Intraoperative iatrogenic type A aortic dissection and perioperative outcome

We assessed the risks and causative mechanisms of intraoperative iatrogenic aortic dissection type A. During a 3-year period (2002-2004) with 3000 open heart cases, 7 patients sustained an intraoperative aortic dissection type A, resulting in an incidence of 0.23%. The original procedures were mitral valve replacement in 3 patients, aorto coronary bypass surgery in 2 patients, ascending aortic replacement with aortic valve replacement and single lung transplantation with ECMO support in 1 patient each. Dissection occurred during aortic cannulation or decannulation in 3 patients, during insertion of the antegrade cardioplegia line in 1 patient, during manipulation of the aortic cannula in 1 patient and through direct cannulation of the axillary artery in 1 patient, and during femoral artery cannulation in 1 patient. Replacement of the ascending aorta with resection of the entry side was successfully performed in all 7 patients (median OT time 387 min, ECC 192 min, ACC 101 min, CA 25 min). Patients with iatrogenic aortic dissection have an increased mortality rate and risk factors for bad outcome are as follows: a mean aortic pressure of less than 50 mmHg during the change of arterial cannulation site, advanced age and the time of diagnosis of the dissection.     

Blunt injuries to the innominate artery

Two patients with aneurysm secondary to blunt traumatic subadventitial rupture of the distal innominate artery (IA) are reported. IA rupture was identified because of a cervical bruit in one patient and detected during thoracic aortography in the other patient. The patients had associated cardiovascular lesions consisting of traumatic aneurysm of the subclavian artery and rupture of the aortic valve, respectively. Both lesions were surgically repaired by resection of the lacerated intima and direct closure of the adventitia. In the patient who underwent repair of the aortic valve with simultaneous cardiopulmonary bypass the IA was approached after cannulation of the right common carotid artery. In the other patient the IA was repaired without use of a shunt under close EEG monitoring. Injury to the IA is rare because the artery is short and relatively well protected by the bony cage. Other cardiovascular lesions may be associated with IA rupture and a routine search should be made.     

Epicardial echocardiography: diagnostic utility for evaluating aortic valve disease during coronary surgery

Intraoperative epicardial echocardiography is commonly used to evaluate the ascending aorta for atheromatous disease before cannulation and cross clamping. In addition, it may serve as a cardiac imaging technique in patients where placement of a transesophageal echocardiography (TEE) probe is contraindicated, probe advancement is difficult, or a TEE probe is not available. We report a patient who was taken to the OR for coronary artery bypass grafting. Intraoperative TEE was planned to evaluate aortic valve function. However, attempts to place a TEE probe were abandoned due to high resistance on probe insertion. Epicardial echocardiography revealed previously undiagnosed aortic valve disease resulting in replacement of this valve.     

New cannulation technique for the severely calcified ascending aorta

Severe calcific atherosclerosis involving the femoral arteries, ascending aorta, right subclavian artery, and aortic arch precluded standard cannulation techniques for a patient requiring emergency revascularization. A cannula was passed from the apex of the left ventricle across the aortic valve to lie in the proximal ascending aorta, and successful cardiopulmonary bypass was achieved to allow revascularization.     

Minimized mortality and neurological complications in surgery for chronic arch aneurysm: axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and total arch aorta

OBJECTIVE: Cerebral complication is still a major concern in surgery for arteriosclerotic aortic arch disease. For preventing this complication, axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and arch aorta were applied to thoracic aortic aneurysm involving aortic arch. METHOD: From May 1999 to July 2002, consecutive 39 patients with true aneurysm (29 patients) or chronic aortic dissection (10 patients) involving aortic arch underwent replacement of the ascending and arch aorta with an elephant trunk under hypothermic cardiopulmonary bypass through the axillary artery cannulation and selective cerebral perfusion. The brain was continuously perfused without any intermission through the axillary artery. Concomitant operation included coronary artery bypass grafting (CABG) in two patients, aortic valve replacement (AVR) in one, Bentall operation in two, mitral valve replacement (MVR) in one, and aortic valve sparing operation in one. Patient age at operation was 40-84 (72 + 9) years and 24 of them were older than 70 years of age. RESULTS: There was one operative death (2.5%) due to bleeding from the left lung, and one hospital death due to respiratory failure. Postoperative permanent neurological dysfunction was found in one patient (2.5%). Two patients presented temporary neurological dysfunction (5%). Thirty-six of the 39 patients were discharged from hospital on foot. CONCLUSION: Continuous perfusion through the axillary artery with selective cerebral perfusion and replacement of the ascending and arch aorta may minimize cerebral complication leading to satisfactory results in patients with chronic aortic aneurysm involving aortic arch.     

Minimally invasive "pocket incision" aortic valve surgery.

A minimally invasive approach to aortic valve surgery through a transverse incision ("pocket incision") at the right second intercostal space was examined. Sixteen patients with a mean age of 30 years underwent this approach. The third costal cartilage was either excised (n = 5) or dislocated (n = 11). The right internal mammary artery was preserved. Cardiopulmonary bypass (CPB) was established with aortic-right atrial cannulation in all except the first case. Aortic valve replacements (AVR) were performed in 15 patients and one had aortic valve repair with concomitant ventricular septal defect closure. There was no mortality and no major complications. The aortic cross-clamp, CPB and operative times were 72 +/- 19 mins, 105 +/- 26 mins and 3 hrs 00 min +/- 29 mins respectively. The mean time to extubation was 5.7 +/- 4.0 hrs, ICU stay of 27 +/- 9 hrs and postoperative hospital stay of 5.1 +/- 1.2 days. Minimally invasive "pocket incision" aortic valve surgery is technically feasible and safe. It has the advantages of central cannulation for CPB, preservation of the internal mammary artery and avoiding sternotomy. This approach is cosmetically acceptable and allows rapid patient recovery.     

Usefulness of the axillary artery as vascular access for cardiopulmonary bypass

AIM: In this paper we report our clinical experience with extended utilization of axillary artery cannulation for cardiopulmonary bypass (CPB) and discuss the indications and the results of the procedure in terms of complications and usefulness. METHODS: Between January 1999 and May 2004, 26 patients underwent right axillary artery cannulation for CPB. Fifteen patients presented acute type A aortic dissection and were operated urgently. Axillary cannulation was also used in 11 elective cases: 3 reoperative coronary surgery, 3 valve redo-operations and 5 cases of aortic valve regurgitation+aneurysm of the ascending aorta. RESULTS: All axillary artery cannulations were successful (21 direct and 5 with a side graft) without neurologic or vascular injuries to the right upper extremities. Hospital mortality was 7.7% and included 2 patients operated in an emergency procedure because of acute type A aortic dissection. In all cases, this cannulation site provided adequate perfusion, with a range of peak flows from 4.1 to 5.7 L/min. CONCLUSION: Our preliminary results demonstrate that the right axillary artery may be considered an alternative cannulation site for achieving full CPB and providing antegrade flow, thus avoiding complications related to retrograde flow when femoral artery perfusion is performed. This safe and useful method may be used not only in aortic surgery but in other such complex cardiac procedures as redo-operations.     

A complication of percutaneous cannulation of the internal jugular vein

Reviews of the use of the technique of percutaneous cannulation of the internal jugular vein for central venous pressure monitoring have indicated that it is free from serious complications. A patient is reported here in whom the ascending cervical artery was damaged during attempted cannulation of the internal jugular vein prior to aortic valve replacement. Haemorrhage from this site after the operation led initially to an extrapleural haematoma and soon afterwards to a haemothorax, which proved fatal despite immediate resuscitation and exploration.     

Early reoperation for iatrogenic left main stenosis after aortic valve replacement: a perilous situation

BACKGROUND: Iatrogenic left main coronary artery (LMCA) stenosis secondary to direct ostial cannulation during aortic valve replacement still occurs and is a morbid situation due to the difficulties of early reoperation and in providing adequate myocardial protection. METHODS: A retrospective analysis was performed and identified seven patients with an iatrogenic LMCA stenosis, after 2158 aortic valve replacements (AVR) (0.3%) in our institution since 1987. RESULTS: All patients with LMCA stenosis after AVR had undergone direct ostial cannulation with self-inflating balloon cannulas at the time of AVR. At reoperation for LMCA stenosis, severe ischemia developed in one patient and injury to cardiac structures occurred in four patients. Four patients suffered a perioperative myocardial infarction and congestive heart failure developed in two patients at late follow-up. CONCLUSIONS: LMCA stenosis following coronary ostial cannulation at the time of AVR is a rare yet morbid complication. Reoperation for this condition is fraught with a high operative morbidity rate and poor long-term outcome. Prevention of this complication is quintessential, avoiding ostial cannulation with self-inflating balloons.     

Entrapment of pulmonary artery catheter in a suture at the inferior vena cava cannulation site

Entrapment of a pulmonary artery catheter (Swan-Ganz catheter) in the heart, vena cava, or pulmonary artery is a very rare and serious complication that may lead to life-threatening complications such as cardiac rupture, pulmonary artery rupture, cardiac tamponade, among others, if not recognized and treated early. We report entrapment of a Swan-Ganz catheter in the purse-string suture at the inferior vena cava cannulation site for a patient undergoing aortic valve replacement. This situation required a repeat sternotomy to release the pulmonary artery catheter.     

Mitral Valve Repair in Redo Cardiac Surgery

ABSTRACT An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible. A right anterior thoracotomy approach is preferred in most patients, coupled with hypothermic fibrillatory arrest. A repeat sternotomy may be favored in select circumstances such as when there is a need for bypass grafting or moderate aortic insufficiency is present. Special attention to cannulation techniques, perfusion conditions, valve exposure, and de-airing maneuvers are all important to ensure good clinical results. Using a tailored approach we have performed mitral valve repair in 22 patients with a patent left internal mammary artery graft following coronary artery bypass grafting between July 1992 and February 2000 with acceptable morbidity and low mortality.     

Mitral valve repair in redo cardiac surgery

An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible. A right anterior thoracotomy approach is preferred in most patients, coupled with hypothermic fibrillatory arrest. A repeat sternotomy may be favored in select circumstances such as when there is a need for bypass grafting or moderate aortic insufficiency is present. Special attention to cannulation techniques, perfusion conditions, valve exposure, and de-airing maneuvers are all important to ensure good clinical results. Using a tailored approach we have performed mitral valve repair in 22 patients with a patent left internal mammary artery graft following coronary artery bypass grafting between July 1992 and February 2000 with acceptable morbidity and low mortality.     

Bailed out by TEVAR in a horrendous bleeding aortic arch cannulation site

BackgroundThoracic Endovascular Aortic Repair [TEVAR] is used as a gold standard treatment for aortic disease such as Type B dissection, proximal descending thoracic aortic disruption and descending thoracic aortic fistulas. There was never a report, before this one, of TEVAR utilization for uncontrolled bleeding on the aortic arch cannulation site.Case presentationThis case report is of a 72-year-old female patient who presented to our facility with a day history of anterior sharp pain and dyspnea. Clinical examination revealed a frail patient in distress with tachycardia, tachypnea and elevated blood pressure. The patient had an early diastolic murmur of aortic valve insufficiency. Blood investigations were all normal. Radiological investigations (chest X-ray and Computed Tomography scan) showed prominent ascending aorta, widening mediastinum and dissection affecting the ascending aorta and the root. The patient was optimized in ICU and underwent composite ascending aortic replacement with a stentless composite valve and Dacron graft. The aortic arch cannula site bled uncontrollably and was controlled with a TEVAR stent bypass, as a staged hybrid procedure.DiscussionThe patient had a bovine arch type B configuration, which ensured that the left common carotid artery was not occluded, when deploying the TEVAR stent. However, due to inadequate landing zone three, the left subclavian artery was over-stented and further intentionally occluded with an endovascular occluder to prevent steal phenomenon.ConclusionTEVAR was a real bailout procedure in such situation. Its indication, as in this case report was never reported before; hence, it was an interesting case to write-on.     

Aortic valve replacement through right anterolateral thoracotomy for aortic stenosis after mediastinal radiation therapy

A 76-year-old woman had severe aortic stenosis on transthoracic echocardiography [aortic valve area (AVA): 0.7 cm2, max pressure gradient (PG): 108 mmHg]. Since she was on radiation therapy for breast cancer, we considered that median sternotomy was a risk factor for mediastinitis, and right thoracotomy was chosen for aortic valve replacement. The operation was performed through a right anterolateral thoracotomy. Cardiopulmonary bypass was established with right femoral artery cannulation, right atrial cannulation, and right superior pulmonary vein cannulation for venting. The patient's postoperative course was uneventful. This method appears to be an alternative approach for aortic valve replacement in patients that are not suitable candidates for median sternotomy.     

Comparison of direct aortic and femoral cannulation for port-access cardiac operations.

BACKGROUND: Differences in outcome after direct aortic cannulation (AORT) in the chest versus standard femoral arterial cannulation (FEM) have not been defined for minimally invasive cardiac operations utilizing the port-access approach. METHODS: A retrospective study was performed of 165 patients undergoing port-access cardiac mitral valve operation (n = 126) or coronary artery bypass grafting (n = 39). In 113 patients, FEM was used, while in 52 patients, AORT was accomplished through a port in the first intercostal space. RESULTS: AORT eliminated endoaortic balloon clamp migration (0/36 [0%] vs. 17/95 [18%]), and groin wound or femoral arterial complications (0/52 [0%] vs. 11/113 [10%]) without changing procedure times (363+/-55 vs. 355+/-70 minutes). Complications attributable to AORT were injury to the right internal mammary artery and aortic cannulation site bleeding in 1 patient each. CONCLUSIONS: Direct aortic cannulation is technically easy, allows use of an endoaortic clamp, and avoids aorto-iliac arterial disease, the groin incision, and possible femoral arterial injury associated with femoral arterial cannulation. Direct arterial cannulation should expand the pool of patients eligible for port-access operation, and may become the standard for port-access procedures.     

Direct aortic cannulation for port-access mitral or coronary artery bypass grafting

A technique is described for direct aortic arterial cannulation during Port-Access mitral valve or coronary artery bypass grafting. Femoral arterial cannulation is avoided, and endoaortic balloon occlusion is used for cardioplegic arrest. To date, excellent results have been obtained in 45 patients.     

A successful repair of intraoperative retrograde type A aortic dissection in a patient with aortic regurgitation and ascending aortic aneurysm

The patient was a 67-year-old male with aortic regurgitation and ascending aortic aneurysm. We noticed the type A retrograde aortic dissection occurring from the cannulation site through the right femoral artery. We discontinued cardio-pulmonary bypass immediately, and established selective cerebral perfusion (SCP) eleven minutes after retrograde cerebral perfusion (RCP). We underwent simultaneous aortic valve replacement and ascending and arch graft replacement with an aid of SCP combined with RCP and systemic low flow perfusion. Postoperative course was satisfactory, although patient had a transient neurologic deficit. Intraoperative aortic dissection is a rare but potentially fatal complication. RCP may be a simple and useful method in emergency operation for intraoperative retrograde type A aortic dissection to avoid serious cerebral damage.     

Femoral cannulation is safe for type A dissection repair

Background

Recently, surgeons have embraced axillary artery cannulation for type A aortic dissection repair out of concern for malperfusion phenomena with traditional femoral artery cannulation. My colleagues and I sought to determine whether these concerns are justified.

Methods

Records of 86 consecutive patients (51 men and 35 women; age, 30 to 86 years; mean, 62 years) undergoing surgical repair for acute type A dissection were reviewed. Cannulation site, specific operative repair, and complications related to cannulation were noted.

Results

Seventy-nine cannulations were performed in the femoral artery (47 left, 23 right, and 9 unspecified), 3 in the axillary artery (1 left and 2 right), and 4 in the ascending aorta or arch. Deep hypothermic arrest was used in 64 operations. Seven involved re-sternotomy. Seventy patients had supracoronary grafts (2 with valve replacement and 10 with valve resuspension), and 16 underwent aortic root replacement. Fourteen patients were in shock from cardiac tamponade. Eighty patients survived the operation, and 71 were hospital survivors. Malperfusion on initiation of cardiopulmonary bypass was noted in 3 patients. In 1, the original cannulation site was the ascending aorta, and the cannula was moved to the femoral artery for correction. In 2, the original cannulation site was the femoral artery, and the cannula was moved to the ascending aorta. Malperfusion on clamping of the aorta or on resumption of aortic flow was noted in no patient. Postoperative ischemia of any vascular bed was noted locally only in 3 (cannulated) lower extremities.

Conclusions

Straight femoral cannulation for all phases of type A dissection repair is appropriate and yields excellent clinical results. The anticipated malperfusion events are actually rare (2 of 79 with femoral artery cannulation, or 2.5%).     

Aortic root replacement in cardiac dextroversion

Adult cardiac surgery in patients with malrotation of the heart is rare. A 60 year-old lady, with known cardiac dextroversion, presented with dyspnoea and pre-syncopal attacks. Echocardiographical and radiological investigation confirmed the dextroversion, with clockwise rotation of the heart through its longitudinal axis. This resulted in the right ventricular outflow tract and pulmonary artery being wrapped anteriorly around the aorta, with posterior displacement of the right atrium. The presence of a heavily calcified, bicuspid aortic valve and dilated ascending aorta was also demonstrated. At surgery, venous cannulation was established by rotating the heart anticlockwise and access to the aortic valve gained with a more superior oblique aortotomy. In the presence of a dilated ascending aorta with a calcified, bicuspid aortic valve, the aortic root was replaced with a valved conduit. To the authors' knowledge, this is the first report of an aortic root replacement in a patient with cardiac dextroversion.     

Axillary Artery Cannulation for Cardiopulmonary Bypass during Surgery on the Ascending Aorta and Arch

Abstract   Background: Performing axillary artery cannulation, during cardiopulmonary bypass in patients with an atherosclerotic ascending aorta or acute dissection of the ascending aorta and arch, is of growing interest. Our aim is to present our experience, to describe the surgical technique, and to demonstrate the sufficient cerebral and total body perfusion through axillary artery cannulation. Patients and Methods: Twenty-two patients (17 male, five female) underwent surgical treatment with the axillary technique. The log euro SCORE ranged from 6.77% to 70% (mean 28.28). Nine of these patients underwent elective procedure. Eight underwent aortic surgery for pathologies of the aorta and in one patient we performed combined aortic valve replacement and coronary artery bypass grafting. Thirteen patients underwent emergency operation because of acute dissection of the aorta. Twelve of these patients had a type A dissection (according to Stanford classification) and one patient had a type B aortic dissection. Results: The majority of complications were associated with ruptured dissection of the thoracoabdominal aorta and acute dissection of ascending aorta. Despite preoperative disease states that placed our patients at high risk of stroke and visceral end-organ injury, no clinically demonstrable permanent postoperative deficits were observed. Our patients had no neurological dysfunction, stroke, or other complications. Conclusions: Antegrade cerebral perfusion is of paramount importance in cases of aortic atherosclerosis or aortic dissection. The axillary artery provides an excellent site for safe antegrade perfusion, which may play a role in preventing stroke.