Eur J Cardiothorac Surg 2004;26:863-865
© 2004 Elsevier Science NL
Aortic root replacement after recent intracerebral hemorrhage
Simon Baysa,
Eamon Nicholsonb,
Nigel Humphreysc,
Andrew Parrya,*
a Department of Pediatric Cardiac Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8BJ, UK
b Department of Clinical Perfusion, Bristol Royal Hospital for Children, Bristol, UK
c Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
Received 12 February 2004;
received in revised form 19 June 2004;
accepted 8 July 2004.
* Corresponding author. Tel.: +44-117-342-8854; fax: +44-117-342-8857. (E-mail: andrew.parry{at}ubht.swest.nhs.uk).
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Abstract
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A 12-year-old boy presented with an intracerebral haemorrhage secondary to Staphylococcus aureus endocarditis. He developed worsening aortic regurgitation and required aortic root replacement. In view of his recent haemorrhage, a heparin-bonded cardiopulmonary bypass circuit with low dose systemic heparinisation was used. No further intracerebral bleeding ensued and his neurological condition slowly improved.
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1. Introduction
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Patients who require cardiac surgery soon after an intracerebral bleed pose a difficult problem to cardiac surgeons and perfusionists. While it is generally considered an absolute contraindication to undertake open cardiac surgery at this time, on occasion the surgeon has no choice in a patient with catastrophic haemodynamic compromise. Strategies to minimise anticoagulation and the risk of bleeding are evidently essential in these circumstances. We present a case of a child who required emergency aortic root replacement for endocarditis but who had suffered a major intracerebral haemorrhage secondary to the endocarditis 5 days previously. Surgery was performed using low dose heparinisation and a heparin-bonded bypass circuit.
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2. Case report
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A 12-year-old boy presented with a 2-day history of malaise. On the day of admission, he had awoken confused and over the day developed a dense left hemi-paresis. A CT scan performed at this time showed a large intracerebral bleed (Fig. 1). He was electively intubated and ventilated but his condition deteriorated due to florid sepsis. Staphylococcus aureus was isolated from blood cultures and he was found to have aortic valve endocarditis with moderate regurgitation. There was evidence of increasing intracranial pressure and the intracerebral haematoma was evacuated in order to maintain neurological function and cerebral perfusion. The aortic incompetence rapidly progressed over the next 3 days to free regurgitation and he required escalation of inotropic support to maintain an adequate perfusion pressure. A transoesophageal echocardiogram also demonstrated a large abscess around the aortic root.
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Fig. 1. The initial CT scan demonstrates the right fronto-parietal intracerebral haematoma with significant midline shift.
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Despite the risk of causing further intracerebral bleeding, due to the precarious haemodynamic state of the patient it was considered necessary to operate to stabilise his cardiovascular state. After having a full and frank discussion with his parents cardiac surgery was agreed upon. It was decided to minimise heparinisation and to use a heparin-bonded circuit to minimise the risk of a further intracerebral bleed.
Through a median sternotomy the heart was exposed. One gram of tranexamic acid was given and after administering 100IU/kg of heparin (our normal dosage for paediatric CPB being 300IU/kg), the activated clotting time (ACT) was measured at 230s. A fully heparin-bonded, Carmeda coated bypass circuit (Medtronic Ltd, UK) was used comprising an Affinity oxygenator, BP80 Biomedicus centrifugal pump-head, soft shell venous reservoir, and 1/2in. venous/3/8in. arterial line pack. The circuit was primed using 1000ml Plasmalyte-A (Baxter, UK), 900ml Gelofusine, 150ml 20% mannitol, 1500 units of heparin, and 1g of tranexamic acid. The heart was cannulated using heparin-bonded, Carmeda coated cannulae; a straight wire-wound arterial cannula to the ascending aorta and a two-stage venous cannula was inserted into the right atrial appendage. Cardiopulmonary bypass was commenced with a flow of 2.6l/min/m2 cooling to 28°C with a mean arterial pressure of 65–70mmHg. The left ventricle was vented through the left superior pulmonary vein.
The heart was arrested using cold cardioplegic solution instilled directly into the coronary ostia after opening the aortic root. The valve was inspected. The right coronary cusp had been completely rotted by the infection, except for a large vegetation at its free margin. The infectious process had also destroyed the adjacent sinus, and there was a large abscess cavity in the aortic wall and the left ventricular outflow tract. The valve leaflets and all potentially infected tissue were completely excised leaving a large defect in the outflow tract, which was reconstructed with bovine pericardium. The aortic root was replaced using a 21mm cryopreserved homograft as the degree of edema around the pulmonary root precluded a Ross-procedure. Surgically, the rest of the operation was performed in a standard fashion. During the course of bypass, the heparin was titrated to maintain an ACT of 200–270s.
Following protamine administration, the patient was weaned from bypass on a low dose adrenaline infusion, and the protamine was then given. He was commenced on an Aprotonin infusion (500,000KIU/h) on arrival on the intensive care unit until hourly blood losses were less than 50ml/h, a total of 2h post-surgery. Initial recovery was uneventful. The chest tubes were removed 42h following surgery after total losses of 165ml. He was extubated 5 days after surgery at which time clinically his neurological status was the same as it had been pre-operatively. A repeat CT scan was performed (Fig. 2), which showed no evidence of further intracerebral bleeding. Intravenous antibiotics were continued for 6 weeks, after which time he was transferred to a specialist unit for neurological rehabilitation.
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Fig. 2. The repeat CT scan following evacuation of the haematoma and aortic root replacement shows residual oedema with no recurrence of the bleed.
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3. Discussion
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Open cardiac surgery soon after intracerebral bleeding is a prospect few surgeons would relish. There are no clear data determining what constitutes a safe interval following the neurological insult. Recent previous intracranial bleeding has been considered to be an absolute contraindication to bypass [1], yet rarely intervention is essential due to catastrophic haemodynamic decompensation. In these circumstances, as here, strategies to minimise intra and post-operative bleeding are of paramount importance.
It has been shown before that CPB can be used without systemic heparinisation in a similar adult situation [2], and we elected to use a heparin-bonded circuit with low dose heparinisation. This has been previously shown to cause less post-operative bleeding in adults [3,4], though it has been less extensively studied in children. In one series, children of parents who were Jehovah's witnesses successfully underwent cardiac surgery without the need for blood transfusion using a similar strategy [5].
Open cardiac surgery following embolic stroke has been undertaken more frequently. Surgery is recommended early, within 72h of the event [1], to minimise the risk of secondary haemorrhage, and in these circumstances similar precautions to those we have detailed have been taken with successful outcome [1,6].
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References
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- Piper C, Wiemer M, Schulte HD, Horstkotte D. Stroke is not a contraindication for urgent valve replacement in acute infective endocarditis. J Heart Valve Dis 2001;10:703-711.[Medline]
- von Segesser LK, Garcia E, Turina M. Perfusion without systemic heparinization for rewarming in accidental hypothermia. Ann Thorac Surg 1991;52(3):560-561.[Abstract]
- Suehiro S, Shibata T, Sasaki Y, Hattori K, Kumano H, Hosono M, Kinoshita H. Use of heparin-coated cardiopulmonary bypass circuit with low-dose heparin reduces postoperative bleeding. Ann Thorac Cardiovasc Surg 1999;5(4):225-229.[Medline]
- Ovrum E, Tangen G, Oystese R, Ringdal MA, Istad R. Heparin-coated circuits (Duraflo II) with reduced versus full anticoagulation during coronary artery bypass surgery. J Card Surg 2003;18(2):140-146.[CrossRef][Medline]
- Miyaji K, Hannan RL, Ojito JW, White JA, Burke RP. The Ross operation in a Jehovah's Witness: a paradigm for heart surgery in children without transfusion. Ann Thorac Surg 2000;69(3):935-937.[Abstract/Free Full Text]
- Zisbrod Z, Rose DM, Jacobowitz IJ, Kramer M, Acinapura AJ, Cunningham Jr JN. Results of open heart surgery in patients with recent cardiogenic embolic stroke and central nervous system dysfunction. Circulation 1987:V109-V112.
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Abstract
1. Introduction
