Eur J Cardiothorac Surg 2003;24:827-829
© 2003 Elsevier Science NL
Intraoperative transesophageal echocardiographic assessment of myocardial protection in a redo ascending-arch aortic operation
Yukio Kuniyoshia*,
Kageharu Kojaa,
Kazufumi Miyagia,
Manabu Kakinohanab
a Second Department of Surgery, Faculty of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Okinawa 903-0215, Japan
b Department of Anesthesiology, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
Received 26 May 2003;
received in revised form 29 July 2003;
accepted 9 August 2003.
* Corresponding author. Tel.: +81-98-895-1168; fax: +81-98-895-1422
e-mail: kuni9244{at}med.u-ryukyu.ac.jp
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Abstract
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In a redo operation of the ascending aortic arch, transesophageal echocardiography was useful in confirming antegrade infusion flow of cardioplegia solution into the left main coronary artery.
Key Words: Transesophageal echocardiography • Myocardial protection • Redo ascending-arch aortic operation
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1. Introduction
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Achieving myocardial protection during a redo cardiac operation is even more important for postoperative recovery than during an initial cardiac operation [1]. In a redo ascending-arch aortic operation adhesions around the previously implanted graft may be extensive, and make it quite difficult to insert cannulae into the coronary ostia for delivering cardioplegia solution. In this case report we describe an alternative approach. We performed antegrade cardioplegia infusion through a Foley catheter, and employed transesophageal echocardiography (TEE) monitoring to confirm that cardioplegia infusion was flowing into the left main coronary artery, thus assuring the presence of myocardial protection.
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2. Case report
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In 2001 a 67-year-old woman underwent graft replacement of the ascending aorta for an acute type I dissecting aortic aneurysm. The postoperative course was uneventful, and she was discharged and followed at an outpatient center of another hospital. Twenty months later enhanced computed tomography examination showed formation of a large pseudoaneurysm at the distal anastomotic site, and a redo operation was planned. Preoperative echocardiography demonstrated the presence of mild aortic regurgitation. Although the pseudoaneurysm pressed against the sternum, resternotomy was successfully completed under normothermic partial extracorporeal circulation without perforation of the pseudoaneurysm. The pseudoaneurysm also compressed the heart downward, and there were severe adhesions to the surrounding structures. Only the lower margins of the right atrium (RA) and right ventricle (RV) were visible. We did not attempt to dissect the pseudoaneurysm from the heart and the implanted graft because of the severe adhesions. Hypothermia was begun, and when rectal temperature reached 20 °C circulatory arrest was initiated. Then the pseudoaneurysm was incised, its entry site at the distal anastomosis of the original graft identified, and a new distal anastomotic ostium created between the left common carotid and subclavian arteries with placement of a second graft. However the original graft could not be exposed proximally down to the aortic root because of tight adhesions to the pseudoaneurysmal wall. The adhesions on the surface of the RA also prevented cannulation for retrograde infusion of cardioplegia solution.
Because of these limitations, a decision was made to infuse cardioplegia solution antegradely through a Foley catheter, which was inflated within the previously implanted graft (Fig. 1) . The left main coronary artery at its origin from the ascending aorta was visualized by TEE, and constant flow of cardioplegia solution into this vessel confirmed by TEE Doppler (Fig. 2)
. Since mild aortic regurgitation was present, relatively large volumes of cardioplegia solution (800–1000 ml/20 min) were infused. Proximal anastomosis of the new graft to the previously implanted graft was then performed. The total extracorporeal circulation (ECC) time was 175 min, and weaning from ECC was smooth. Postoperatively the peak value of CPK-MB was 61.0 mg/dl. The patient's postoperative course was uneventful.
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Fig. 1. Intraoperative photo of insertion site of Foley catheter for cardioplegia administration. The Foley catheter (black arrow) was inflated within the previously implanted graft. The aortic root had severe adhesions that were felt to jeopardize any attempts at dissection to visualize the coronary ostium. The figure also shows that the distal anastomosis was already completed (white arrow).
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Fig. 2. (Left) The left main coronary artery (arrow) was visualized. (Right) The infusion flow of cardioplegia was demonstrated by Doppler TEE (arrow).
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3. Discussion
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Myocardial protection during cardiac arrest is a determining factor for reducing operative risk, especially in redo operations, and several techniques for myocardial protection have been described [2]. In redo operations retrograde infusion of cardioplegia is often recommended. However in the present case the RA and RV surfaces were almost covered by pseudoaneurysmal wall, and it was felt that dissection in this area would carry a high operative risk. Accordingly, we used the alternative approach of antegrade perfusion. Since it was not possible to place cannulae directly into the coronary ostia, we elected to infuse cardioplegia solution into the remaining intact graft attached to the aortic root. In this situation TEE proved to be quite useful in confirming the presence of flow into the left main coronary artery. This vessel was initially identified by visualizing its branch point from the ascending aorta, and intraluminal flow was detected by Doppler TEE (Fig. 2). The success of this effort in maintaining myocardial protection was confirmed by the uncomplicated postoperative course and by the relatively low peak postoperative CPK-MB level.
There are other examples in the literature of the value of TEE in confirming positioning or location of perfusion cannulae. In port-access minimally invasive cardiac surgery this technique has proven useful for the correct positioning of catheters [3,4]. TEE has been also generally accepted as an essential technique for monitoring intraoperative cardiac function [5], and there are well-documented reports describing the utility of TEE for visualizing coronary artery disease or assessing coronary flow [6,7].
In conclusion, a unique approach to achieving and monitoring coronary perfusion in a redo ascending-arch aortic operation has been described, and the value of intraoperative TEE for confirming cardioplegia infusion demonstrated. This approach may provide a valuable additional option for managing the complex problem of redo ascending aortic arch surgery.
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References
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Abstract
1. Introduction
