- Email: [email protected]
Transapical Thoracic Endovascular Aortic Repair as a Bridge to Open Repair of an Infected Ascending Aortic Pseudoaneurysm
Ann Thorac Surg 2015;100:1883–6
(T2aN2M0), and he underwent anticancer chemotherapy concurrent with radiotherapy at 45 days after the operation.
CASE REPORT SHULTS ET AL TRANSAPICAL TEVAR
2.
Comment
References 1. Huang CT, Chen CY, Ho CC, Yu CJ. A rare constellation of empyema, lung abscess, and mediastinal abscess as a Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
3.
4. 5. 6.
7.
complication of endobronchial ultrasound-guided transbronchial needle aspiration. Eur J Cardiothorac Surg 2011;40: 264–5. Parker KL, Bizekis CS, Zurvos MD. Severe mediastinal infection with abscess formation after endobronchial ultrasound-guided transbronchial needle aspiration. Ann Thorac Surg 2010;89:1271–2. Gochi F, Chen F, Aoyama A, Date H. Mediastinal infectious complication after endobronchial ultrasound-guided transbronchial needle aspiration. Interact Cardiovasc Throrac Surg 2013;17:751–3. Moffatt-Bruce S, Ross P. Mediastinal abscess after endobronchial ultrasound with transbronchial needle aspiration: a case report. J Cardiothorac Surg 2010;5:33–5. Haas AR. Infectious complications from full extension endobronchial ultrasound transbronchial needle aspiration. Eur Respir J 2009;33:935–8. Asano F, Aoe M, Ohsaki Y, et al. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res 2013;14:50–7. Aerts JG, Kloover J, Los J, van der Heijden O, Janssens A, Tournoy KG. EUS-FNA of enlarged necrotic lymph nodes may cause infectious mediastinitis. J Thorac Oncol 2008;3: 1191–3.
Transapical Thoracic Endovascular Aortic Repair as a Bridge to Open Repair of an Infected Ascending Aortic Pseudoaneurysm Christian C. Shults, MD, Edward P. Chen, MD, Vinod H. Thourani, MD, and Bradley G. Leshnower, MD Division of Cardiothoracic Surgery, Medstar Washington Hospital Center, Washington, DC, and Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
Pseudoaneurysms of the ascending aorta pose a significant risk for free rupture during open aortic repair. This report describes the use of a modified thoracic aortic stent graft, delivered through transapical access, as a successful bridge to homograft replacement of the ascending aorta for the treatment of a mycotic ascending aortic pseudoaneurysm. (Ann Thorac Surg 2015;100:1883–6) Ó 2015 by The Society of Thoracic Surgeons
P
seudoaneurysms of the ascending aorta typically develop from dehiscence, infection, or both of a previous graft suture line or cannulation site. The optimal treatment requires ascending aortic replacement with extirpation of all infected tissue, and it carries high operative mortality [1]. Mediastinal reentry can be extremely challenging when the pseudoaneurysm is
Accepted for publication Dec 16, 2014. Address correspondence to Dr Leshnower, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365A Clifton Rd NE, Ste 2236, Atlanta, GA 30322; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.097
FEATURE ARTICLES
Obtaining a tissue diagnosis of mediastinal adenopathy can be challenging. EBUS-TBNA has replaced mediastinoscopy and VATS as a useful diagnostic procedure for such lesions and is becoming widely performed for the examination of mediastinal lymph nodes. EBUS-TBNA has a high diagnostic yield and minimizes the invasiveness and surgical complications associated with mediastinoscopy. Although a number of large-scale studies have found no complications associated with EBUSTBNA, infectious complications have been reported with the increasing use of this procedure [1–6]. Several case reports have described mediastinitis or pericarditis after EBUS-TBNA, and in Japan, 0.1% and 0.01% of patients, respectively, have been reported to experience these complications [6]. Mediastinitis originating from a cervical or oral lesion (termed descending mediastinitis) is a life-threatening condition that requires aggressive treatment with both broad-spectrum antibiotics and surgical intervention, and the mortality rate is roughly 50%. Although our present patient had no pericardial effusion on admission, circulatory dynamics deteriorated significantly over a short period because of cardiac tamponade resulting from pericardial effusion after pericarditis, and cardiac arrest occurred when the patient was placed in the left decubitus position for surgical intervention. This may have been fatal if pericardial drainage had been delayed further. Although no fatality has been reported previously in patients with mediastinitis or pericarditis after EBUS-TBNA, a quick decision about surgical intervention is required if mediastinitis develops. Among 7 reported cases of mediastinitis after EBUSTBNA in Japan, ultrasonographic examination at the puncture site suggested necrotic areas in 2 cases, findings other than necrosis or cysts in 2 cases, and unclear findings in 2 cases, whereas no description was available in 1 case [6]. Aerts and colleagues [7] reported a case of infectious mediastinitis after EBUS-FNA that occurred after puncture of a large malignant necrotic lymph node [7]. In the present case, mediastinitis also developed after puncture of a necrotic lymph node. Although few cases have been reported, puncture of necrotic lymph nodes may carry a risk of mediastinitis. In conclusion, we have described a case of acute severe mediastinitis and pericarditis that was treated successfully with surgical drainage. Although mediastinitis and pericarditis after EBUS-TBNA are very rare, sometimes they can lead to serious and rapid deterioration for which surgical intervention is indicated.
1883
1884
CASE REPORT SHULTS ET AL TRANSAPICAL TEVAR
Ann Thorac Surg 2015;100:1883–6
FEATURE ARTICLES
Fig 1. (A) Computed tomographic angiogram (CTA) of a contained rupture of a recurrent mycotic ascending aortic pseudoaneurysm. (B) CTA after ascending thoracic endovascular aortic repair.
located anteriorly and abuts the posterior sternal table. In this location, there is a high risk of free aortic rupture and exsanguination. This report describes the use of thoracic endovascular aortic repair (TEVAR) of a recurrent mycotic ascending aortic pseudoaneurysm through transapical access as a bridge to safe open aortic replacement with homograft. A 62-year-old man with end-stage emphysema underwent bilateral lung transplantation through a bilateral anterior thoracotomy incision with the use of cardiopulmonary bypass (CPB). Five months later he presented with fever, chest pain, and cough, and he was found to have a pseudoaneurysm at the aortic cannulation site. This was initially repaired through a median sternotomy, by use of CPB, with aortic debridement and a bovine pericardial aortoplasty. Cultures grew Staphylococcus aureus, and the patient was treated for 6 weeks with intravenous vancomycin. Two months later he presented again with similar symptoms, and a computed tomographic angiogram (CTA) of the chest demonstrated recurrence with contained rupture of the pseudoaneurysm (Fig 1A). The patient was counseled that optimal therapy would involve homograft replacement of the aorta to eradicate all infected tissue through redo sternotomy. However, the appearance and location of the pseudoaneurysm presented a high risk of free rupture upon sternal reentry. Therefore, TEVAR was recommended as a bridge to a safe open repair. The patient was taken to the hybrid operating room, and percutaneous access was obtained in the right brachial artery, and right femoral artery and vein. After the preoperative ascending aortic diameter and length measurements were confirmed by intravascular ultrasonography, a pigtail catheter was placed into the aortic root for aortograms, and a transvenous pacemaker was placed into the right ventricle through the right femoral vein. A redo left anterior thoracotomy was performed, and the apex was exposed. Two rings of concentric 3-0 pledgeted Prolene pursestring sutures were placed around the apex. On the basis of preoperative measurements, a Talent Captivia proximal freeflow 40 40 114 mm thoracic
endoprosthesis (Medtronic, Santa Rosa, CA) was deployed on the back table, cut to a length of 70 mm with an ophthalmic cautery, and resheathed into the delivery system (Fig 2). The patient was given heparin, transapical access was obtained, and a 0.035-inch Benson wire was carefully guided across the arch by use of a JR4 catheter. This was subsequently exchanged for a 0.035-inch Lunderquist wire, which was placed into the abdominal aorta. The modified endograft was advanced into the ascending aorta and deployed under rapid ventricular pacing with placement of the bare metal springs of the endograft across the ostia of the innominate artery. An aortogram was performed and demonstrated a type IA endoleak. Therefore, a Talent Captivia 46 46 52 mm distal extension endograft was placed 1 cm more proximally with the bare metal springs placed at the sinotubular junction. Balloon aortoplasty of the proximal and distal landing zones was performed, and all devices were removed. The patient had an uneventful postoperative course and was discharged on postoperative day 5 with a 6-week course of intravenous vancomycin, followed by lifelong oral Bactrim for suppression therapy in addition to his transplant immunosuppressive regimen. A CTA before he was discharged revealed complete thrombosis of the aneurysm sac (Fig 1B).
Fig 2. Modification of the length of a Talent (Medtronic, Santa Rosa CA) stent graft with ophthalmic cautery before resheathing.
Ann Thorac Surg 2015;100:1883–6
The patient’s symptoms resolved initially, and he was followed up closely with surveillance imaging every 3 months. He was readmitted because of fever 7 months after undergoing TEVAR and was found to have Staphylococcus aureus bacteremia. A CTA revealed recurrence of the pseudoaneurysm (Fig 3). After a 7-day course of vancomycin, which cleared the bacteremia, the patient underwent redo sternotomy, explantation of the endograft, and ascending and hemiarch aortic replacement with homograft by use of moderate hypothermic circulatory arrest with unilateral selective antegrade cerebral perfusion through the right axillary artery. The patient did well from this operation and was discharged home with a course of 6 weeks of intravenous vancomycin. He has been prescribed lifelong oral suppressive Bactrim therapy, and he remains alive and free of infection 24 months from his homograft ascending and hemiarch replacement.
The TEVAR procedure for ascending aortic pathology has been selectively used to treat pseudoaneurysms, and aortic dissection in patients who are considered at high risk or inoperable [2, 3]. The obstacles to safe ascending aortic endografting are multifactorial. The ascending aorta is a short (5–7 cm) curved structure that is bordered proximally by the aortic root and distally by the great vessels. Inaccurate deployment carries the risk of coronary ischemia, aortic valve dysfunction, or a cerebrovascular accident. Further complicating accurate delivery are the strong hemodynamic forces generated in the proximal aorta compared with other aortic segments. Finally, the currently available thoracic aortic stent graft devices are designed to treat descending thoracic aortic pathologic conditions. This affects both the endografts and their
1885
delivery systems. The endografts are frequently too long for the ascending aorta and require modification and repackaging before deployment. Depending on the patient’s body habitus, the delivery systems may be too short to reach the sinotubular junction. If they are long enough, the nosecones (unlike the TAVR delivery systems) are long and rigid, and they represent a significant risk of ventricular perforation. The use of the transapical approach removes several obstacles for ascending aortic TEVAR. The aforementioned problems with the lengths of the nosecone and delivery system are eliminated. The short distance from apex to ascending aorta gives the operator a significantly higher degree of device control during deployment. The “1 to 1” device control gained with transapical access combined with the reduction in pulse pressure with rapid ventricular pacing enables precise landing. In our case, we were able to precisely land two stent grafts using a slow controlled deployment to successfully endograft the ascending aorta from the sinotubular junction to the ostia of the innominate artery (Fig 3A). The use of stent grafts in the setting of infection should always be performed as a bridge to open repair, because inevitably the endograft becomes infected and fails. Similar to the reported use of endografts in aortoesophageal fistulas as bridge therapy [4], we performed ascending aortic TEVAR in our case as a bridge to open homograft replacement of the ascending aorta. This allowed for the mediastinum to become less hostile, and it facilitated a safe reentry that was successfully accomplished without aortic rupture. Although it is unlikely that TEVAR will ever serve as a definitive therapy for infection, endografts designed for the ascending aorta are currently under development [5]. These devices may ultimately become an “off the shelf” endovascular option to treat aneurysms, pseudoaneurysms, and dissections of the ascending aorta. Fig 3. (A) 3-dimensional volume reconstruction after ascending thoracic endovascular aortic repair at 6 months. (B) 3-dimensional volume reconstruction demonstrating recurrence of pseudoaneurysm at 7 months.
FEATURE ARTICLES
Comment
CASE REPORT SHULTS ET AL TRANSAPICAL TEVAR
1886
CASE REPORT KUJIRA ET AL SCAR VENTRICULAR TACHYCARDIA ABLATION
References
FEATURE ARTICLES
1. Mohammadi S, Bonnet N, Leprince P, et al. Reoperation for false aneurysm of the ascending aorta after its prosthetic replacement: surgical strategy. Ann Thorac Surg 2005;79:147–52. 2. Lu Q, Feng J, Zhou J, et al. Endovascular repair of ascending aortic dissection: a novel treatment option for patients judged unfit for direct surgical repair. J Am Coll Cardiol 2013;61: 1917–24. 3. Szeto WY, Moser WG, Desai ND, et al. Transapical deployment of endovascular thoracic aortic stent graft for an ascending aortic pseudoaneurysm. Ann Thorac Surg 2010;89: 616–8. 4. Canaud L, Ozdemir BA, Bee WW, Bahia S, Hold P, Thompson M. Thoracic endovascular aortic repair in management of aortoesophageal fistulas. J Vasc Surg 2014;59: 248–54. 5. Metcalfe MJ, Karthikesalingam A, Black SA, Loftus IM, Morgan R, Thompson MM. The first endovascular repair of an acute type A dissection using an endograft designed for the ascending aorta. J Vasc Surg 2012;55:220–2.
Ventricular Tachycardia Rotating a Scar of a Total Right Ventricular Exclusion Kazuto Kujira, MD, Kazuyasu Yoshitani, MD, Ayano Futsuki, MD, Kenta Imai, MD, Yoshimi Hiraumi, MD, PhD, Hisanori Sakazaki, MD, PhD, Yukihito Sato, MD, PhD, Yoshiki Takatsu, MD, PhD, Keiko Toyohara, MD, and Keiichi Fujiwara, MD, PhD Departments of Cardiovascular Medicine, Cardiovascular Surgery, and Pediatric Cardiology, Hyogo Prefectural Amagasaki Hospital, Amagasaki; Department of Pediatrics, Hyogo Prefectural Tsukaguchi Hospital, Amagasaki; and Department of Pediatric Cardiology, Tokyo Women’s Medical University, Tokyo, Japan
We describe a 15-year-old postoperative girl who underwent surgical 3-dimensional mapping and ablation of hemodynamically unstable ventricular tachycardia (VT) with an on-pump beating heart surgical technique. She had previously received a tricuspid valve closure, entire right ventricular free wall resection, and finally Fontan operation with an extracardiac conduit to treat a severe Ebstein’s anomaly. Activation mapping revealed a VT rotating around a large right ventricular free wall incisional scar with a narrow conduction channel between the scar and a tricuspid annulus (TA). A linear radiofrequency ablation connecting the scar and the TA terminated the VT. (Ann Thorac Surg 2015;100:1886–8) Ó 2015 by The Society of Thoracic Surgeons
I
n patients with a severe symptomatic Ebstein’s anomaly, an extremely enlarged right ventricle (RV) can
Accepted for publication Dec 23, 2014. Address correspondence to Dr Yoshitani, Department of Cardiovascular Medicine, Hyogo Prefectural Amagasaki Hospital, 1-1-1 Higashidaimotsu, Amagasaki, Hyogo, 660-0828 Japan; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;100:1886–8
compress the left ventricle (LV) and cause both LV failure and RV failure. In such patients, a total RV exclusion procedure consisting of a tricuspid valve (TV) closure, resection of the entire RV free wall, and subsequent total cavopulmonary connection can be chosen, and that strategy has been reported to increase LV end-diastolic volume, restore the LV shape, and improve contractile LV function [1, 2]. Here we report a patient after a total RV exclusion procedure who underwent surgical ventricular tachycardia (VT) ablation by use of electroanatomic mapping with an on-pump beating heart surgical technique. A 15-year-old girl was admitted for electrophysiologic study and treatment of a wide QRS tachycardia. Her history of congenital heart disease consisted of a severely symptomatic Ebstein’s anomaly. Initially, biventricular repair had been planned, and she underwent a right original Blalock-Taussig (BT) shunt at the age of 7 months and a left modified BT shunt at the age of 12 months because of severe cyanosis. After that, she gradually became worse because of heart failure and recurrence of cyanosis. When she was 7 years old, we had to switch to a univentricular strategy because the RV had become extremely large for a biventricular repair. Therefore she underwent a modified Starns procedure, which consisted of a TV closure with a fenestrated patch, entire RV free wall resection, pulmonary valve closure, and bidirectional Glenn procedure. Subsequently, at the age of 8, she underwent an extracardiac conduit Fontan procedure, after which she became free of any symptoms for almost 7 years until she was admitted because of a syncopal attack caused by sustained wide QRS tachycardia, which required electrical cardioversion. The QRS morphology of the clinical tachycardia (Fig 1) was a left bundle branch block pattern with left axis deviation. An electrophysiologic test was performed to confirm the diagnosis of tachycardia with the patient under general anesthesia. Even a single ventricular extrastimulus at the LV apex could reproducibly induce a hemodynamically unstable monomorphic wide QRS tachycardia with VA dissociation; thus, the diagnosis of VT was confirmed. We considered that an implantable cardioverter defibrillator (ICD) was indicated in this case. Because we were suspicious about locating the circuit of the VT in the RV free wall, where neither catheters nor leads were accessible endocardially, we decided to perform a surgical VT ablation and ICD implantation. First of all, we attempted to use an electroanatomic mapping system (CARTO-XP, Biosense Webster Inc, Diamond Bar, CA) in the operating room. The location pad was placed on the operating table to avoid any electromagnetic interference from the operating room table. A mattress was laid over the location pad and was fixed to keep an appropriate distance between the patient and pad to create an accurate electroanatomic map. With the patient under general anesthesia, a median sternotomy was performed. While the pericardial 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.099
(T2aN2M0), and he underwent anticancer chemotherapy concurrent with radiotherapy at 45 days after the operation.
CASE REPORT SHULTS ET AL TRANSAPICAL TEVAR
2.
Comment
References 1. Huang CT, Chen CY, Ho CC, Yu CJ. A rare constellation of empyema, lung abscess, and mediastinal abscess as a Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
3.
4. 5. 6.
7.
complication of endobronchial ultrasound-guided transbronchial needle aspiration. Eur J Cardiothorac Surg 2011;40: 264–5. Parker KL, Bizekis CS, Zurvos MD. Severe mediastinal infection with abscess formation after endobronchial ultrasound-guided transbronchial needle aspiration. Ann Thorac Surg 2010;89:1271–2. Gochi F, Chen F, Aoyama A, Date H. Mediastinal infectious complication after endobronchial ultrasound-guided transbronchial needle aspiration. Interact Cardiovasc Throrac Surg 2013;17:751–3. Moffatt-Bruce S, Ross P. Mediastinal abscess after endobronchial ultrasound with transbronchial needle aspiration: a case report. J Cardiothorac Surg 2010;5:33–5. Haas AR. Infectious complications from full extension endobronchial ultrasound transbronchial needle aspiration. Eur Respir J 2009;33:935–8. Asano F, Aoe M, Ohsaki Y, et al. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res 2013;14:50–7. Aerts JG, Kloover J, Los J, van der Heijden O, Janssens A, Tournoy KG. EUS-FNA of enlarged necrotic lymph nodes may cause infectious mediastinitis. J Thorac Oncol 2008;3: 1191–3.
Transapical Thoracic Endovascular Aortic Repair as a Bridge to Open Repair of an Infected Ascending Aortic Pseudoaneurysm Christian C. Shults, MD, Edward P. Chen, MD, Vinod H. Thourani, MD, and Bradley G. Leshnower, MD Division of Cardiothoracic Surgery, Medstar Washington Hospital Center, Washington, DC, and Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
Pseudoaneurysms of the ascending aorta pose a significant risk for free rupture during open aortic repair. This report describes the use of a modified thoracic aortic stent graft, delivered through transapical access, as a successful bridge to homograft replacement of the ascending aorta for the treatment of a mycotic ascending aortic pseudoaneurysm. (Ann Thorac Surg 2015;100:1883–6) Ó 2015 by The Society of Thoracic Surgeons
P
seudoaneurysms of the ascending aorta typically develop from dehiscence, infection, or both of a previous graft suture line or cannulation site. The optimal treatment requires ascending aortic replacement with extirpation of all infected tissue, and it carries high operative mortality [1]. Mediastinal reentry can be extremely challenging when the pseudoaneurysm is
Accepted for publication Dec 16, 2014. Address correspondence to Dr Leshnower, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365A Clifton Rd NE, Ste 2236, Atlanta, GA 30322; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.097
FEATURE ARTICLES
Obtaining a tissue diagnosis of mediastinal adenopathy can be challenging. EBUS-TBNA has replaced mediastinoscopy and VATS as a useful diagnostic procedure for such lesions and is becoming widely performed for the examination of mediastinal lymph nodes. EBUS-TBNA has a high diagnostic yield and minimizes the invasiveness and surgical complications associated with mediastinoscopy. Although a number of large-scale studies have found no complications associated with EBUSTBNA, infectious complications have been reported with the increasing use of this procedure [1–6]. Several case reports have described mediastinitis or pericarditis after EBUS-TBNA, and in Japan, 0.1% and 0.01% of patients, respectively, have been reported to experience these complications [6]. Mediastinitis originating from a cervical or oral lesion (termed descending mediastinitis) is a life-threatening condition that requires aggressive treatment with both broad-spectrum antibiotics and surgical intervention, and the mortality rate is roughly 50%. Although our present patient had no pericardial effusion on admission, circulatory dynamics deteriorated significantly over a short period because of cardiac tamponade resulting from pericardial effusion after pericarditis, and cardiac arrest occurred when the patient was placed in the left decubitus position for surgical intervention. This may have been fatal if pericardial drainage had been delayed further. Although no fatality has been reported previously in patients with mediastinitis or pericarditis after EBUS-TBNA, a quick decision about surgical intervention is required if mediastinitis develops. Among 7 reported cases of mediastinitis after EBUSTBNA in Japan, ultrasonographic examination at the puncture site suggested necrotic areas in 2 cases, findings other than necrosis or cysts in 2 cases, and unclear findings in 2 cases, whereas no description was available in 1 case [6]. Aerts and colleagues [7] reported a case of infectious mediastinitis after EBUS-FNA that occurred after puncture of a large malignant necrotic lymph node [7]. In the present case, mediastinitis also developed after puncture of a necrotic lymph node. Although few cases have been reported, puncture of necrotic lymph nodes may carry a risk of mediastinitis. In conclusion, we have described a case of acute severe mediastinitis and pericarditis that was treated successfully with surgical drainage. Although mediastinitis and pericarditis after EBUS-TBNA are very rare, sometimes they can lead to serious and rapid deterioration for which surgical intervention is indicated.
1883
1884
CASE REPORT SHULTS ET AL TRANSAPICAL TEVAR
Ann Thorac Surg 2015;100:1883–6
FEATURE ARTICLES
Fig 1. (A) Computed tomographic angiogram (CTA) of a contained rupture of a recurrent mycotic ascending aortic pseudoaneurysm. (B) CTA after ascending thoracic endovascular aortic repair.
located anteriorly and abuts the posterior sternal table. In this location, there is a high risk of free aortic rupture and exsanguination. This report describes the use of thoracic endovascular aortic repair (TEVAR) of a recurrent mycotic ascending aortic pseudoaneurysm through transapical access as a bridge to safe open aortic replacement with homograft. A 62-year-old man with end-stage emphysema underwent bilateral lung transplantation through a bilateral anterior thoracotomy incision with the use of cardiopulmonary bypass (CPB). Five months later he presented with fever, chest pain, and cough, and he was found to have a pseudoaneurysm at the aortic cannulation site. This was initially repaired through a median sternotomy, by use of CPB, with aortic debridement and a bovine pericardial aortoplasty. Cultures grew Staphylococcus aureus, and the patient was treated for 6 weeks with intravenous vancomycin. Two months later he presented again with similar symptoms, and a computed tomographic angiogram (CTA) of the chest demonstrated recurrence with contained rupture of the pseudoaneurysm (Fig 1A). The patient was counseled that optimal therapy would involve homograft replacement of the aorta to eradicate all infected tissue through redo sternotomy. However, the appearance and location of the pseudoaneurysm presented a high risk of free rupture upon sternal reentry. Therefore, TEVAR was recommended as a bridge to a safe open repair. The patient was taken to the hybrid operating room, and percutaneous access was obtained in the right brachial artery, and right femoral artery and vein. After the preoperative ascending aortic diameter and length measurements were confirmed by intravascular ultrasonography, a pigtail catheter was placed into the aortic root for aortograms, and a transvenous pacemaker was placed into the right ventricle through the right femoral vein. A redo left anterior thoracotomy was performed, and the apex was exposed. Two rings of concentric 3-0 pledgeted Prolene pursestring sutures were placed around the apex. On the basis of preoperative measurements, a Talent Captivia proximal freeflow 40 40 114 mm thoracic
endoprosthesis (Medtronic, Santa Rosa, CA) was deployed on the back table, cut to a length of 70 mm with an ophthalmic cautery, and resheathed into the delivery system (Fig 2). The patient was given heparin, transapical access was obtained, and a 0.035-inch Benson wire was carefully guided across the arch by use of a JR4 catheter. This was subsequently exchanged for a 0.035-inch Lunderquist wire, which was placed into the abdominal aorta. The modified endograft was advanced into the ascending aorta and deployed under rapid ventricular pacing with placement of the bare metal springs of the endograft across the ostia of the innominate artery. An aortogram was performed and demonstrated a type IA endoleak. Therefore, a Talent Captivia 46 46 52 mm distal extension endograft was placed 1 cm more proximally with the bare metal springs placed at the sinotubular junction. Balloon aortoplasty of the proximal and distal landing zones was performed, and all devices were removed. The patient had an uneventful postoperative course and was discharged on postoperative day 5 with a 6-week course of intravenous vancomycin, followed by lifelong oral Bactrim for suppression therapy in addition to his transplant immunosuppressive regimen. A CTA before he was discharged revealed complete thrombosis of the aneurysm sac (Fig 1B).
Fig 2. Modification of the length of a Talent (Medtronic, Santa Rosa CA) stent graft with ophthalmic cautery before resheathing.
Ann Thorac Surg 2015;100:1883–6
The patient’s symptoms resolved initially, and he was followed up closely with surveillance imaging every 3 months. He was readmitted because of fever 7 months after undergoing TEVAR and was found to have Staphylococcus aureus bacteremia. A CTA revealed recurrence of the pseudoaneurysm (Fig 3). After a 7-day course of vancomycin, which cleared the bacteremia, the patient underwent redo sternotomy, explantation of the endograft, and ascending and hemiarch aortic replacement with homograft by use of moderate hypothermic circulatory arrest with unilateral selective antegrade cerebral perfusion through the right axillary artery. The patient did well from this operation and was discharged home with a course of 6 weeks of intravenous vancomycin. He has been prescribed lifelong oral suppressive Bactrim therapy, and he remains alive and free of infection 24 months from his homograft ascending and hemiarch replacement.
The TEVAR procedure for ascending aortic pathology has been selectively used to treat pseudoaneurysms, and aortic dissection in patients who are considered at high risk or inoperable [2, 3]. The obstacles to safe ascending aortic endografting are multifactorial. The ascending aorta is a short (5–7 cm) curved structure that is bordered proximally by the aortic root and distally by the great vessels. Inaccurate deployment carries the risk of coronary ischemia, aortic valve dysfunction, or a cerebrovascular accident. Further complicating accurate delivery are the strong hemodynamic forces generated in the proximal aorta compared with other aortic segments. Finally, the currently available thoracic aortic stent graft devices are designed to treat descending thoracic aortic pathologic conditions. This affects both the endografts and their
1885
delivery systems. The endografts are frequently too long for the ascending aorta and require modification and repackaging before deployment. Depending on the patient’s body habitus, the delivery systems may be too short to reach the sinotubular junction. If they are long enough, the nosecones (unlike the TAVR delivery systems) are long and rigid, and they represent a significant risk of ventricular perforation. The use of the transapical approach removes several obstacles for ascending aortic TEVAR. The aforementioned problems with the lengths of the nosecone and delivery system are eliminated. The short distance from apex to ascending aorta gives the operator a significantly higher degree of device control during deployment. The “1 to 1” device control gained with transapical access combined with the reduction in pulse pressure with rapid ventricular pacing enables precise landing. In our case, we were able to precisely land two stent grafts using a slow controlled deployment to successfully endograft the ascending aorta from the sinotubular junction to the ostia of the innominate artery (Fig 3A). The use of stent grafts in the setting of infection should always be performed as a bridge to open repair, because inevitably the endograft becomes infected and fails. Similar to the reported use of endografts in aortoesophageal fistulas as bridge therapy [4], we performed ascending aortic TEVAR in our case as a bridge to open homograft replacement of the ascending aorta. This allowed for the mediastinum to become less hostile, and it facilitated a safe reentry that was successfully accomplished without aortic rupture. Although it is unlikely that TEVAR will ever serve as a definitive therapy for infection, endografts designed for the ascending aorta are currently under development [5]. These devices may ultimately become an “off the shelf” endovascular option to treat aneurysms, pseudoaneurysms, and dissections of the ascending aorta. Fig 3. (A) 3-dimensional volume reconstruction after ascending thoracic endovascular aortic repair at 6 months. (B) 3-dimensional volume reconstruction demonstrating recurrence of pseudoaneurysm at 7 months.
FEATURE ARTICLES
Comment
CASE REPORT SHULTS ET AL TRANSAPICAL TEVAR
1886
CASE REPORT KUJIRA ET AL SCAR VENTRICULAR TACHYCARDIA ABLATION
References
FEATURE ARTICLES
1. Mohammadi S, Bonnet N, Leprince P, et al. Reoperation for false aneurysm of the ascending aorta after its prosthetic replacement: surgical strategy. Ann Thorac Surg 2005;79:147–52. 2. Lu Q, Feng J, Zhou J, et al. Endovascular repair of ascending aortic dissection: a novel treatment option for patients judged unfit for direct surgical repair. J Am Coll Cardiol 2013;61: 1917–24. 3. Szeto WY, Moser WG, Desai ND, et al. Transapical deployment of endovascular thoracic aortic stent graft for an ascending aortic pseudoaneurysm. Ann Thorac Surg 2010;89: 616–8. 4. Canaud L, Ozdemir BA, Bee WW, Bahia S, Hold P, Thompson M. Thoracic endovascular aortic repair in management of aortoesophageal fistulas. J Vasc Surg 2014;59: 248–54. 5. Metcalfe MJ, Karthikesalingam A, Black SA, Loftus IM, Morgan R, Thompson MM. The first endovascular repair of an acute type A dissection using an endograft designed for the ascending aorta. J Vasc Surg 2012;55:220–2.
Ventricular Tachycardia Rotating a Scar of a Total Right Ventricular Exclusion Kazuto Kujira, MD, Kazuyasu Yoshitani, MD, Ayano Futsuki, MD, Kenta Imai, MD, Yoshimi Hiraumi, MD, PhD, Hisanori Sakazaki, MD, PhD, Yukihito Sato, MD, PhD, Yoshiki Takatsu, MD, PhD, Keiko Toyohara, MD, and Keiichi Fujiwara, MD, PhD Departments of Cardiovascular Medicine, Cardiovascular Surgery, and Pediatric Cardiology, Hyogo Prefectural Amagasaki Hospital, Amagasaki; Department of Pediatrics, Hyogo Prefectural Tsukaguchi Hospital, Amagasaki; and Department of Pediatric Cardiology, Tokyo Women’s Medical University, Tokyo, Japan
We describe a 15-year-old postoperative girl who underwent surgical 3-dimensional mapping and ablation of hemodynamically unstable ventricular tachycardia (VT) with an on-pump beating heart surgical technique. She had previously received a tricuspid valve closure, entire right ventricular free wall resection, and finally Fontan operation with an extracardiac conduit to treat a severe Ebstein’s anomaly. Activation mapping revealed a VT rotating around a large right ventricular free wall incisional scar with a narrow conduction channel between the scar and a tricuspid annulus (TA). A linear radiofrequency ablation connecting the scar and the TA terminated the VT. (Ann Thorac Surg 2015;100:1886–8) Ó 2015 by The Society of Thoracic Surgeons
I
n patients with a severe symptomatic Ebstein’s anomaly, an extremely enlarged right ventricle (RV) can
Accepted for publication Dec 23, 2014. Address correspondence to Dr Yoshitani, Department of Cardiovascular Medicine, Hyogo Prefectural Amagasaki Hospital, 1-1-1 Higashidaimotsu, Amagasaki, Hyogo, 660-0828 Japan; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2015;100:1886–8
compress the left ventricle (LV) and cause both LV failure and RV failure. In such patients, a total RV exclusion procedure consisting of a tricuspid valve (TV) closure, resection of the entire RV free wall, and subsequent total cavopulmonary connection can be chosen, and that strategy has been reported to increase LV end-diastolic volume, restore the LV shape, and improve contractile LV function [1, 2]. Here we report a patient after a total RV exclusion procedure who underwent surgical ventricular tachycardia (VT) ablation by use of electroanatomic mapping with an on-pump beating heart surgical technique. A 15-year-old girl was admitted for electrophysiologic study and treatment of a wide QRS tachycardia. Her history of congenital heart disease consisted of a severely symptomatic Ebstein’s anomaly. Initially, biventricular repair had been planned, and she underwent a right original Blalock-Taussig (BT) shunt at the age of 7 months and a left modified BT shunt at the age of 12 months because of severe cyanosis. After that, she gradually became worse because of heart failure and recurrence of cyanosis. When she was 7 years old, we had to switch to a univentricular strategy because the RV had become extremely large for a biventricular repair. Therefore she underwent a modified Starns procedure, which consisted of a TV closure with a fenestrated patch, entire RV free wall resection, pulmonary valve closure, and bidirectional Glenn procedure. Subsequently, at the age of 8, she underwent an extracardiac conduit Fontan procedure, after which she became free of any symptoms for almost 7 years until she was admitted because of a syncopal attack caused by sustained wide QRS tachycardia, which required electrical cardioversion. The QRS morphology of the clinical tachycardia (Fig 1) was a left bundle branch block pattern with left axis deviation. An electrophysiologic test was performed to confirm the diagnosis of tachycardia with the patient under general anesthesia. Even a single ventricular extrastimulus at the LV apex could reproducibly induce a hemodynamically unstable monomorphic wide QRS tachycardia with VA dissociation; thus, the diagnosis of VT was confirmed. We considered that an implantable cardioverter defibrillator (ICD) was indicated in this case. Because we were suspicious about locating the circuit of the VT in the RV free wall, where neither catheters nor leads were accessible endocardially, we decided to perform a surgical VT ablation and ICD implantation. First of all, we attempted to use an electroanatomic mapping system (CARTO-XP, Biosense Webster Inc, Diamond Bar, CA) in the operating room. The location pad was placed on the operating table to avoid any electromagnetic interference from the operating room table. A mattress was laid over the location pad and was fixed to keep an appropriate distance between the patient and pad to create an accurate electroanatomic map. With the patient under general anesthesia, a median sternotomy was performed. While the pericardial 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.099