Bentall’s procedure, two minimally-invasive mitral valve operations. One patient underwent a redo AVR in the given timeframe. There were three urgent procedures, the ejection fraction was 64 ± 11%, and 11/14 had NYHA IIIIV functional symptoms. Preoperative haemoglobin was 140 ± 12 g/L, 10 patients took aspirin within 24 h of surgery, and four received preoperative erythropoietin and/or iron supplementation. Four patients accepted albumix as a transfusion product. Results: Cardiopulmonary bypass time was 97 ± 45 min, aortic cross-clamp time was 60 ± 39 min. The lowest measured haemoglobin during admission was 89 ± 21 g/L, and the total volume of Day 1 bleeding through drains was 805 ± 543 mL. One patient had to return to theatre for reopening for bleeding, and there was one operative mortality. Two patients experienced strokes, and one required a prolonged ventilator wean necessitating a tracheostomy. Haemoglobin at discharge was 100 ± 19 g/L. Discussion: In our limited study series, the early surgical results of Jehovah’s Witness patients were acceptable. Nevertheless, suitable measures in order to minimise morbidity and mortality, including the use of preoperative
ABSTRACTS
Heart, Lung and Circulation 2013;22:455–489
486
2012 ANZSCTS Annual Scientific Meeting
Heart, Lung and Circulation 2013;22:455–489
ABSTRACTS
carditis. The aortic root was replaced with a 27 mm Freestyle prosthesis.
Fig. 1. Lymphoscintigram not conclusive for chylothorax due to slow leak of nuclear tracer.
effusion with coexisting bronchopleural fistula facilitating chyloptysis, one of the accepted mechanisms.4 Iatrogenic injury to the thoracic duct is a not uncommon consequence of thoracic cavity surgery. We present a case of such an injury following distal aortic arch repair, with persistent chylothorax and chyloptysis as a consequence. Right assisted video-assisted thoracoscopy luct digation has been used as a successful treatment modality. http://dx.doi.org/10.1016/j.hlc.2013.03.063 2012 Poster Presentation/Panel 38 Extra Anatomical Repair of Coarctation of Aorta Following Multiple Previous Interventions Robert Xu ∗ , Ritwick Bhuyan, James Edwards, Robert Stuklis D’Arcy Sutherland Cardiothoracic Surgery Unit, Royal Adelaide Hospital, South Australia, Australia Introduction: Coarctation of the aorta is one of the most common congenital anomalies to need multiple interventions. This is partly because of the complex natural history of the disease and association with other cardiac pathologies. Persistence and recurrence of stenosis is a complication of coarctation repair and is associated with major long-term morbidity. Methods: A 30-year male presented with a very complex history of coaractation repair. At the age of four years, he underwent surgical correction with resection and end-to-end anastomosis through a left thoracotomy. He subsequently underwent two balloon dilatation procedures in 1990 and 1997, and a dilatation and stenting in 2001. He subsequently had an episode of aortic valve endocarditis in 2002, and progressed towards a leaking aortic valve, presenting in early 2011 with NYHA functional class III symptoms. Echocardiogram revealed diffuse restenosis of his previously stented coarctation and severe aortic regurgitation with an ejection fraction of 58%. The ascending aorta was 3.8 cm in diameter and aortic root was also 3.8 cm in diameter. Results: He underwent an aortic root replacement as the first stage of the procedure. The aortic valve was bicuspid, heavily calcified and stenotic and had definite erosion from the previous endo-
He was subsequently planned for the second stage of the procedure–an extra anatomical bypass to relieve his recurrent coarctation of aorta. This was performed eight months following his aortic root replacement. The arch of the aorta was narrowed down distal to the origin of the left common carotid artery with a significantly dilated left subclavian artery (about 15 mm in diameter) and the stent took off immediately distal to the subclavian artery and that segment of the aorta was very narrow. A 16 mm straight Dacron Graft was first anastomosed to the undersuface of the left subclavian artery. The distal end of this graft was then anastomosed to the distal descending aorta in an end to side fashion. Discussion: Management options for combined aortic valve disease and recurrent coarctation of aorta in the adult population have not been well described. The obvious problem for the surgeon is which management option to select: one-stage correction of both lesions simultaneously through a median sternotomy with valve replacement and an extraanatomic bypass graft from the ascending to the descending aorta or a two stage approach. The two stage approach has the advantage of correction of the valvular lesion before the coarctation. To the best of our knowledge sixth cardiac intervention with a two stage Bentalls procedure and extra-anatomical bypass has not been described previously. http://dx.doi.org/10.1016/j.hlc.2013.03.064