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patients with active destructive endocarditis. Based on these earlier experiences, we similarly applied commissural patch repair using autologous fresh pericardium to the present infant, who had acute progressive mitral regurgitation due to multiple chordal rupture of both the anterior and posterior leaflets. Edge-to-edge sutures and artificial chordal replacement were ineffective because the leaflets were extremely edematous and fragile. However, commissuroplasty with autologous fresh pericardium was very effective in repairing the mitral prolapse of both the anterior and posterior leaflets at the anterolateral commissure. Others have reported successful mitral repair using pericardium in infants after excising mitral valve leaflets damaged by mitral endocarditis [4, 5]. Here, we applied the same technique to treat MV insufficiency with edematous and fragile mitral leaflets. Mitral valve replacement with a mechanical valve was a potential alternative therapeutic approach for this infant. However, most pediatric patients require redo replacement due to patient-prosthesis mismatches or significant pannus formation. We therefore prefer to attempt MV repair for pediatric patients to at least delay the need for replacement. Mitral commissural repair with a pericardial patch is simple and effective, for not only patients with endocarditis but also for those with acute progressive mitral regurgitation resulting from chordal rupture. Follow-up echocardiography of our patient for up to 7 years confirmed only trivial mitral regurgitation and the absence of mitral stenosis and mitral valve infection. However, further follow-up will proceed to exclude late mitral incompetence.

References 1. Murashita T, Hoashi T, Kagisaki K, et al. Long-term results of mitral valve repair for severe mitral regurgitation in infants: fate of artificial chordate. Ann Thorac Surg 2012;94: 581–6. 2. Delmo Walter EM, Siniawski H, Ovroutski S, Hetzer R. Mitral valve growth after posterior annular stabilization with untreated autologous pericardial strip in children with mitral valve insufficiency. Ann Thorac Surg 2010;90: 1577–85. 3. Healy DG, Wood AE. Anterior mitral leaflet reconstruction with pericardium in a 1.9 kg infant with endocarditis. Ann Thorac Surg 2006;81:2310–2. 4. Lai DT, Chard RB. Commissuroplasty: a method of valve repair for mitral and tricuspid endocarditis. Ann Thorac Surg 1999;68:1727–30. 5. Ushijima T, Kikuchi Y, Takata M, Yamamoto Y, Kawachi K, Watanabe G. Commissural autologous pericardial patch repair: a novel technique for active mitral valve endocarditis involving the mitral annulus. Ann Thorac Surg 2009;88: e29–30. 6. Araji OA, Barquero JM, Almendro M, et al. Replacement of A2 and A3 by pericardium due to endocarditis of the anterior leaflet of the mitral valve. Ann Thorac Surg 2009;87: 653–4. 7. Ng CK, Nesser J, Punzengruber C, et al. Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology. Ann Thorac Surg 2001;71:78–85. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

Ann Thorac Surg 2014;97:1066–8

Innominate Pseudoaneurysm Subtotally Compressing the Trachea as a Result of Blunt Trauma Xingrong Liu, MD, Qi Miao, MD, Jianzhou Liu, MD, Chaoji Zhang, MD, Chao Wang, MD, Guotao Ma, MD, Xiaofeng Li, MD, and Lihua Cao, MD Department of Cardiac Surgery, Peking Union Medical College Hospital, Beijing, China PR

Blunt traumatic innominate pseudoaneurysm is rare, and coexisting airway distress is even rarer. We describe a case of innominate pseudoaneurysm that subtotally compressed the trachea in a 45-year-old man. The patient also had bovine-type arch anatomy. He experienced exacerbated respiratory distress on anesthesia induction. A cardiopulmonary bypass (CPB) circuit was immediately established through the femoral vessels. The aortic arch was replaced with a branched graft under circulatory arrest and antegrade cerebral perfusion. The pseudoaneurysm was eliminated and airway compression was completely relieved. The patient fully recovered without major complications. The unique feature of this case is its association with airway compression, which is uncommon but potentially lethal. (Ann Thorac Surg 2014;97:1066–8) Ó 2014 by The Society of Thoracic Surgeons

B

lunt traumatic innominate pseudoaneurysm is uncommon. In 2004 Hirose and Gill [1] reviewed the literature and found only 117 similar cases. Occasionally it is associated with airway compression in a chronic pattern [2, 3]. We describe a case of blunt innominate pseudoaneurysm that severely compressed the trachea and caused acute respiratory distress. A 45-year-old male construction worker was referred to our hospital because of dyspnea and back pain 61 hours after blunt trauma to his back. He was accidentally hit by a swinging plank at the level of the scapula. Initially he could walk back to his room and rested for a few hours. He was then sent to a nearby hospital because of escalating dyspnea and back pain. A chest roentgenogram showed a widened upper mediastinum and pneumothorax in the left side. A chest tube was placed in the second intercostal space in the left midclavian line. Although repeated chest roentgenography showed complete lung reinflation, the patient complained of increasing back pain and shortness of breath on the following day. He was referred to our hospital. On arrival, he was in respiratory distress with

Accepted for publication May 15, 2013. Address correspondence to Dr Miao, Department of Cardiac Surgery, Peking Union Medical College Hospital, Shaufuyuan No.1, Wangfujing Street, Beijing 100730, China PR; e-mail: [email protected].

0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.05.119

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stridor. The pulse rate was 132 beats per minute, blood pressure was 150/70 mm Hg, and breath rate was 40 breaths per minute. He was intubated and ventilated immediately to relieve respiratory distress. Computed tomography aortography demonstrated a tear in the proximal portion of the innominate artery (Fig 1), formation of a giant pseudoaneurysm that extended posteriorly and subtotally compressed the trachea (Fig 2). Computed tomography also revealed that the patient had a bovine arch anatomy, ie, the left common carotid artery originated from the innominate artery (Fig 3). The patient was instantly taken to the operating theater. During induction of anesthesia, he experienced respiratory arrest. Tidal volume dropped to 50 mL, blood pressure dropped to 75/30 mm Hg, and the heart rate dropped to 75 beats per minute. Right-sided groin vessels

Fig 2. Saggital reformatting of computed tomographic scan showed that pseudoaneurysm extended posteriorly and tracheal lumen was occluded subtotally.

Fig 3. Computed tomographic aortogram demonstrated that left common carotid artery arises from proximal portion of innominate artery.

were urgently exposed and cardiopulmonary bypass (CPB) was promptly established through femoral cannulation. Hemodynamic stability was achieved. The right axillary artery was isolated and an 8-mm graft was anastomosed to the vessel end to side. A median sternotomy was performed, and the pericardium was opened. The innominate vein was mobilized and retracted. The pseudoaneurysm ruptured while isolation of the left common carotid artery was attempted. The bleeding was temporarily stopped by compression. The ascending aorta was cross clamped and antegrade cardioplegia was administered. After the patient was cooled to a core temperature of 18 C, circulatory arrest was initiated. The aortic lumen was entered, and an intimal tear of one-third circumference was found in the posterior wall of the proximal innominate artery. The innominate artery was excised distally to healthy tissue and then clamped for antegrade selective cerebral perfusion (SCP) through the graft connected to the right axillary artery. The distal arch was transected between the origins of the innominate artery and the left subclavian artery. After the distal aortic stump was anastomosed with a 26-mm quadrifurcated graft (MAQUET, Rastatt, Germany), perfusion of the lower body was resumed. The innominate artery and the left common carotid artery were anastomosed to branches of the graft, respectively. SCP was stopped and CPB was resumed through a sidearm of the graft. The proximal anastomosis was completed between the graft and the ascending aorta. The blood clots posterior to the innominate artery and the ascending aorta were evacuated to relieve compression on the trachea. CPB was weaned without difficulties, and the chest was closed after hemostasis was achieved. The circulatory arrest time was 29 minutes, SCP time was 25 minutes, and total CPB time was 211 minutes. The patient was taken to the intensive care unit, where he awoke about 10 hours later without neurologic deficit. He was ventilated for 20 hours

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Fig 1. Computed tomographic scan at level of innominate vein; intimal tear can be clearly seen in posterior wall of innominate artery. Tracheal lumen can be barely seen because of external compression.

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postoperatively and was discharged 10 days after the operation without major complications. He was still doing well at the end of 8-month follow-up.

Comment

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Next to the isthmus of the thoracic aorta, the innominate artery is the second most vulnerable for blunt injury. In civilian patients, mechanisms of injury are motor vehicle accidents in 90%, crush injuries in 8%, and falls in 2% [1]. It was proposed that 2 types of forces are responsible for the innominate artery injury. One is transverse compression between the sternum and the spine, and the other is longitudinal shear stretch when the neck is hyperextended and the heart is displaced downward. Both forces cause increased tension on the innominate artery, especially in the proximal segment, because it is relatively fixed on the arch. Bovine arch anatomy is a predisposing factor for innominate artery injury, which is seen in 11% of the general population but in 29% of patients with innominate artery injury [4]. The underlying cause for this association is that bovine arch anatomy results in fewer aortic arch fixation points and consequently more concentrated force on the origin of the innominate artery. In the majority of patients, the diagnosis of innominate artery injury after blunt trauma can be established in the acute phase. However, delayed presentation—up to 34 years after the injury [2]—has been reported in 12.3% of patients. The most common types of innominate artery injury are intimal tears and pseudoaneurysm formation. Concomitant respiratory manifestations, mainly resulting from pneumothorax, can be seen in about 15% of patients [5]. Airway distress caused by direct compression from the pseudoaneurysm, as seen in this patient, is rare. Several operative approaches have been reported for innominate artery injury, including primary repair, graft replacement, and bypass. Protective measures for cerebral perfusion, such as shunting and CPB, may or may not be used. Most patients with a normal circle of Willis can tolerate temporary clamping of the innominate artery. However, shunting must be used when backflow pressure is insufficient (

Innominate pseudoaneurysm subtotally compressing the trachea as a result of blunt trauma.

Blunt traumatic innominate pseudoaneurysm is rare, and coexisting airway distress is even rarer. We describe a case of innominate pseudoaneurysm that ...
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