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proximal descending thoracic aorta. The hematologic workup and echocardiography were within normal limits. Operative and bypass strategy was similar to the first patient, except that the right axillary artery was used for arterial inflow and the left common carotid artery was perfused. The thrombus could easily be separated from the aortic wall. There was no attachment. The aortic wall did not show any evidence of atherosclerosis. The patient made an uneventful recovery and started antiplatelet therapy with warfarin. Histopathologic findings were similar to those in the first case. The patient is doing well at 2 years of follow-up.


References 1. Farah MG, Hawawini H. Thrombus of the ascending aorta as a source of cerebral embolism. Chest 1993;104:1604–5. 2. Kalangos A, Baldovinos A, Vuille C, Montessuit M, Faidutti B. Floating thrombus in the ascending aorta: a rare cause of peripheral emboli. J Vasc Surg 1997;26:150–4. 3. Eguchi K, Ohtaki E, Misu K, et al. Acute myocardial infarction caused by embolism of thrombus in the right coronary sinus of Valsalva: a case report and review of the literature. J Am Soc Echocardiogr 2004;17:173–7. 4. Choi JB, Choi SH, Kim NH. Floating thrombus in the proximal aortic arch. Tex Heart Inst J 2004;31:432–4. 5. Walther T, Mochalski M, Falk V, Mohr FW. Resection of a thrombus floating in the aortic arch. Ann Thorac Surg 1996;62: 899–901. 6. Kalangos A, Vala D, Bednarkiewicz M, Faidutti B. Technical implications regarding surgical removal of a floating thrombus located in the ascending aorta or aortic arch. Ann Vasc Surg 1999;13:115–20. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier


Factor VIIa for Annulus Rupture After Transcatheter Aortic Valve Replacement Jeffrey E. Keenan, MD, John P. Vavalle, MD, Asvin M. Ganapathi, MD, Hanghang Wang, MD, J. Kevin Harrison, MD, Andrew Wang, MD, and G. Chad Hughes, MD Division of Cardiovascular and Thoracic Surgery, Department of Surgery; and Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina

Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as an effective treatment for inoperable and selected high surgical-risk patients with aortic stenosis. However, management of procedural complications with TAVR represents a major challenge as most TAVR patients carry prohibitive or high-risk of mortality with open surgical conversion. Here we present a case of TAVR complicated by aortic annulus rupture that was successfully managed nonoperatively by pericardial drainage, blood product transfusion, and adjunctive administration of recombinant activated factor VIIa. (Ann Thorac Surg 2015;100:313–5) Ó 2015 by The Society of Thoracic Surgeons


evere aortic stenosis is a life-threatening disease that can be effectively treated by aortic valve replacement (AVR). Surgical AVR is generally held to be the goldstandard approach for the management of this condition. However, over the last decade transcatheter AVR (TAVR) has emerged as an effective therapy for inoperable and selected high surgical-risk aortic stenosis patients. Despite the success of TAVR, one of the ongoing challenges with this procedure is how to best manage serious procedural complications. Because TAVR patients carry high risk of mortality with open surgery, determining effective nonoperative strategies for such TAVR complications is paramount. Herein, we present a TAVR case complicated by aortic annulus rupture that was successfully managed nonoperatively by pericardial drainage, blood product transfusion, and adjunctive recombinant activated factor VII (rFVIIa). A 92-year-old woman presented with New York Heart Association class IV congestive heart failure due to severe aortic stenosis. Echocardiography revealed left Accepted for publication Sept 9, 2014. Address correspondence to Dr Hughes, Duke Center for Structural Heart Disease, Duke University Medical Center, Division of Cardiovascular and Thoracic Surgery, Box 3051, Durham, NC 27710; e-mail:

Dr Andrew Wang discloses a financial relationship with Edwards Lifesciences.



The first report of an ascending aortic thrombus that caused a cerebral embolism was published by Farah and Hawawini in 1993 [1]. Atherosclerosis, dissection, malignancy, coagulopathies, and hormone therapy have been implicated in formation of thrombus in aorta; however, the cause of the thrombus formation remains unknown in most of these cases [2]. Eguchi and colleagues [3] have suggested the role of turbulence in blood flow to be responsible for the thrombus formation. However, the exact mechanism of thrombogenesis remains unknown [3]. Hypercoagulable state can also contribute to spontaneous intraarterial thrombus formation. Traditionally, the aortic thrombus have been removed after establishing deep hypothermic circulatory arrest either by distal ascending aortic cannulation [4] and antegrade perfusion or by femoral cannulation [5] and retrograde perfusion. Kalangos and colleagues [2] have proposed the removal of aortic arch thrombus without the need for circulatory arrest by performing selective cerebral perfusion along with femoral artery perfusion [6]. The technique we have proposed is simple, easily reproducible, and does not require circulatory arrest or retrograde femoral perfusion. The lower body ischemia time is short and easily tolerated.





ventricular hypertrophy, an ejection fraction greater than 0.55, a peak systolic velocity of 5.8 m/second across the aortic valve, and a mean transvalvular gradient of 86 mm Hg. Additionally, computed tomographic angiography demonstrated an aortic annulus diameter of 22 mm with severe confluent calcification of the aortic and mitral annuli (Fig 1). Her STS predicted risk of mortality with surgical AVR was 11.2%. She was therefore deemed an appropriate candidate for TAVR. After medical optimization, the patient underwent TAVR with a 23-mm Edwards SAPIEN (Edwards Lifesciences Corporation, Irvine, CA) device by transfemoral approach. After deployment, angiography demonstrated satisfactory valve position, trivial aortic insufficiency, and no evidence of contrast extravasation (Fig 2). While initially stable, upon groin closure the patient became progressively hypotensive. Intraoperative transesophageal echocardiography demonstrated a slowly enlarging pericardial effusion with edema evident around the aortic root (Fig 3), consistent with rupture of the aortic annulus. Due to the patient’s advanced age, frailty, and medical comorbidities it was felt she would likely not survive open surgical repair of this injury. Further, during preoperative counseling, the patient and her family stated they would not want open surgical conversion should this potentially be required. Therefore, the decision was made to attempt to manage the injury nonoperatively. Accordingly, a subxiphoid pericardial window was created and a pericardial drain placed. Heparin was reversed with protamine, and platelets (1 pack) and packed red blood cells (PRBCs) (3 units) were transfused intraoperatively. These measures slowed the bleeding, allowing transfer to the intensive care unit (ICU) for further resuscitation. After ICU admission, the patient was coagulopathic (internationalized normal ratio 1.5. partial thromboplastin

Ann Thorac Surg 2015;100:313–5

Fig 2. (A) and (B) Balloon aortic valvuloplasty with simultaneous root angiogram immediately prior to transcatheter aortic valve replacement. (C) Deployment of transcatheter valve. (D) Completion root angiogram.

time 33.9, fibrinogen 151, platelets 81) with persistent bleeding from her pericardial tube (> 500 mL/hour). Her coagulopathy was treated with fresh frozen plasma (4 units), cryoprecipitate (3 units), and desmopressin (21 mg). She also received additional platelets (2 packs) and PRBCs (6 units). Although normalization of coagulation parameters was achieved, the patient continued to bleed without evidence of clot in the pericardial tube, suggesting ongoing coagulopathy. Therefore, 2 mg of rFVIIa were administered, in accordance with our previously published low dose protocol for persistent coagulopathy after cardiac surgery [1]. Shortly after administration of rFVIIa, the pericardial tube output dropped precipitously and the patient’s hemodynamics stabilized. She did not require further blood products for the remainder of her hospitalization, nor did she suffer any adverse thromboembolic events. Although her subsequent hospital course was notable for transient acute kidney injury, she steadily recovered and was discharged to a skilled nursing facility on postoperative day 15. At 1-month follow-up, her dyspnea had improved and echocardiography demonstrated a normally functioning prosthetic aortic valve with a 12-mm Hg transvalvular gradient. The patient remains alive and well now, 20 months postoperatively.

Comment Fig 1. Reformatted three-dimensional computed tomographic angiography image demonstrating severe confluent calcification of the aortic and mitral valve annuli, anatomy which likely predisposes to the complication of annular rupture with aggressive balloon inflation in the aortic annulus.

Annulus rupture occurs in approximately 1% of TAVRs and carries a mortality rate of at least 50% [2, 3]. Factors associated with annulus rupture include aggressive valve oversizing and heavy annulus calcification [4], the latter of which was present in this patient. Surgical correction must always be considered for the management of this

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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


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.

Factor VIIa for Annulus Rupture After Transcatheter Aortic Valve Replacement.

Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as an effective treatment for inoperable and selected high surgical-ri...
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