Traumatic rupture of the thoracic aorta during the second trimester of pregnancy

Ann Thorac Surg 1996;61:1541-3

1541

CASE REPORT LEMERMEYERET AL TRAUMATIC AORTIC RUPTURE DURING PREGNANCY

Table 1. Support Data and Resulting Hemodynamic and Doppler Parameters Support Mode Variable Support rate PCPS (L/min) PM (beats/min) IABP Hemodynamic parameters (ram Hg) AP (sysldia/mean/augm) PAP (sys/dia/mean) CVP (mean) Doppler parameters Ascending aorta Antegrade flow Vmax (cm/s) VTI (cm/min) Retrograde flow Vmax (cm/s) VTI (cm/min) Common carotid artery Vma× (cm/s) VTI (cm/min) Left coronary artery Vma× (cm/s) VTI (cm/min)

1

2

3

4

4 100 1:1

4 100 Off

4 Off 120 cycles/min

4 Off Off

76/63178/94 60/38/49 17

85/67/70/...

55140/48157

63/41/52 16

.../.../22 20

.../.../57/... .../.../28 18

56 910

20 180

25 672

0 0

41 690

14 550

43 427

12 720

71 2,410

75 2,040

79 1,572

25 1,370

61 1,690

40 1,290

22 876

18 1,010

AP = arterial pressure (systolicldiastoliclmean/augmented pressure of IABP); CVP = central venous pressure; IABP = intraaortic balloon counterpulsation; PAP = pulmonary arterial pressure (systolic/diastolic/mean); PCPS = percutaneous cardiopulmonary support; PM = pacemaker; Vma× = peak flow velocity; VTI = velocity time integral × heart rate.

inflation of the intraaortic b a l l o o n m a y i n t e r m i t t e n t l y c o m p r o m i s e r e t r o g r a d e P C P S flow. This m i g h t e x p l a i n w h y in o u r patient, IABP failed to a u g m e n t m e a n arterial b l o o d p r e s s u r e a n d c o r o n a r y b l o o d flow d u r i n g asystole a n d w h y a beneficial effect of IABP o n c o r o n a r y a n d c e r e b r a l flow w a s o b s e r v e d o n l y after r e s t o r a t i o n of VVI pacing. In conclusion, a r e g u l a r cardiac r h y t h m is e s s e n t i a l e v e n for p a t i e n t s on PCPS. In t h e s e p a t i e n t s c o r o n a r y a n d carotid b l o o d flow can b e m a r k e d l y i m p r o v e d b y t h e a d d i t i o n of IABP.

Traumatic Rupture of the Thoracic Aorta During the Second Trimester of Pregnancy Gillian L e m e r m e y e r , BScN, M a n o j K. Talwar, MD, J o h n C. M u l l e n , M D , a n d N e i l Klassen, M D Division of Cardiothoracic Surgery and Department of Anaesthesia, University of Alberta, Edmonton, Alberta, Canada

References

A 36-year-old woman in the second trimester of pregnancy underwent emergent operative repair of a trau-

1. Rees MR, Browne T, Sivananthan UM, et al. Cardiac resuscitation with percutaneous cardiopulmonary support. Lancet 1992;340:513- 4. 2. Phillips SJ, Zeff RH, Kongtahworn C, et al. Benefits of combined balloon pumping and percutaneous cardiopulmonary bypass. Ann Thorac Surg 1992;54:908-10. 3. Lazar LH, Treanor P, Yang XM, Rivers S, Bernard S, Shemin RJ. Enhanced recovery of ischemic myocardium by combining percutaneous bypass with intraaortic balloon pump support. Ann Thorac Surg 1994;57:663-8. 4. Scholz KH, SchrBder T, Hering JP, et al. Need for active left-ventricular decompression during percutaneous cardiopulmonary support in cardiac arrest. Cardiology 1994;84: 222-30. 5. Kyo S, Matsumura M, Takamoto S, Omoto R. Transesophageal color Doppler echocardiography during mechanical assist circulation. Trans Am Soc Artif Intern Organs 1989;35: 722-5.

matic aortic disruption caused by a motor vehicle accident. Left atrial-to-femoral artery bypass was used to maintain fetal circulation during the cross-clamp period. Her healthy, full-term child was subsequently delivered 3 months later by normal v a g i n a l d e l i v e r y .

© 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc

(Ann Thorac Surg 1996;61:1541-3) u t o p s y studies r e v e a l that 90% of p a t i e n t s w i t h t r a u m a t i c r u p t u r e of the thoracic aorta die at the a c c i d e n t s c e n e a n d 25% r e a c h i n g the h o s p i t a l do n o t

A

Accepted for publication Nov 27, 1995. Address reprint requests to Dr Mullen, Departments of Surgery and Pediatrics, University of Alberta, 2D3.78 WC Mackenzie Health Sciences Centre, 8440-112 St, Edmonton, Alberta T6G 2B7, Canada. 0003-4975/96/$15.00 SSDI 0003-4975(95)01179-X

1542

CASE REPORT LEMERMEYER ET AL TRAUMATIC AORTIC RUPTURE DURING PREGNANCY

Ann Thorac Surg

1996;61:1541-3

Fig 1. Thoracic aortograms: (A) Oblique view demonstrat~'ng an indentation distal to the left subclavian artery. (B) Anteroposterior view showing disruption in the descending aorta just distal to the left subclavian artery.

A

survive [1]. When traumatic aortic rupture occurs in a pregnant woman, determining the best course of treatment becomes a dilficult challenge [2]. We describe the successful management of a woman in the second trimester of pregnancy who required emergent repair of an aortic rupture caused by a motor vehicle accident. A 36-year-old woman in the 25th week of her first pregnancy presented to the Emergency Department after a high-speed motor vehicle accident. Her blood pressure remained stable after volume resuscitation. She was found to have a dislocation of her right hip and a widened mediastinum on chest roentgenogram. The fetal heart rate was normal. Arch aortography showed an aortic disruption distal to the left subclavian artery (Fig 1). In the operating theater under general anesthesia, the right hip dislocation was reduced first. Blood pressure was monitored via right radial and femoral arterial cannulas. The left femoral artery was exposed and the chest was entered through a left posterolateral thoracotomy. A hemothorax (1 L) was evacuated. A large hematoma involved the descending aorta from the level of the left subclavian artery. Left atrial-to-left femoral artery bypass was employed to provide perfusion to the lower body (and thereby fetal perfusion) during the cross-clamp period. A Bio-Medicus centrifugal p u m p (Medtronic Inc. Minneapolis, MN) was used and a low dose of heparin (5000 IU intravenously) was given. The aorta was clamped proximal to the left subclavian artery and distal to the hematoma. The mean arterial pressure in the distal aorta was monitored and maintained greater than 50 m m Hg. There was complete disruption of the aorta for a 5-cm length, not amenable to primary repair, which

B

was replaced w i t h a 22-ram Hemashield collagenimpregnated woven double-velour Dacron graft (Meadox Medicals Inc, Oakland, NJ) using 4-0 polypropylene sutures. The cross-clamp time was 40 minutes and the bypass time was 45 minutes. Premature labor occurred 8 hours postoperatively and was arrested with intravenous magnesium sulfate. Her remaining postoperative course was uneventful. At 41 weeks of gestation spontaneous labor was augmented with oxytocin, and epidural anesthesia was employed for pain control. Blood pressure was monitored frequently noninvasively and remained well controlled. A healthy baby boy weighing 3.2 kg was delivered. Both mother and child were discharged in excellent condition 2 days later. Comment

Immediate treatment of traumatic aortic rupture is critically important. A pregnant patient with this condition imposes the additional challenge to save the fetus. Becker's [3] survey of nonemergent cardiac operations using cardiopulmonary bypass in pregnant women showed high maternal and fetal survival. He recommended highflow, high-pressure normothermic perfusion during cardiopulmonary bypass to optimize fetal safety. Zitnik and colleagues [4] also found open heart operations during pregnancy to be safe. Williams and associates [5] reported a similar patient (32 weeks pregnant) with traumatic aortic rupture who was managed by performing a cesarean section and then proceeding with aortic repair with partial cardiopulmonary bypass (femoral vein to femoral artery). Another case report in the literature involved a 27-year-old

Ann Thorac Surg 1996;61:1543-5

w o m a n who was 6 m o n t h s p r e g n a n t [6]. Partial cardiop u l m o n a r y b y p a s s was e m p l o y e d for fetal perfusion, a n d 2 m o n t h s later the child was delivered by p l a n n e d cesarean section. The initial decision as to the course of m a n a g i n g this patient was a difficult one. I m m e d i a t e cesarean section w o u l d have led to a greatly increased risk for the 25-week p r e m a t u r e infant as well as for the mother, as b l o o d loss associated with a cesarean section m a y have led to dramatic h e m o d y n a m i c changes. Left atrial-to-left femoral artery b y p a s s provides consistent, controllable flow to the lower body, decreasing the risk of p a r a p l e g i a a n d k i d n e y damage, a n d ensuring perfusion of the placenta. Distal perfusion p r e s s u r e was carefully m a i n t a i n e d to preserve uterine blood flow as the placental vasculature is maximally dilated [2]. Left atrial cannulation eliminates the n e e d for an oxygenator a n d can reduce or eliminate the n e e d for h e p a r i n to p r e v e n t clot formation. H i g h - d o s e h e p a r i n was avoided to decrease the risk of b l e e d i n g at the site of the aortic replacement. H e p a r i n is safe during p r e g n a n c y [2] as it does not cross the placental barrier. In Merin a n d associates' [6] patient, who was similar to our patient, a cesarean section was p e r f o r m e d electively at t e r m b a s e d on the concern that the acute rise in systemic blood pressure d u r i n g labor a n d delivery might lead to r e - r u p t u r e due to r e p o r t e d changes [7] in the aortic wall d u r i n g p r e g n a n c y (accumulation of m u c o i d material, decrease in acid mucopolysaccharides in the reticulum fibers, a n d h y p e r t r o p h y of smooth muscle). Other reports suggest that vaginal delivery after cardiac repairs is possible a n d safe [4, 8]. Blood p r e s s u r e was carefully m o n i t o r e d a n d controlled d u r i n g vaginal delivery of this child, a n d the child was born without incident. W e r e c o m m e n d left atrial-to-femoral b y p a s s as the most i m p o r t a n t adjunct in surgical t r e a t m e n t of traumatic aortic disruption during pregnancy, to optimize the chance for a successful outcome for both m o t h e r a n d child.

References 1. Lee RB, Stahlman GC, Sharp KW. Treatment priorities in patients with traumatic rupture of the thoracic aorta. Am Surg 1992;58:37-43. 2. Strickland RA, Oliver WC, Chantigian RC, Ney JA, Danielson GK. Anaesthesia, cardiopulmonary bypass, and the pregnant patient. Mayo Clin Proc 1991;66:411-29. 3. Becker RM. Intracardiac surgery in pregnant women. Ann Thorac Surg 1983;36:453-8. 4. Zitnik RS, Brandenburg RO, Sheldon R, Wallace RB. Pregnancy and open-heart surgery. Circ 1969;39(Suppl 1):257-62. 5. Williams GM, Gott VL, Brawley RIG Schauble JF, Labs JD. Aortic disease associated with pregnancy. J Vasc Surg 1988;8: 470-5. 6. Merin G, Bitran D, Donchin Y, Weinshtein D, Borman JB. Traumatic rupture of the thoracic aorta during pregnancy. Chest 1981;79:99-100. 7. Manalo-Estrella P, Barker AE. Histopathologic findings in human aortic media associated with pregnancy. Arch Pathol 1967;83:336-41. 8. Pamulapati M, Teague S, Stelzer P, Thadani U. Successful surgical repair of a ruptured aneurysm of the sinus of Valsalva in early pregnancy. Ann Intern Med 1991;115:880-2. © 1996 by The Society of Thoracic Surgeons Published by Elsevier Science Inc

CASE REPORT STRUBERET AL NITRIC OXIDEAND SURFACTANT

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Therapy for Lung Failure Using Nitric Oxide Inhalation and Surfactant Replacement Martin Striiber, MD, Michael Brandt, MD, Joachim Cremer, MD, Wolfgang Harringer, MD, S t e p h a n W. Hirt, MD, a n d Axel Haverich, MD Department of Cardiovascular Surgery, Christian Albrechts University, Kiel, Germany

Nitric oxide inhalation and surfactant replacement therapy are relatively new concepts in the treatment of respiratory failure due to h y p o x i a and reperfusion injury after lung transplantation. We report on a patient in whom reperfusion injury of the lung developed after resuscitation and i m p l a n t a t i o n of a biventricular assist device for sudden cardiac arrest. Lung failure developed within 12 hours after implantation of the biventricular assist device. Lung function was reestablished using combined therapy of nitric oxide and surfactant. Heart transplantation was performed successfully thereafter. This case indicates the potential role of a combined therapy of nitric oxide and surfactant in acute hypoxic l u n g failure.

(Ann Thorac Surg 1996;61:1543-5) he role of inhaled nitric oxide (NO) in the t r e a t m e n t of p u l m o n a r y h y p e r t e n s i o n a n d i m p a i r e d lung function due to ventilation-perfusion m i s m a t c h has b e e n e x p a n d i n g rapidly. First u s e d in adult respiratory distress s y n d r o m e [1], it was also found to be effective in p u l m o nary h y p e r t e n s i o n after operation for congenital heart defects [2] a n d graft dysfunction after lung transplantation [3]. In reperfusion injury after lung transplantation, transtracheal application of surfactant i m p r o v e d lung function [4]. The beneficial effect m a y be due to the r e p l a c e m e n t of surfactant w h e n the production of a lung is i m p a i r e d after hypoxia [5]. W e r e p o r t on the successful t r e a t m e n t of a patient with lung failure due to hypoxia before heart transplantation using both N O inhalation a n d surfactant r e p l a c e m e n t therapy.

T

A 38-year-old m a n with extensive coronary artery disease was a d m i t t e d for surgical revascularization. Otherwise he was healthy. Shortly after a d m i s s i o n s u d d e n cardiac arrest developed, most likely due to acute m y o c a r d i a l infarction. Resuscitation was a p p l i e d immediately. Because cardiac function could not be r e e s t a b l i s h e d he was taken to the operating r o o m for e m e r g e n c y revascularAccepted for publication Nov 11, 1995. Address reprint requests to Dr Striiber, Department of Cardiovascular Surgery, Christian Albrechts University, Arnold Heller Str 7, 24105 Kiel, Germany. 0003-4975/96/$15.00 SSDI 0003-4975(95)01164-1