Eur J Cardiothorac Surg 2006;29:1061-1063
© 2006 Elsevier Science NL
Hemiarch replacement during pregnancy (19 weeks) utilizing normothermic selective cerebral perfusion
Hitoshi Matsuda
a
,
*
,
Hitoshi Ogino
a
,
Reiko Neki
b
,
Soichiro Kitamura
a
a Department of Cardio-Vascular Surgery, National CardioVascular Center, Suita, Osaka, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
b Department of Obstetrics, National CardioVascular Center, Suita, Osaka, Japan
Received 12 November 2005;
received in revised form 2 March 2006;
accepted 13 March 2006.
* Corresponding author. Tel.: +81 6 6833 5012; fax: +81 6 6872 7486. (Email: hitmat{at}hsp.ncvc.go.jp).
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Abstract
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A 20-year-old woman with Marfan syndrome in the 19 weeks of pregnancy was admitted for a dissecting aneurysm of the ascending aorta to the proximal arch. She wanted to continue with pregnancy. A cardiotocography and a trans-esophageal echo probe which allowed visualization of the fetal heart contraction were attached on the abdomen. A cardio-pulmonary bypass was established via the right axillar and femoral arteries with bicaval drainage. The aortic isthmus and arch branches were clamped. After opening the ascending aorta, selective cerebral perfusion was initiated by quick cannulation into the left carotid and left subclavian arteries. Peripheral pressure was maintained above 80 mmHg with the flow of the selective cerebral perfusion at 1.0 L/min and flow from the femoral artery at 3.5 L/min. Hemi-arch replacement was performed using a Dacron graft. The body temperature passively descended to 35 °C. She normally delivered a healthy female baby after 37 weeks’ of gestation.
Key Words: Dissecting aortic aneurysm • Pregnancy • Cerebral perfusion
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1. Introduction
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An acute aortic pathology occurring during pregnancy, such as aortic dissection or aortic trauma, is usually treated after normal delivery or Caesarian section. However, if the gestational period is insufficient, it is difficult to save the fetus. We report a case of successful aortic replacement utilizing normothermic cerebral perfusion in a patient in the 19th week of pregnancy.
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2. Case report
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A 20-year-old woman in the 19th week of pregnancy was referred for a dissecting aortic aneurysm of the ascending aorta to the proximal arch which was 78 mm in diameter (Fig. 1
) and was associated with mild aortic regurgitation. The patient had been diagnosed with Marfan syndrome and had developed back pain 11 months before, which was treated with the analgesics. Urgent operation was indicated, however, she wanted to continue with the pregnancy. The maternal and fetal risks of aortic replacement and the potential need to induce an abortion after fetal death were explained to the patient and her closest family members and their informed consent was obtained.
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Fig. 1. Preoperative 3D-CT. Enlarged ascending aorta is visualized on 3D-CT. In lower abdomen, placenta and fetal skelton are also seen.
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For the double fetal monitor, a flat cardiotocography and a flexible trans-esophageal echo probe were attached on the left lower abdomen. The latter allowed the continuous visualization of the fetal heart contraction all through the surgery. After muscle relaxation, these monitors were stabilized and did not interfere with the operative field.
A cardio-pulmonary bypass (CPB) was established via the right axillar (RAxA) and femoral arteries (RFA) with bicaval drainage, through a median sternotomy. The left recurrent nerve was carefully released and the aortic isthmus was clamped. The brachiocephalic (BCA), left common carotid (LCCA), and left subclavian (LSCA) arteries, and the left vertebral artery which branched out from the aortic arch were clamped. At the longitudinal incision of the ascending aorta, the entry was detected in the middle of the ascending aorta. The aortic dissection extended proximally to the sino-tubular junction and distally to the orifice of BCA. Two balloon catheters were inserted into the LCCA and LSCA and selective cerebral perfusion (SCP) was promptly initiated. Peripheral pressure was monitored at the right temporal, left radial, and left dorsal pedis arteries and was maintained above 80 mmHg. The total flow of SCP was 1.0 L/min and flow from the RFA was 3.5 L/min (BSA: 1.29 m2).
The aortic arch was divided obliquely from the origin of the BCA at the major curvature to the opposite side of the LSCA at the minor curvature. A knitted Dacron graft (22 mm x 10 mm, Intergard, InterVascular, France) was anastomosed and reinforced with Teflon felt strip. During the antegrade perfusion (3.9 L/min) from the branch of the graft, the graft was proximally anastomosed just above the sino-tubular junction. The duration of SCP and CPB was 32 and 137 min. The pharyngeal temperature passively descended to 35 °C. Myocardial protection was achieved by the intermittent infusion of a cold blood cardioplegic solution via the retrograde cannulation. The hemoglobin was maintained at 9.6–9.9 mg/dl, and pH was controlled at 7.34–7.48 during CPB. The potassium level increased to 5.71 mEq/L, but the fetal heart beat was maintained at around 120 beats/min and observed throughout the procedures. No uterine contraction occurred. Bleeding was noted at the aortic isthmus and managed with a mattress suture. Her postoperative course was uneventful. She normally delivered a healthy female baby at 37 weeks’ gestation.
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3. Discussion
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In case of acute aortic dissection during pregnancy, aortic surgery has been usually indicated after normal delivery or Cesarean section, because dissection usually occurs during the last weeks of pregnancy [1]. However, if dissection occurs before the 26th week of pregnancy, fetal death is highly feared. Successful cases are rarely reported; Buffolo et al. [2] reported a case of successful repair of an arch aneurysm under circulatory arrest at 19 °C in a woman in the 21st week of gestation.
According to the establishment of operative maneuvers and organs protection, we basically employ antegrade SCP with lower body circulatory arrest at 28 °C for the replacement of the aortic arch [3]. However, in a pregnant patient, the hypothermic circulatory arrest would have affected the fetus and induced uterine contractions during the rewarming phase [4]. In this regard, pulsatile perfusion is thought to reduce uterine contractions, and moderate perfusion with continuous full flow perfusion has been recommended in patients with Marfan syndrome [1,5]. Touati et al. [6] reported that replacement of the aortic arch under normothermia preserved autoregulation of cerebral blood flow and maintained body perfusion without high vascular resistance. Normothemia is considered to be more advantageous for a pregnant patient.
We emphasize the advantages of SCP utilizing the cannulation of RAxA and a higher CPB flow in the aortic arch surgery under normothermia. When RAxA is cannulated, cerebral perfusion will never be interrupted provided the cerebral (Willis) arterial circle is patent and complete cerebral perfusion can be initiated after prompt cannulation into of the LCCA and LSCA. The higher CPB flow will maintain the maternal arterial pressure at the desired level for fetal oxygenation [4].
To our knowledge, this is the first report of a successful hemiarch replacement carried out during pregnancy utilizing normothermic cerebral perfusion.
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Acknowledgments
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We much appreciate Dr Yoshihiko Onishi, Department of Anesthesiology, and Dr Masahiro Higashi, Department of Radiology, for their sincere contribution for this surgery.
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References
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- Sakaguchi M, Kitahara H, Seto T, Furusawa T, Fukui D, Yanagiya N, Nishimura K, Amano J. Surgery for acute type A aortic dissection in pregnant patients with Marfan syndrome. Eur J Cardiothorac Surg 2005;28:280-283[discussion 283–5].[Abstract/Free Full Text]
- Buffolo E, Palma JH, Gomes WJ, Vega H, Born D, Moron AF, Carvalho AC. Successful use of deep hypothermic circulatory arrest in pregnancy. Ann Thorac Surg 1994;58:1532-1534.[Abstract]
- Minatoya K, Ogino H, Matsuda H, Sasaki H, Yagihara T, Kitamura S. Surgical management of distal arch aneurysm: another approach with improved results. Ann Thorac Surg 2006;81:1353-1356.[Abstract/Free Full Text]
- Pomini F, Mercogliano D, Cavalletti C, Caruso A, Pomini P. Cardiopulmonary bypass in pregnancy. Ann Thorac Surg 1996;61:259-268.[Abstract/Free Full Text]
- Jahangiri M, Clark J. Surgery for type A aortic dissection in pregnant patients with Marfan syndrome. Eur J Cardiothorac Surg. 2006;29:264-265.[Free Full Text]
- Touati GD, Roux N, Carmi D, Degandt A, Benamar A, Marticho P, Nzomvuama A, Poulain HJ. Totally normothermic aortic arch replacement without circulatory arrest. Ann Thorac Surg. 2003;76:2115-2117.[Abstract/Free Full Text]
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Abstract
1. Introduction
