Ann Thorac Surg 2015;99:2213–6
CASE REPORT GONZALEZ-SANTOS ET AL TRICUSPID RING CAUSING CORONARY OCCLUSION
2213
Comment Coronary artery aneurysms are a rare occurrence. Those qualifying as giant are loosely defined as having a diameter 1.5 times greater than the adjacent artery [4]. No established treatment protocol exists. To date, surgical intervention is the most commonly reported treatment option and was the course we selected. Complete resection of the giant coronary artery aneurysm with distal coronary artery bypass proved effective to relieve the patient’s symptoms. We were able to successfully reestablish blood flow to previously occluded vasculature as well as maintain vessels not directly affected by the aneurysm. We have demonstrated the effectiveness of surgical intervention as a long-term remedy for giant coronary artery aneurysms [2], and advocate for resection of the aneurysm with distal coronary revascularization [5].
References Fig 2. Giant aneurysm of the left coronary circumflex artery after resection.
Acute Right Coronary Artery Occlusion After Tricuspid Valve Ring Annuloplasty Jose María Gonz alez-Santos, PhD, María Elena Arn aiz-García, MD, Jose Alfonso Sastre-Rinc on, PhD, María E. Bueno-Codo~ ner, MD, María Jos e Dalmau-Sorlí, PhD, Adolfo Ar evalo-Abascal, MD, Javier L opez-Rodríguez, PhD, and Alejandro Diego-Nieto, PhD Departments of Cardiac Surgery, Anesthesiology, and Cardiology, University Hospital of Salamanca, Salamanca, Spain
A patient was submitted to mitral valve replacement and tricuspid ring annuloplasty. During immediate postoperative course, signs of inferior myocardial ischemia appeared. Acute entrapment of the right coronary artery due to tricuspid ring sutures was confirmed by coronary angiography. The patient was reoperated and a right coronary bypass graft was successfully performed. Accepted for publication Aug 29, 2014.
Fig 3. Bisected giant coronary aneurysm. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Address correspondence to Dr Arn aiz-García, Cardiac Surgery Department, University Hospital of Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.068
FEATURE ARTICLES
circumflex artery was divided and ligated at this point. The aneurysm was then mobilized off the heart, and the distal circumflex exiting the aneurysm was identified and divided. The aneurysm was then removed from the patient (Fig 2). The left internal mammary artery was harvested as a pedicled graft and anastomosed end to end to the true circumflex, before the first marginal branch. The patient was routinely weaned from cardiopulmonary bypass. His postoperative course was uneventful. The aneurysm exhibited peripheral wall calcification and internal heterogeneity, which included a large area of low-density tissue consistent with thrombosis on the left border of the heart (Fig 3).
1. Tuncer E, Onsel Turk U, Alioglu E. Giant saccular aneurysm of the left main coronary artery. J Geriatr Cardiol 2013;10:110–2. 2. Lazar JF, Compton M, Li F, Knight P. Excising a giant: report of a 7-cm coronary artery aneurysm. Tex Heart Inst J 2013;40:173–5. 3. Li D, Wu Q, Sun L, et al. Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg 2005;130:817–21. 4. Mariscalco G, Mantovani V, Ferrarese S, Leva C, Orru A, Sala A. Coronary artery aneurysm: management and association with abdominal aortic aneurysm. Cardiovasc Pathol 2006;15:100–4. 5. Berdajs D, Ruchat P, Suva M, Ferrari E, Ligang L, von Segesser LK. Congenital giant aneurysm of the left coronary artery. Heart Lung Circ 2011;20:663–5.
2214
CASE REPORT GONZALEZ-SANTOS ET AL TRICUSPID RING CAUSING CORONARY OCCLUSION
Tricuspid procedures have shown to be effective and secure with a low rate of complication. Few cases of right coronary artery occlusion have been described and the majority not treated. Exceptional cases of right coronary occlusion related to tricuspid ring annuloplasty have been reported with a favorable outcome, as the case described herein. (Ann Thorac Surg 2015;99:2213–6) Ó 2015 by The Society of Thoracic Surgeons
S
FEATURE ARTICLES
urgical techniques used for correction of tricuspid valve regurgitation have shown to be effective and secure procedures. Scarce complications have been reported related to these techniques, especially for tricuspid ring annuloplasty where complications are really exceptional. However, the proximity to the tricuspid annulus of anatomic structures such as the right coronary artery (RCA) or the atrioventricular conduction system, causes these structures to be potentially damaged during surgery. The presence of signs of myocardial ischemia immediately after cardiac surgery requires a prompt diagnosis and effective treatment. An acute right coronary occlusion by sutures used for tricuspid ring annuloplasty is extremely rare but possible. An aggressive approach as a reoperation for coronary revascularization assures a favorable outcome for the patient. A 73-year-old woman with no cardiovascular risk factors was admitted to our institution for surgical correction of a chronic rheumatic heart valve disease. She had been previously diagnosed with severe mitral valve stenosis and severe functional tricuspid valve insufficiency. At the moment of admission she was in atrial fibrillation and in New York Heart Association functional class III. A preoperative coronary angiography revealed RCA dominance and no coronary abnormalities (Fig 1A). Mitral valve replacement and a tricuspid annuloplasty were decided and the patient underwent cardiac surgery. Though a conventional median sternotomy, standard cardiopulmonary bypass was established with ascending aorta and bicaval venous cannulation. The ascending aorta was cross-clamped and the heart arrested using both antegrade and retrograde cold blood cardioplegia. The right ventricle and tricuspid annulus was severely dilated but no other structural valve tricuspid valve abnormalities were appreciated. The mitral valve was accessed through the superior septal approach, and severe fibrosis and retraction of mitral apparatus was confirmed. The mitral valve was replaced with a 31-mm Labcor TLPB porcine bioprosthesis (Labcor Laboratories, Belo Horizonte, Brazil) and a tricuspid annuloplasty was performed using a 32-mm Tricuspid Physio ring (Edwards Lifesciences Company, Irvine, CA). The patient was easily weaned from cardiopulmonary bypass under external ventricular pacing due to atrial quiescence and very slow spontaneous ventricular activity. Intraoperative echocardiography showed a well functioning mitral prosthesis and a competent tricuspid valve. Systolic function seemed to be preserved in
Ann Thorac Surg 2015;99:2213–6
both ventricles, except for septal dyskinesia. No further attempts to determinate spontaneous electrical activity were done and the patient was transferred to the postoperative care unit without vasoactive drug support. However, at arrival in the postoperative care unit, spontaneous electrical activity was tested again revealing an extensive ST segment elevation in the postero-inferior wall, suggesting ongoing ischemia in the RCA territory (Fig 2A). Dobutamine infusion running at 5 mcg $ kg 1 $ min 1 was initiated and the patient was immediately transferred to the hemodynamic laboratory. A coronary angiography was urgently performed to rule out a surgery-related coronary injury. A distal RCA occlusion between the acute marginal branch and the crux cordis was confirmed, just in the area of greater proximity between the RCA and the prosthetic ring (Fig 1B). A percutaneous revascularization was unsuccessfully attempted due to the impossibility of crossing the occlusion with the catheter guide. Given the important amount of myocardium at risk and despite the acceptable hemodynamic situation of the patient, it was decided to carry out an emergent surgical revascularization. An intraaortic balloon pump was placed for optimization of coronary flow and perioperative support. The patient was transferred to the operating room and an aorta to distal RCA saphenous vein bypass graft was performed under cardiopulmonary bypass. Inotropic and vasoactive drugs infusion was initially necessary for hemodynamic support during the immediate postoperative period. Dobutamine infusion running at 5 mcg $ kg 1 $ min 1 and noradrenaline running at 0.044 mcg $ kg 1 $ min 1 were initiated and maintained because of low cardiac output until the sixth postoperative day. The intraaortic balloon pump was removed 36 hours after RCA bypass. On follow-up the patient recovered well and had an uneventful recovery. At discharge, new Q waves, and located in the inferior and lateral leads, suggested incomplete myocardial ischemia necrosis (Fig 2B).
Comment Functional tricuspid valve regurgitation is frequently associated with left side valvulopathy in patients with advanced rheumatic heart valve disease. Different techniques have been developed during the last decades for repairing the tricuspid valve. Both suture and ring annuloplasty have shown to be effective and secure procedures with a lower risk of related complications [1, 2]. A few references of RCA injuries with these tricuspid valve repair techniques have been reported, most with the suture annuloplasty as the de Vega technique [1, 3, 4]. However, only exceptional cases of right coronary artery occlusion have been described in patients undergoing a tricuspid ring annuloplasty [1, 2, 4]. Indeed, the case we report is the only RCA injury detected in our group in 800 tricuspid rings implanted. Direct arterial injury with the sutures applied for tricuspid ring fixation or RCA distortion caused by annulus plication are the mechanism that can lead to this event. This complication is especially possible in the presence of anatomic variations of
Ann Thorac Surg 2015;99:2213–6
CASE REPORT GONZALEZ-SANTOS ET AL TRICUSPID RING CAUSING CORONARY OCCLUSION
2215
Fig 1. Coronary angiography. (A) Preoperative and selective right coronary angiogram showing a dominant right coronary artery (RCA) without coronary lesions (arrow). (B) Postoperative RCA angiogram showing complete occlusion of RCA (arrow) at the mid level of the posterior tricuspid valve leaflet. Tricuspid valve ring (*) and sternotomy wires (**) are labeled.
RCA distribution or whenever relationship between the RCA and the tricuspid annulus is altered due to right ventricle remodeling or severe tricuspid annulus dilatation [1–4]. A lesion to the RCA should be considered in the case of an unstable patient during the immediate postoperative period of a tricuspid valve surgery. Deep hypotension, ventricular tachycardia, inferior ischemia, or acute postoperative right ventricular dysfunction may appear
frequently in the course of this event. Once this serious complication is suspected a complementary image test must be ordered for confirmation. Prompt recognition has crucial importance and an emergent management is mandatory to assure a successful patient evolution. Although a conservative attitude has been previously proposed in stable patients [1, 4], we believe that a more aggressive approach is indicated to assure patient outcome and avoid future complications such as massive right
FEATURE ARTICLES
Fig 2. (A) First electrocardiogram carried out after tricuspid ring annuloplasty in the intensive care unit. It is clearly patent an ST elevation segment in the posterior and lateral wall, corresponding to the right coronary territory. (B) Postoperative electrocardiogram at moment of discharging patient home. New Q waves and inverse T waves appeared as a residual finding of previous right myocardial ischemia.
2216
CASE REPORT COPELAND ET AL LVAD IMPLANTATION IN A SINGLE-LUNG PATIENT
coronary infarct. Percutaneous revascularization, including the placement of a stent, is the fastest way to solve the obstruction when it is detected in the hemodynamic laboratory. However, when this technique is not successful an emergent right coronary bypass is the best option to assure a correct right coronary revascularization and a favorable postoperative evolution. To undo the tricuspid ring annuloplasty is an alternative but it does not guarantee the problem solution in the case of direct artery injury. Herein, we present an exceptional case of an acute RCA occlusion in a patient undergoing a tricuspid valve annuloplasty. A prompt and surgical management was decided for right coronary artery bypass revascularization. The patient had an uneventful recovery.
References
FEATURE ARTICLES
1. Díez-Villanueva P, Guti errez-Iba~ nes E, Cuerpo-Caballero GP, et al. Direct injury to right coronary artery in patients undergoing tricuspid annuloplasty. Ann Thorac Surg 2014;97: 1300–5. 2. Varghese R, Akujuo A, Adams DH. Right coronary artery injury after tricuspid valve repair. Semin Thorac Cardiovasc Surg 2010;22:189–90. 3. Calafiore AM, Iac o AL, Bartoloni G, Di Mauro M. Right coronary occlusion during tricuspid band annuloplasty. J Thorac Cardiovasc Surg 2009;138:1443–4. 4. Cuerpo GP, Stuart JR, Ruiz M, Pinto AG. Right coronary artery injury as a complication of de Vega tricuspid annuloplasty. Rev Esp Cardiol 2009;62:1501–3.
Implantation of HeartMate II Left Ventricular Assist Device in a Single-Lung Patient Hannah Copeland, MD, Liset Stoletniy, MD, Antoine Sakr, MD, and Anees Razzouk, MD
Ann Thorac Surg 2015;99:2216–8
commonly used to treat end-stage heart failure for destination therapy and as a bridge to transplantation. Blood delivery, by continuous-flow LVADs, is sensitive to preload, right ventricular function, and changes in pulmonary vascular resistance. As the experience with LVADs grows, unusual applications of the technology becomes more common, such as in patients with single-lung physiology and slightly elevated pulmonary vascular resistance. A 64-year-old man with a 5-year history of chronic systolic and diastolic congestive heart failure (nonischemic cardiomyopathy) receiving maximal medical therapy, including home inotropic support, presented to the hospital with rapidly progressive symptoms, including orthopnea, dyspnea, paroxysmal nocturnal dyspnea, fluid retention, and weight gain with recurrent arrhythmias. Fifteen years earlier, the patient had a left pneumonectomy for a left mainstem bronchial carcinoid tumor. He also had an implantable cardioverter-defibrillator placed 1 year before admission. On echocardiogram, the left ventricular ejection fraction was 10% with global hypokinesis. The mitral valve had severe regurgitation with annular dilation and severe bileaflet tenting. The tricuspid valve had moderate to severe central regurgitation. The right ventricle was severely hypokinetic and dilated. At cardiac catheterization, right atrial pressure was 20 mm Hg, pulmonary artery pressure was 52/41 mm Hg (mean 42 mm Hg), and pulmonary capillary wedge pressure was 28 mm Hg. Cardiac index was 1.5 L $ min 1 $ m 2; the pulmonary vascular resistance was 3.74 Woods units, and the transpulmonary gradient was 12 mm Hg. The coronary angiogram showed normal coronary arteries. A prior pulmonary workup included a chest computed tomography scan (Fig 1) that showed increased expansion of the right lung with mediastinal
Departments of Cardiovascular and Thoracic Surgery and Medicine, Division of Cardiology, Loma Linda University, Loma Linda, California
The use of mechanical assist devices has been established as an effective therapy for patients with end-stage heart failure. Implantable left ventricular assist devices are becoming more common in the clinical practice of cardiac surgery. This report illustrates the use of a HeartMate II (Thoratec Pleasanton, CA) left ventricular assist device in a patient with a single lung and dilated cardiomyopathy. To our knowledge, this is the first report of a left ventricular assist device placement in a patient with a prior pneumonectomy. (Ann Thorac Surg 2015;99:2216–8) Ó 2015 by The Society of Thoracic Surgeons
M
echanical assist devices are an effective treatment modality for patients with circulatory failure. Implantable left ventricular assist devices (LVADs) are Accepted for publication Aug 15, 2014. Address correspondence to Dr Razzouk, 11175 Campus St, Ste 21121, Loma Linda, CA 92354; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Computed tomography scan of the chest demonstrates surgical absence of the left lung, cardiomegaly, and significant mediastinal shift. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.053
CASE REPORT GONZALEZ-SANTOS ET AL TRICUSPID RING CAUSING CORONARY OCCLUSION
2213
Comment Coronary artery aneurysms are a rare occurrence. Those qualifying as giant are loosely defined as having a diameter 1.5 times greater than the adjacent artery [4]. No established treatment protocol exists. To date, surgical intervention is the most commonly reported treatment option and was the course we selected. Complete resection of the giant coronary artery aneurysm with distal coronary artery bypass proved effective to relieve the patient’s symptoms. We were able to successfully reestablish blood flow to previously occluded vasculature as well as maintain vessels not directly affected by the aneurysm. We have demonstrated the effectiveness of surgical intervention as a long-term remedy for giant coronary artery aneurysms [2], and advocate for resection of the aneurysm with distal coronary revascularization [5].
References Fig 2. Giant aneurysm of the left coronary circumflex artery after resection.
Acute Right Coronary Artery Occlusion After Tricuspid Valve Ring Annuloplasty Jose María Gonz alez-Santos, PhD, María Elena Arn aiz-García, MD, Jose Alfonso Sastre-Rinc on, PhD, María E. Bueno-Codo~ ner, MD, María Jos e Dalmau-Sorlí, PhD, Adolfo Ar evalo-Abascal, MD, Javier L opez-Rodríguez, PhD, and Alejandro Diego-Nieto, PhD Departments of Cardiac Surgery, Anesthesiology, and Cardiology, University Hospital of Salamanca, Salamanca, Spain
A patient was submitted to mitral valve replacement and tricuspid ring annuloplasty. During immediate postoperative course, signs of inferior myocardial ischemia appeared. Acute entrapment of the right coronary artery due to tricuspid ring sutures was confirmed by coronary angiography. The patient was reoperated and a right coronary bypass graft was successfully performed. Accepted for publication Aug 29, 2014.
Fig 3. Bisected giant coronary aneurysm. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Address correspondence to Dr Arn aiz-García, Cardiac Surgery Department, University Hospital of Salamanca, Paseo de San Vicente 58-182, 37007, Salamanca, Spain; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.068
FEATURE ARTICLES
circumflex artery was divided and ligated at this point. The aneurysm was then mobilized off the heart, and the distal circumflex exiting the aneurysm was identified and divided. The aneurysm was then removed from the patient (Fig 2). The left internal mammary artery was harvested as a pedicled graft and anastomosed end to end to the true circumflex, before the first marginal branch. The patient was routinely weaned from cardiopulmonary bypass. His postoperative course was uneventful. The aneurysm exhibited peripheral wall calcification and internal heterogeneity, which included a large area of low-density tissue consistent with thrombosis on the left border of the heart (Fig 3).
1. Tuncer E, Onsel Turk U, Alioglu E. Giant saccular aneurysm of the left main coronary artery. J Geriatr Cardiol 2013;10:110–2. 2. Lazar JF, Compton M, Li F, Knight P. Excising a giant: report of a 7-cm coronary artery aneurysm. Tex Heart Inst J 2013;40:173–5. 3. Li D, Wu Q, Sun L, et al. Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg 2005;130:817–21. 4. Mariscalco G, Mantovani V, Ferrarese S, Leva C, Orru A, Sala A. Coronary artery aneurysm: management and association with abdominal aortic aneurysm. Cardiovasc Pathol 2006;15:100–4. 5. Berdajs D, Ruchat P, Suva M, Ferrari E, Ligang L, von Segesser LK. Congenital giant aneurysm of the left coronary artery. Heart Lung Circ 2011;20:663–5.
2214
CASE REPORT GONZALEZ-SANTOS ET AL TRICUSPID RING CAUSING CORONARY OCCLUSION
Tricuspid procedures have shown to be effective and secure with a low rate of complication. Few cases of right coronary artery occlusion have been described and the majority not treated. Exceptional cases of right coronary occlusion related to tricuspid ring annuloplasty have been reported with a favorable outcome, as the case described herein. (Ann Thorac Surg 2015;99:2213–6) Ó 2015 by The Society of Thoracic Surgeons
S
FEATURE ARTICLES
urgical techniques used for correction of tricuspid valve regurgitation have shown to be effective and secure procedures. Scarce complications have been reported related to these techniques, especially for tricuspid ring annuloplasty where complications are really exceptional. However, the proximity to the tricuspid annulus of anatomic structures such as the right coronary artery (RCA) or the atrioventricular conduction system, causes these structures to be potentially damaged during surgery. The presence of signs of myocardial ischemia immediately after cardiac surgery requires a prompt diagnosis and effective treatment. An acute right coronary occlusion by sutures used for tricuspid ring annuloplasty is extremely rare but possible. An aggressive approach as a reoperation for coronary revascularization assures a favorable outcome for the patient. A 73-year-old woman with no cardiovascular risk factors was admitted to our institution for surgical correction of a chronic rheumatic heart valve disease. She had been previously diagnosed with severe mitral valve stenosis and severe functional tricuspid valve insufficiency. At the moment of admission she was in atrial fibrillation and in New York Heart Association functional class III. A preoperative coronary angiography revealed RCA dominance and no coronary abnormalities (Fig 1A). Mitral valve replacement and a tricuspid annuloplasty were decided and the patient underwent cardiac surgery. Though a conventional median sternotomy, standard cardiopulmonary bypass was established with ascending aorta and bicaval venous cannulation. The ascending aorta was cross-clamped and the heart arrested using both antegrade and retrograde cold blood cardioplegia. The right ventricle and tricuspid annulus was severely dilated but no other structural valve tricuspid valve abnormalities were appreciated. The mitral valve was accessed through the superior septal approach, and severe fibrosis and retraction of mitral apparatus was confirmed. The mitral valve was replaced with a 31-mm Labcor TLPB porcine bioprosthesis (Labcor Laboratories, Belo Horizonte, Brazil) and a tricuspid annuloplasty was performed using a 32-mm Tricuspid Physio ring (Edwards Lifesciences Company, Irvine, CA). The patient was easily weaned from cardiopulmonary bypass under external ventricular pacing due to atrial quiescence and very slow spontaneous ventricular activity. Intraoperative echocardiography showed a well functioning mitral prosthesis and a competent tricuspid valve. Systolic function seemed to be preserved in
Ann Thorac Surg 2015;99:2213–6
both ventricles, except for septal dyskinesia. No further attempts to determinate spontaneous electrical activity were done and the patient was transferred to the postoperative care unit without vasoactive drug support. However, at arrival in the postoperative care unit, spontaneous electrical activity was tested again revealing an extensive ST segment elevation in the postero-inferior wall, suggesting ongoing ischemia in the RCA territory (Fig 2A). Dobutamine infusion running at 5 mcg $ kg 1 $ min 1 was initiated and the patient was immediately transferred to the hemodynamic laboratory. A coronary angiography was urgently performed to rule out a surgery-related coronary injury. A distal RCA occlusion between the acute marginal branch and the crux cordis was confirmed, just in the area of greater proximity between the RCA and the prosthetic ring (Fig 1B). A percutaneous revascularization was unsuccessfully attempted due to the impossibility of crossing the occlusion with the catheter guide. Given the important amount of myocardium at risk and despite the acceptable hemodynamic situation of the patient, it was decided to carry out an emergent surgical revascularization. An intraaortic balloon pump was placed for optimization of coronary flow and perioperative support. The patient was transferred to the operating room and an aorta to distal RCA saphenous vein bypass graft was performed under cardiopulmonary bypass. Inotropic and vasoactive drugs infusion was initially necessary for hemodynamic support during the immediate postoperative period. Dobutamine infusion running at 5 mcg $ kg 1 $ min 1 and noradrenaline running at 0.044 mcg $ kg 1 $ min 1 were initiated and maintained because of low cardiac output until the sixth postoperative day. The intraaortic balloon pump was removed 36 hours after RCA bypass. On follow-up the patient recovered well and had an uneventful recovery. At discharge, new Q waves, and located in the inferior and lateral leads, suggested incomplete myocardial ischemia necrosis (Fig 2B).
Comment Functional tricuspid valve regurgitation is frequently associated with left side valvulopathy in patients with advanced rheumatic heart valve disease. Different techniques have been developed during the last decades for repairing the tricuspid valve. Both suture and ring annuloplasty have shown to be effective and secure procedures with a lower risk of related complications [1, 2]. A few references of RCA injuries with these tricuspid valve repair techniques have been reported, most with the suture annuloplasty as the de Vega technique [1, 3, 4]. However, only exceptional cases of right coronary artery occlusion have been described in patients undergoing a tricuspid ring annuloplasty [1, 2, 4]. Indeed, the case we report is the only RCA injury detected in our group in 800 tricuspid rings implanted. Direct arterial injury with the sutures applied for tricuspid ring fixation or RCA distortion caused by annulus plication are the mechanism that can lead to this event. This complication is especially possible in the presence of anatomic variations of
Ann Thorac Surg 2015;99:2213–6
CASE REPORT GONZALEZ-SANTOS ET AL TRICUSPID RING CAUSING CORONARY OCCLUSION
2215
Fig 1. Coronary angiography. (A) Preoperative and selective right coronary angiogram showing a dominant right coronary artery (RCA) without coronary lesions (arrow). (B) Postoperative RCA angiogram showing complete occlusion of RCA (arrow) at the mid level of the posterior tricuspid valve leaflet. Tricuspid valve ring (*) and sternotomy wires (**) are labeled.
RCA distribution or whenever relationship between the RCA and the tricuspid annulus is altered due to right ventricle remodeling or severe tricuspid annulus dilatation [1–4]. A lesion to the RCA should be considered in the case of an unstable patient during the immediate postoperative period of a tricuspid valve surgery. Deep hypotension, ventricular tachycardia, inferior ischemia, or acute postoperative right ventricular dysfunction may appear
frequently in the course of this event. Once this serious complication is suspected a complementary image test must be ordered for confirmation. Prompt recognition has crucial importance and an emergent management is mandatory to assure a successful patient evolution. Although a conservative attitude has been previously proposed in stable patients [1, 4], we believe that a more aggressive approach is indicated to assure patient outcome and avoid future complications such as massive right
FEATURE ARTICLES
Fig 2. (A) First electrocardiogram carried out after tricuspid ring annuloplasty in the intensive care unit. It is clearly patent an ST elevation segment in the posterior and lateral wall, corresponding to the right coronary territory. (B) Postoperative electrocardiogram at moment of discharging patient home. New Q waves and inverse T waves appeared as a residual finding of previous right myocardial ischemia.
2216
CASE REPORT COPELAND ET AL LVAD IMPLANTATION IN A SINGLE-LUNG PATIENT
coronary infarct. Percutaneous revascularization, including the placement of a stent, is the fastest way to solve the obstruction when it is detected in the hemodynamic laboratory. However, when this technique is not successful an emergent right coronary bypass is the best option to assure a correct right coronary revascularization and a favorable postoperative evolution. To undo the tricuspid ring annuloplasty is an alternative but it does not guarantee the problem solution in the case of direct artery injury. Herein, we present an exceptional case of an acute RCA occlusion in a patient undergoing a tricuspid valve annuloplasty. A prompt and surgical management was decided for right coronary artery bypass revascularization. The patient had an uneventful recovery.
References
FEATURE ARTICLES
1. Díez-Villanueva P, Guti errez-Iba~ nes E, Cuerpo-Caballero GP, et al. Direct injury to right coronary artery in patients undergoing tricuspid annuloplasty. Ann Thorac Surg 2014;97: 1300–5. 2. Varghese R, Akujuo A, Adams DH. Right coronary artery injury after tricuspid valve repair. Semin Thorac Cardiovasc Surg 2010;22:189–90. 3. Calafiore AM, Iac o AL, Bartoloni G, Di Mauro M. Right coronary occlusion during tricuspid band annuloplasty. J Thorac Cardiovasc Surg 2009;138:1443–4. 4. Cuerpo GP, Stuart JR, Ruiz M, Pinto AG. Right coronary artery injury as a complication of de Vega tricuspid annuloplasty. Rev Esp Cardiol 2009;62:1501–3.
Implantation of HeartMate II Left Ventricular Assist Device in a Single-Lung Patient Hannah Copeland, MD, Liset Stoletniy, MD, Antoine Sakr, MD, and Anees Razzouk, MD
Ann Thorac Surg 2015;99:2216–8
commonly used to treat end-stage heart failure for destination therapy and as a bridge to transplantation. Blood delivery, by continuous-flow LVADs, is sensitive to preload, right ventricular function, and changes in pulmonary vascular resistance. As the experience with LVADs grows, unusual applications of the technology becomes more common, such as in patients with single-lung physiology and slightly elevated pulmonary vascular resistance. A 64-year-old man with a 5-year history of chronic systolic and diastolic congestive heart failure (nonischemic cardiomyopathy) receiving maximal medical therapy, including home inotropic support, presented to the hospital with rapidly progressive symptoms, including orthopnea, dyspnea, paroxysmal nocturnal dyspnea, fluid retention, and weight gain with recurrent arrhythmias. Fifteen years earlier, the patient had a left pneumonectomy for a left mainstem bronchial carcinoid tumor. He also had an implantable cardioverter-defibrillator placed 1 year before admission. On echocardiogram, the left ventricular ejection fraction was 10% with global hypokinesis. The mitral valve had severe regurgitation with annular dilation and severe bileaflet tenting. The tricuspid valve had moderate to severe central regurgitation. The right ventricle was severely hypokinetic and dilated. At cardiac catheterization, right atrial pressure was 20 mm Hg, pulmonary artery pressure was 52/41 mm Hg (mean 42 mm Hg), and pulmonary capillary wedge pressure was 28 mm Hg. Cardiac index was 1.5 L $ min 1 $ m 2; the pulmonary vascular resistance was 3.74 Woods units, and the transpulmonary gradient was 12 mm Hg. The coronary angiogram showed normal coronary arteries. A prior pulmonary workup included a chest computed tomography scan (Fig 1) that showed increased expansion of the right lung with mediastinal
Departments of Cardiovascular and Thoracic Surgery and Medicine, Division of Cardiology, Loma Linda University, Loma Linda, California
The use of mechanical assist devices has been established as an effective therapy for patients with end-stage heart failure. Implantable left ventricular assist devices are becoming more common in the clinical practice of cardiac surgery. This report illustrates the use of a HeartMate II (Thoratec Pleasanton, CA) left ventricular assist device in a patient with a single lung and dilated cardiomyopathy. To our knowledge, this is the first report of a left ventricular assist device placement in a patient with a prior pneumonectomy. (Ann Thorac Surg 2015;99:2216–8) Ó 2015 by The Society of Thoracic Surgeons
M
echanical assist devices are an effective treatment modality for patients with circulatory failure. Implantable left ventricular assist devices (LVADs) are Accepted for publication Aug 15, 2014. Address correspondence to Dr Razzouk, 11175 Campus St, Ste 21121, Loma Linda, CA 92354; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Computed tomography scan of the chest demonstrates surgical absence of the left lung, cardiomegaly, and significant mediastinal shift. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.08.053
