Ann Thorac Surg 2015;100:315–8
CASE REPORT MAKDISI ET AL ACUTE AORTIC DISSECTION INTO THE LUNG
315
Fig 3. Intraoperative transesophageal echocardiography. (A) and (B) Long and short-axis views, respectively, of aortic root prior to transcatheter aortic valve replacement (TAVR). (C) and (D) Long and shortaxis views, respectively, of the aortic root after TAVR with edema and new fluid around the aortic root (white arrows), a diagnostic feature of annular rupture. (AV ¼ aortic valve; LA ¼ left atrium; LV ¼ left ventricle; LVOT - left ventricular outflow tract; RA ¼ right atrium.)
References 1. Andersen ND, Bhattacharya SD, Williams JB, et al. Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations. Ann thorac Surg 2012;93:1921–9. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
2. Pasic M, Unbehaun A, Dreysse S, et al. Rupture of the device landing zone during transcatheter aortic valve implantation: a life-threatening but treatable complication. Circ Cardiovasc Interv 2012;5:424–32. 3. Rezq A, Basavarajaiah S, Latib A, et al. Incidence, management, and outcomes of cardiac tamponade during transcatheter aortic valve implantation: a single-center study. JACC Cardiovasc Interv 2012;5:1264–72. 4. Barbanti M, Yang TH, Rodes Cabau J, et al. Anatomical and procedural features associated with aortic root rupture during balloon-expandable transcatheter aortic valve replacement. Circulation 2013;128:244–53. 5. Hayashida K, Bouvier E, Lef evre T. Successful management of annulus rupture in transcatheter aortic valve implantation. JACC Cardiovasc Interv 2013;6:90–1. 6. Goodnough LT, Levy JH. Off-label use of recombinant human factor VIIa. Ann Thorac Surg 2014;98:393–5. 7. Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011;91:944–82. 8. Karkouti K, Beattie WS, Arellano R, et al. Comprehensive canadian review of the off-label use of recombinant activated factor VII in cardiac surgery. Circulation 2008;118:331–8.
Acute Aortic Dissection Extending Into the Lung George Makdisi, MD, Sameh M. Said, MD, and Hartzell V. Schaff, MD Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
The radiologic manifestations of ruptured acute aortic dissection, Stanford type A aortic dissection, DeBakey type 1 can present in different radiographic scenarios with devastating outcomes. Here, we present a rare case of a 70-year-old man who presented to the emergency 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.060
FEATURE ARTICLES
potentially fatal complication. However, since TAVR patients often carry high risk of mortality with an open operation, conversion to open surgery in order to address an annulus rupture may, in many cases, be futile [2, 3]. Therefore, establishing effective nonoperative strategies for the management of such injuries will be important, especially as the volume of TAVR increases. Isolated cases of successful nonoperative management of annulus rupture after TAVR by pericardial drainage and aggressive blood product resuscitation have been reported previously [2, 3, 5]. However, to our knowledge, this is the first report to describe the use of rFVIIa as an adjunct to these measures. The off-label use of rFVIIa for refractory bleeding or coagulopathy after cardiac surgery remains controversial due questions over efficacy and safety [6]. However, the most recent guidelines from the Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists recommend the use of rFVIIa for refractory microvascular bleeding based on evidence that rFVIIa can be an effective adjunct in this setting [1, 7, 8]. While concerns persist that rFVIIa may cause increased rates of thromboembolic events, in the setting of refractory bleeding that cannot be addressed surgically this potential risk seems justifiable as the alternative is almost certainly death [6]. In total, the report herein suggests that rFVIIa holds promise as an effective tool for the management of refractory bleeding after TAVR. Further study into the efficacy of rFVIIa and other adjunctive hemostatic measures is needed in order to elucidate optimal management of annulus rupture and other procedural injuries in TAVR.
316
CASE REPORT MAKDISI ET AL ACUTE AORTIC DISSECTION INTO THE LUNG
Ann Thorac Surg 2015;100:315–8
department with chest pain radiating to the back. A chest computed tomography scan showed a Stanford type A, DeBakey type 1, acute aortic dissection ruptured into the aortopulmonary window and stenosing the pulmonary trunk, both main pulmonary arteries, and dissecting the bronchovascular sheaths and flow into the pulmonary interstitium, causing pulmonary interstitial hemorrhage. The patient underwent emergent ascending aorta replacement with hemiarch replacement with circulatory arrest. The postoperative course was unremarkable. (Ann Thorac Surg 2015;100:315–8) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
A
cute dissection of the ascending aorta has devastating results. Early diagnosis and surgical repair can play a major role in survival and better outcomes. Recognizing the clinical and radiologic scenarios with better understanding of the anatomic pathology might be critical. Rupture of acute aortic dissection, Stanford type A aortic dissection, DeBakey type 1, presents with different radiographic scenarios. We present a rare case where the dissection ruptured into the aortopulmonary window and dissected the bronchovascular sheaths and flow into the pulmonary interstitium, and in this situation, the hemorrhage from the ruptured aorta extended along the pulmonary artery. A 70-year-old man with a history of hypertension presented to the emergency department of an outside hospital with chest pain radiating to the back for 5 hours. A chest radiograph (Fig 1) showed widened mediastinum and patchy infiltrates in both lungs. A computed tomography scan (Figs 2 through 4) to rule out pulmonary emboli showed an acute aortic dissection, Stanford type A aortic dissection, DeBakey type 1, starting at the sinotubular junction and extending throughout the whole computed tomography scan into the abdominal aorta below the renal arteries. It also showed extraluminal, perivascular extraversion blood along the pulmonary arteries with compression and stenosis of the pulmonary artery trunk and both pulmonary arteries and its branches by intramural hematoma. That was also associated with intraparenchymal hemorrhage. The patient was transferred to our hospital. On arrival in the operating room, he was in critical condition with ongoing chest pain, shortness of breath, and moderate hypotension. Intraoperative transesophageal echocardiogram showed circumferential thickening of the aorta beginning at the sinotubular junction and extending throughout the visualized ascending aorta. During surgery, cardiopulmonary bypass was established through femoral arterial cannulation and right atrial cannulation, and profound hypothermic circulatory arrest was initiated. The intraoperative findings were consistent with a large amount of blood in the Accepted for publication Aug 25, 2014. Address correspondence to Dr Schaff, Division of Cardiovascular Surgery, 200 First St SW, Rochester, MN 55905; e-mail: [email protected].
Fig 1. Chest radiograph shows widened mediastinum and patchy infiltrates in both lungs.
pericardium and blood pressure increase, suggesting a degree of tamponade before bypass. There was an enormous hematoma over the ascending aorta, a great deal of thrombus in the anterior mediastinum, and a tear on the medial aspect of the aorta was identified. This was not a penetrating ulcer. It was a typical dissection, but the false lumen was completely circumferential and was filled with fresh thrombus. The patient underwent ascending aortic and hemiarch replacement under circulatory arrest. A bronchoscopy the next day showed deeply hyperemic mucosa, most likely an infiltrate from external blood staining (Fig 5). The postoperative course was unremarkable, and the patient was discharged home on postoperative day 7.
Fig 2. (A) Circumferential dissection (red arrow); (B) stenosis of the right main pulmonary artery by intramural hematoma (blue arrow); (C) extraluminal, perivascular extraversion blood along the right lower lobe pulmonary artery branch (purple arrow); and (D) extraluminal, perivascular extraversion of blood around the segmental branches of the left lower lobe (green arrow).
Ann Thorac Surg 2015;100:315–8
Comment The radiologic manifestations of acute dissection of the ascending aorta can present in different radiographic scenarios with devastating outcomes. There are some reported cases in the literature describing Stanford type A aortic dissection, DeBakey type 1 extending into the
Fig 4. (A) Circumferential dissection (red arrow); (B) extraluminal, perivascular extraversion blood along the right lower lobe pulmonary artery branch (purple arrow); (C) extraluminal, perivascular extraversion of blood around the segmental branches of the left lower lobe (blue arrows); and (D) extraluminal, peribronchial extraversion of blood around the segmental bronchial branches (green arrows).
317
Fig 5. Deeply hyperemic mucosa, most likely infiltrate from external blood staining.
pulmonary arteries or into lung parenchyma [1–4]. The clinical scenarios of the ruptured intramural hematoma or aortic dissection of Stanford type A aortic dissection, DeBakey type 1, vary depending on the site or rupture. If the rupture occurs in the anterior wall inside pericardium, the patient will have tamponade, with the blood entering the anterior mediastinum. In cases of rupture of the posterior wall, or the left lateral side of aortic wall, the extravasated blood can enter directly between the adventitia and the media of the main or left pulmonary artery, and may extend into the pulmonary interstitium or alveoli or both [5]. The mechanism of a pulmonary hemorrhage from an aortic rupture was best described by Roberts [6]. Anatomically, the ascending aorta and pulmonary trunk have a common adventitia at the root of the great vessels. Under this anatomic condition, extravasated blood from the ascending aorta can extend beneath the adventitia of the main pulmonary artery and cross the barrier of the pulmonary hilum. The extravasated blood may narrow the lumen of the main pulmonary artery because the intrapulmonary artery pressure is low. Charnsangavej [2] reported occlusion of the right pulmonary artery by acute aortic dissection. Distally, the stretched adventitia might disrupt as the blood can enter the pulmonary interstitium or alveoli with increasing pressure, causing intrapulmonary hemorrhage or even hemoptysis. Sueyoshi and associates [5] noted hemorrhage along the pulmonary artery in 21 cases (9.1%) in a series of 232 patients with a Stanford type A aortic dissection. They reported that 4 patients with external compression and resulting stenosis of the main pulmonary trunk from extravasated blood extending between the adventitia and media of the pulmonary trunk all died. They also reported the deaths of 5 of 6 patients (85%) with
FEATURE ARTICLES
Fig 3. (A) Ascending aortic dissection (red arrow); (B) intramural hematoma along the left main pulmonary artery, extending to the left upper lobe pulmonary artery (blue arrow); and (C) extraluminal, perivascular extraversion of blood around the basal segmental branches of the left lower lobe pulmonary artery branches (purple arrow).
CASE REPORT MAKDISI ET AL ACUTE AORTIC DISSECTION INTO THE LUNG
318
CASE REPORT SAITO ET AL SURGICAL REMOVAL OF AMPLATZER SEPTAL OCCLUDER
Ann Thorac Surg 2015;100:318–20
hemorrhage extending distally to the interlobular septa into the alveoli. They concluded that a thoracic computed tomography scan showing a Stanford type A dissecting aneurysm with a hemorrhagic pericardial effusion and intrapulmonary extramural perivascular extravasation of blood into the alveoli implies a very poor prognosis [5]. In our case, we report successful repair of an extreme case with both stenosis in the main artery and parenchymal hemorrhage.
septal defect is mandatory for successful treatment using the Amplatzer septal occluder. (Ann Thorac Surg 2015;100:318–20) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
References 1. Panicek DM, Ewing DK, Markarian B, Heitzman ER. Interstitial pulmonary hemorrhage from mediastinal hematoma secondary to aortic rupture. Radiology 1987;162:165–6. 2. Charnsangavej C. Occlusion of the right pulmonary artery by acute dissecting aortic aneurysm. AJR Am J Roentgenol 1979;132:274–6. 3. Cao DB, Yang SR, Tong Q, Zheng Y. Interstitial pulmonary hemorrhage along the pulmonary artery secondary to ruptured aortic dissection. Intern Med 2010;49:1681–2. 4. Sueyoshi E, Sakamoto I, Uetani M, Matsuoka Y, Suenaga E. CT findings of ruptured intramural hematoma of the aorta extending along the pulmonary artery. Cardiovasc Intervent Radiol 2007;30:321–3. 5. Sueyoshi E, Matsuoka Y, Sakamoto I, Uetani M. CT and clinical features of hemorrhage extending along the pulmonary artery due to ruptured aortic dissection. Euro Radiol 2009;19:1166–74. 6. Roberts WC. Aortic dissection: anatomy, consequences, and causes. Am Heart J 1981;101:195–214.
Migration of Amplatzer Septal Occluder to the Deep Aortic Arch in a Patient With Multiple Anatomic Anomalies Tomohiro Saito, MD, Volker D€ usterh€ oft, MD, PhD, and Roland Hetzer, MD, PhD Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
Atrial septal defect closure using the Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) device is an established treatment option with excellent clinical outcome. However, several structural characteristics have been reported to be prognostic factors for failure of catheter interventional treatment. We report successful surgical removal of an Amplatzer septal occluder that had become dislocated and had migrated into the deep aortic arch. Compatible with previous reports, the patient presented with an atrial septal defect complicated by multiple anatomic deformities that were considered to be a contraindication for interventional treatment. Detailed structural assessment of the atrial Accepted for publication Aug 29, 2014. Address correspondence to Dr Saito, Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353 Berlin, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
D
evice dislocation is a rare complication, but most prevalent adverse events for percutaneous closure of an atrial septal defect (ASD) may occur despite the current excellent clinical outcome using the Amplatzer septal occluder (ASO; (AGA Medical Corp, Golden Valley, MN). Urgent surgical retrieval is required in 77% of patients with device dislocation [1]. The approach strategy to the device and the establishment of cardiopulmonary bypass are important to consider, especially in the case of extracardiac migration of the device. A 53-year-old man was referred to our institution for removal of an ASO. He had multiple coronary risk factors, including smoking, hypertension, hyperlipidemia, and obesity. He had undergone a percutaneous coronary intervention to the right coronary artery with implantation of 2 drug-eluting stents 2 years earlier. During the followup, he presented with a small left cerebellar infarction. A secundum type ASD was first diagnosed on echocardiography at the age of 52 years. The diameter of the defect was approximately 28 mm, and the shunt direction was left-toright in bubble-contrast echocardiography. Owing to the patient’s history of paradoxical embolism, the indication for interventional closure of the ASD was regarded as given. The procedure was uneventfully performed 2 weeks later using a 30-mm ASO under fluoroscopic guidance as scheduled. However, the patient presented the day after treatment with atrial flutter with 2:1 conduction. Echocardiography revealed a recurrent large shunt through the ASD and the absence of the ASO device. No thrombus was noted. A chest computed tomography scan showed that the ASO device had migrated into the aortic arch distal to the orifice of the brachiocephalic trunk (Fig 1A). Thus, the patient was referred to our center for surgical removal of the device. Transesophageal echocardiography during the operation revealed that the septum with the secundum-type ASD was highly dynamic and flapped erratically (Fig 1B and C). The device was removed through a standard median sternotomy. Cardiopulmonary bypass was initiated with the arterial cannula in the left common femoral artery and bicaval venous drainage through the chest. After the ascending aorta was cross-clamped, cardioplegia was given from the ascending aorta, and after cardiac arrest, the right atrial wall was opened. A secundum-type ASD, sized approximately 30 25 mm, was exposed. The inferior and the posterior rims were thin and short. In addition, the fenestrated primum septum was located behind the rim (Fig 2A). We carefully closed the defect using an autologous pericardial patch; in the direction of the inferior and posterior rim, we sutured the deeper septal wall. Subsequently, the aortic cross-clamp was released under normothermic circulatory arrest, and the ascending aorta was transversely incised in the head-down position. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.084
CASE REPORT MAKDISI ET AL ACUTE AORTIC DISSECTION INTO THE LUNG
315
Fig 3. Intraoperative transesophageal echocardiography. (A) and (B) Long and short-axis views, respectively, of aortic root prior to transcatheter aortic valve replacement (TAVR). (C) and (D) Long and shortaxis views, respectively, of the aortic root after TAVR with edema and new fluid around the aortic root (white arrows), a diagnostic feature of annular rupture. (AV ¼ aortic valve; LA ¼ left atrium; LV ¼ left ventricle; LVOT - left ventricular outflow tract; RA ¼ right atrium.)
References 1. Andersen ND, Bhattacharya SD, Williams JB, et al. Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations. Ann thorac Surg 2012;93:1921–9. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
2. Pasic M, Unbehaun A, Dreysse S, et al. Rupture of the device landing zone during transcatheter aortic valve implantation: a life-threatening but treatable complication. Circ Cardiovasc Interv 2012;5:424–32. 3. Rezq A, Basavarajaiah S, Latib A, et al. Incidence, management, and outcomes of cardiac tamponade during transcatheter aortic valve implantation: a single-center study. JACC Cardiovasc Interv 2012;5:1264–72. 4. Barbanti M, Yang TH, Rodes Cabau J, et al. Anatomical and procedural features associated with aortic root rupture during balloon-expandable transcatheter aortic valve replacement. Circulation 2013;128:244–53. 5. Hayashida K, Bouvier E, Lef evre T. Successful management of annulus rupture in transcatheter aortic valve implantation. JACC Cardiovasc Interv 2013;6:90–1. 6. Goodnough LT, Levy JH. Off-label use of recombinant human factor VIIa. Ann Thorac Surg 2014;98:393–5. 7. Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011;91:944–82. 8. Karkouti K, Beattie WS, Arellano R, et al. Comprehensive canadian review of the off-label use of recombinant activated factor VII in cardiac surgery. Circulation 2008;118:331–8.
Acute Aortic Dissection Extending Into the Lung George Makdisi, MD, Sameh M. Said, MD, and Hartzell V. Schaff, MD Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
The radiologic manifestations of ruptured acute aortic dissection, Stanford type A aortic dissection, DeBakey type 1 can present in different radiographic scenarios with devastating outcomes. Here, we present a rare case of a 70-year-old man who presented to the emergency 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.060
FEATURE ARTICLES
potentially fatal complication. However, since TAVR patients often carry high risk of mortality with an open operation, conversion to open surgery in order to address an annulus rupture may, in many cases, be futile [2, 3]. Therefore, establishing effective nonoperative strategies for the management of such injuries will be important, especially as the volume of TAVR increases. Isolated cases of successful nonoperative management of annulus rupture after TAVR by pericardial drainage and aggressive blood product resuscitation have been reported previously [2, 3, 5]. However, to our knowledge, this is the first report to describe the use of rFVIIa as an adjunct to these measures. The off-label use of rFVIIa for refractory bleeding or coagulopathy after cardiac surgery remains controversial due questions over efficacy and safety [6]. However, the most recent guidelines from the Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists recommend the use of rFVIIa for refractory microvascular bleeding based on evidence that rFVIIa can be an effective adjunct in this setting [1, 7, 8]. While concerns persist that rFVIIa may cause increased rates of thromboembolic events, in the setting of refractory bleeding that cannot be addressed surgically this potential risk seems justifiable as the alternative is almost certainly death [6]. In total, the report herein suggests that rFVIIa holds promise as an effective tool for the management of refractory bleeding after TAVR. Further study into the efficacy of rFVIIa and other adjunctive hemostatic measures is needed in order to elucidate optimal management of annulus rupture and other procedural injuries in TAVR.
316
CASE REPORT MAKDISI ET AL ACUTE AORTIC DISSECTION INTO THE LUNG
Ann Thorac Surg 2015;100:315–8
department with chest pain radiating to the back. A chest computed tomography scan showed a Stanford type A, DeBakey type 1, acute aortic dissection ruptured into the aortopulmonary window and stenosing the pulmonary trunk, both main pulmonary arteries, and dissecting the bronchovascular sheaths and flow into the pulmonary interstitium, causing pulmonary interstitial hemorrhage. The patient underwent emergent ascending aorta replacement with hemiarch replacement with circulatory arrest. The postoperative course was unremarkable. (Ann Thorac Surg 2015;100:315–8) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
A
cute dissection of the ascending aorta has devastating results. Early diagnosis and surgical repair can play a major role in survival and better outcomes. Recognizing the clinical and radiologic scenarios with better understanding of the anatomic pathology might be critical. Rupture of acute aortic dissection, Stanford type A aortic dissection, DeBakey type 1, presents with different radiographic scenarios. We present a rare case where the dissection ruptured into the aortopulmonary window and dissected the bronchovascular sheaths and flow into the pulmonary interstitium, and in this situation, the hemorrhage from the ruptured aorta extended along the pulmonary artery. A 70-year-old man with a history of hypertension presented to the emergency department of an outside hospital with chest pain radiating to the back for 5 hours. A chest radiograph (Fig 1) showed widened mediastinum and patchy infiltrates in both lungs. A computed tomography scan (Figs 2 through 4) to rule out pulmonary emboli showed an acute aortic dissection, Stanford type A aortic dissection, DeBakey type 1, starting at the sinotubular junction and extending throughout the whole computed tomography scan into the abdominal aorta below the renal arteries. It also showed extraluminal, perivascular extraversion blood along the pulmonary arteries with compression and stenosis of the pulmonary artery trunk and both pulmonary arteries and its branches by intramural hematoma. That was also associated with intraparenchymal hemorrhage. The patient was transferred to our hospital. On arrival in the operating room, he was in critical condition with ongoing chest pain, shortness of breath, and moderate hypotension. Intraoperative transesophageal echocardiogram showed circumferential thickening of the aorta beginning at the sinotubular junction and extending throughout the visualized ascending aorta. During surgery, cardiopulmonary bypass was established through femoral arterial cannulation and right atrial cannulation, and profound hypothermic circulatory arrest was initiated. The intraoperative findings were consistent with a large amount of blood in the Accepted for publication Aug 25, 2014. Address correspondence to Dr Schaff, Division of Cardiovascular Surgery, 200 First St SW, Rochester, MN 55905; e-mail: [email protected].
Fig 1. Chest radiograph shows widened mediastinum and patchy infiltrates in both lungs.
pericardium and blood pressure increase, suggesting a degree of tamponade before bypass. There was an enormous hematoma over the ascending aorta, a great deal of thrombus in the anterior mediastinum, and a tear on the medial aspect of the aorta was identified. This was not a penetrating ulcer. It was a typical dissection, but the false lumen was completely circumferential and was filled with fresh thrombus. The patient underwent ascending aortic and hemiarch replacement under circulatory arrest. A bronchoscopy the next day showed deeply hyperemic mucosa, most likely an infiltrate from external blood staining (Fig 5). The postoperative course was unremarkable, and the patient was discharged home on postoperative day 7.
Fig 2. (A) Circumferential dissection (red arrow); (B) stenosis of the right main pulmonary artery by intramural hematoma (blue arrow); (C) extraluminal, perivascular extraversion blood along the right lower lobe pulmonary artery branch (purple arrow); and (D) extraluminal, perivascular extraversion of blood around the segmental branches of the left lower lobe (green arrow).
Ann Thorac Surg 2015;100:315–8
Comment The radiologic manifestations of acute dissection of the ascending aorta can present in different radiographic scenarios with devastating outcomes. There are some reported cases in the literature describing Stanford type A aortic dissection, DeBakey type 1 extending into the
Fig 4. (A) Circumferential dissection (red arrow); (B) extraluminal, perivascular extraversion blood along the right lower lobe pulmonary artery branch (purple arrow); (C) extraluminal, perivascular extraversion of blood around the segmental branches of the left lower lobe (blue arrows); and (D) extraluminal, peribronchial extraversion of blood around the segmental bronchial branches (green arrows).
317
Fig 5. Deeply hyperemic mucosa, most likely infiltrate from external blood staining.
pulmonary arteries or into lung parenchyma [1–4]. The clinical scenarios of the ruptured intramural hematoma or aortic dissection of Stanford type A aortic dissection, DeBakey type 1, vary depending on the site or rupture. If the rupture occurs in the anterior wall inside pericardium, the patient will have tamponade, with the blood entering the anterior mediastinum. In cases of rupture of the posterior wall, or the left lateral side of aortic wall, the extravasated blood can enter directly between the adventitia and the media of the main or left pulmonary artery, and may extend into the pulmonary interstitium or alveoli or both [5]. The mechanism of a pulmonary hemorrhage from an aortic rupture was best described by Roberts [6]. Anatomically, the ascending aorta and pulmonary trunk have a common adventitia at the root of the great vessels. Under this anatomic condition, extravasated blood from the ascending aorta can extend beneath the adventitia of the main pulmonary artery and cross the barrier of the pulmonary hilum. The extravasated blood may narrow the lumen of the main pulmonary artery because the intrapulmonary artery pressure is low. Charnsangavej [2] reported occlusion of the right pulmonary artery by acute aortic dissection. Distally, the stretched adventitia might disrupt as the blood can enter the pulmonary interstitium or alveoli with increasing pressure, causing intrapulmonary hemorrhage or even hemoptysis. Sueyoshi and associates [5] noted hemorrhage along the pulmonary artery in 21 cases (9.1%) in a series of 232 patients with a Stanford type A aortic dissection. They reported that 4 patients with external compression and resulting stenosis of the main pulmonary trunk from extravasated blood extending between the adventitia and media of the pulmonary trunk all died. They also reported the deaths of 5 of 6 patients (85%) with
FEATURE ARTICLES
Fig 3. (A) Ascending aortic dissection (red arrow); (B) intramural hematoma along the left main pulmonary artery, extending to the left upper lobe pulmonary artery (blue arrow); and (C) extraluminal, perivascular extraversion of blood around the basal segmental branches of the left lower lobe pulmonary artery branches (purple arrow).
CASE REPORT MAKDISI ET AL ACUTE AORTIC DISSECTION INTO THE LUNG
318
CASE REPORT SAITO ET AL SURGICAL REMOVAL OF AMPLATZER SEPTAL OCCLUDER
Ann Thorac Surg 2015;100:318–20
hemorrhage extending distally to the interlobular septa into the alveoli. They concluded that a thoracic computed tomography scan showing a Stanford type A dissecting aneurysm with a hemorrhagic pericardial effusion and intrapulmonary extramural perivascular extravasation of blood into the alveoli implies a very poor prognosis [5]. In our case, we report successful repair of an extreme case with both stenosis in the main artery and parenchymal hemorrhage.
septal defect is mandatory for successful treatment using the Amplatzer septal occluder. (Ann Thorac Surg 2015;100:318–20) Ó 2015 by The Society of Thoracic Surgeons
FEATURE ARTICLES
References 1. Panicek DM, Ewing DK, Markarian B, Heitzman ER. Interstitial pulmonary hemorrhage from mediastinal hematoma secondary to aortic rupture. Radiology 1987;162:165–6. 2. Charnsangavej C. Occlusion of the right pulmonary artery by acute dissecting aortic aneurysm. AJR Am J Roentgenol 1979;132:274–6. 3. Cao DB, Yang SR, Tong Q, Zheng Y. Interstitial pulmonary hemorrhage along the pulmonary artery secondary to ruptured aortic dissection. Intern Med 2010;49:1681–2. 4. Sueyoshi E, Sakamoto I, Uetani M, Matsuoka Y, Suenaga E. CT findings of ruptured intramural hematoma of the aorta extending along the pulmonary artery. Cardiovasc Intervent Radiol 2007;30:321–3. 5. Sueyoshi E, Matsuoka Y, Sakamoto I, Uetani M. CT and clinical features of hemorrhage extending along the pulmonary artery due to ruptured aortic dissection. Euro Radiol 2009;19:1166–74. 6. Roberts WC. Aortic dissection: anatomy, consequences, and causes. Am Heart J 1981;101:195–214.
Migration of Amplatzer Septal Occluder to the Deep Aortic Arch in a Patient With Multiple Anatomic Anomalies Tomohiro Saito, MD, Volker D€ usterh€ oft, MD, PhD, and Roland Hetzer, MD, PhD Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
Atrial septal defect closure using the Amplatzer septal occluder (AGA Medical Corp, Golden Valley, MN) device is an established treatment option with excellent clinical outcome. However, several structural characteristics have been reported to be prognostic factors for failure of catheter interventional treatment. We report successful surgical removal of an Amplatzer septal occluder that had become dislocated and had migrated into the deep aortic arch. Compatible with previous reports, the patient presented with an atrial septal defect complicated by multiple anatomic deformities that were considered to be a contraindication for interventional treatment. Detailed structural assessment of the atrial Accepted for publication Aug 29, 2014. Address correspondence to Dr Saito, Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353 Berlin, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
D
evice dislocation is a rare complication, but most prevalent adverse events for percutaneous closure of an atrial septal defect (ASD) may occur despite the current excellent clinical outcome using the Amplatzer septal occluder (ASO; (AGA Medical Corp, Golden Valley, MN). Urgent surgical retrieval is required in 77% of patients with device dislocation [1]. The approach strategy to the device and the establishment of cardiopulmonary bypass are important to consider, especially in the case of extracardiac migration of the device. A 53-year-old man was referred to our institution for removal of an ASO. He had multiple coronary risk factors, including smoking, hypertension, hyperlipidemia, and obesity. He had undergone a percutaneous coronary intervention to the right coronary artery with implantation of 2 drug-eluting stents 2 years earlier. During the followup, he presented with a small left cerebellar infarction. A secundum type ASD was first diagnosed on echocardiography at the age of 52 years. The diameter of the defect was approximately 28 mm, and the shunt direction was left-toright in bubble-contrast echocardiography. Owing to the patient’s history of paradoxical embolism, the indication for interventional closure of the ASD was regarded as given. The procedure was uneventfully performed 2 weeks later using a 30-mm ASO under fluoroscopic guidance as scheduled. However, the patient presented the day after treatment with atrial flutter with 2:1 conduction. Echocardiography revealed a recurrent large shunt through the ASD and the absence of the ASO device. No thrombus was noted. A chest computed tomography scan showed that the ASO device had migrated into the aortic arch distal to the orifice of the brachiocephalic trunk (Fig 1A). Thus, the patient was referred to our center for surgical removal of the device. Transesophageal echocardiography during the operation revealed that the septum with the secundum-type ASD was highly dynamic and flapped erratically (Fig 1B and C). The device was removed through a standard median sternotomy. Cardiopulmonary bypass was initiated with the arterial cannula in the left common femoral artery and bicaval venous drainage through the chest. After the ascending aorta was cross-clamped, cardioplegia was given from the ascending aorta, and after cardiac arrest, the right atrial wall was opened. A secundum-type ASD, sized approximately 30 25 mm, was exposed. The inferior and the posterior rims were thin and short. In addition, the fenestrated primum septum was located behind the rim (Fig 2A). We carefully closed the defect using an autologous pericardial patch; in the direction of the inferior and posterior rim, we sutured the deeper septal wall. Subsequently, the aortic cross-clamp was released under normothermic circulatory arrest, and the ascending aorta was transversely incised in the head-down position. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.084
