Interactive Cardiovascular and Thoracic Surgery 2:636-638(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Vascular thoracic |
Management of intraoperative aortic dissection with a direct cannulation on the intimal flap
Shinichi Mizutani*,
Akihiko Usui,
Toshiaki Akita and
Yuichi Ueda
Department of Cardio-Thoracic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
* Corresponding author. Tel.: +81-52-744-2376; fax: +81-52-744-2383
smizutan{at}med.nagoya-u.ac.jp
Received April 29, 2003;
received in revised form July 21, 2003;
accepted August 20, 2003
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Abstract
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We report a case of severe aortic stenosis in which intraoperative aortic dissection developed from aortic cross-clamp. The patient showed symptoms of malperfusion, but was successfully managed by direct inflow cannulation on the intimal flap into the true lumen. She then recovered well without further incident.
Key Words: Surgical complication; Aortic dissection; Cannulation; True lumen
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1. Introduction
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Intraoperative aortic dissection is a rare but fatal complication in open-heart surgery. Following the onset of dissection, proper management is required immediately. We report a case of intraoperative aortic dissection that was successfully managed with a direct cannulation on the intimal flap.
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2. Case report
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Our patient was a 67-year-old woman. She had suffered several episodes of syncope on effort. Echocardiography revealed severe calcified aortic valve stenosis with 100–150 mmHg of transvalvular pressure gradient, and severe left ventricular (LV) hypertrophy with LV posterior wall thickness of 23.7 mm. The coronary angiography was normal but the catheter could not be passed through the aortic valve.
The operation was performed via median sternotomy. The ascending aorta was slightly dilated to about 4 cm in diameter. The patient was put on cardiopulmonary bypass (CPB) with a cannulation of the ascending aorta and the right atrial appendage. The cardioplegic cannula was placed on the aortic root and an aortic cross-clamp was applied. Though the cold blood cardioplegia was infused, cardiac arrest was not achieved and the heart went into ventricular fibrillation. An LV vent was then introduced via the right superior pulmonary vein. The root was circumferentially distended, and the left radial arterial pressure fell immediately. Transesophageal echocardiography revealed dissection of the descending aorta, this confirmed aortic dissection, which was thought to be caused by the infusion of cardioplegia. The cardioplegia was immediately stopped, the root cannula was removed and the aortic adventitia was incised to prevent extension of the dissection. After removal of the aortic clamp, a 22-F aortic perfusion cannula (Baxter Research Medical Inc., Midvale, UT) was inserted into the true lumen through a 3-0 Prolene purse-string suture on the intimal flap of the ascending aorta (Fig. 1). CPB was re-established with only 6 min interruption and cooling of the patient began. During cooling the ascending aorta had been grasped in order to depress the false lumen and reduce the bleeding, and so as not to occlude the true lumen entirely, this maintained the flow through the heart during the ventricular fibrillation. An additional cannula was inserted into the superior vena cava for retrograde cerebral perfusion (RCP). When the body temperature reached 18 °C, circulatory arrest was applied and the intimal flap was cut open. The heart was arrested with direct antegrade cardioplegia through the coronary artery ostia followed by retrograde cardioplegia every 20 min. The dissection was extended to the right coronary cusp, over the orifice of the right coronary artery. An intimal tear about 1 cm long was found on the lesser curve of the aorta at the cross-clamping site. Under RCP, the ascending aorta was replaced with a one-branched Dacron tube graft with open distal anastomosis and CPB was reinstituted with controlled warming. After debridement of the calcified aortic valve, myectomy of protruded LV outflow tract was performed together with Nicks annular enlargement. The modified Bentall procedure was performed using the button technique and the composite valve graft was anastomosed to the main graft. Upon weaning the patient off the CPB, right heart failure developed due to the dissection of the right coronary artery. Coronary artery bypass grafting with saphenous vein graft was then performed to the right coronary artery on the beating heart, and CPB weaning then proceeded easily. The total CPB time, myocardial ischemic time and RCP time were 390, 184 and 56 min, respectively.
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Fig. 1 Scheme of cannulation. An inflow cannula is inserted directly into the true lumen of the ascending aorta via the intimal flap.
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The patient awoke on the first postoperative day (POD), with no neurological deficit. Due to respiratory failure the patient was not extubated until POD 6. Thereafter she recovered well, but a minor cerebral infarction developed on POD 30. She was discharged home on POD 78 without further incident. Computed tomography at discharge revealed a residual false lumen from the right innominate artery to the left common iliac artery. This was not thrombosed but showed no tendency to dilate.
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3. Discussion
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Intraoperative aortic dissection is a rare but lethal complication of cardiac surgery, and its incidence is reported as 0.16–0.35% [1,2]. Predisposition is reported to arise from severe atherosclerotic change, cystic medial necrosis, collagen vascular disease, and a thin or dilated ascending aorta as in the presented case [2–5]. Aortic cannulation, cross-clamping, partial-occlusion clamping and others are responsible for dissection. Prevention of dissection is clearly preferable to treatment of the dissection, but appropriate and rapid management is required once it has arisen. Dissection was identified most frequently after removal of the aortic clamp [1], but will also occur at the time of cannulation, clamping, decannulation or even postoperatively. If the extent of dissection were limited to a small area, a closed plication technique could be applied without moving the aortic cannula [2]. However, when larger dissections are encountered and the results of malperfusion arise, the perfusion cannula should immediately be moved to another arterial site. While cannulation of femoral or axillary artery [6,7] would normally be applied for the alternative, in such a limited period as our situation it was difficult to confirm that these sites were intact and would not cause further malperfusion. In order to obtain speedy and certain perfusion to the true lumen, we usually apply transapical cannulation when malperfusion develops in surgery of an acute type A dissection. This procedure is considered to be a useful alternative when no other suitable cannulation site can be found [8,9], but it could not be carried out in the present case because of severe aortic stenosis. We therefore incised only the adventitia of the ascending aorta to decompress the false lumen. Keeping the flap intact, we then removed the clamp and applied inflow cannulation from the intimal flap into the true lumen. All this was done in a very short period. The procedure followed here involves many problems and therefore, it may not always be successful to insert the cannula into the true lumen, especially in patients who have a complete circumferential tear in the ascending aorta. However, direct cannulation on the intimal flap should be helpful in a limited number of cases, including ours.
doi:10.1016/S1569-9293(03)00187-7
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References
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Abstract
1. Introduction