Secondary Logo

Journal Logo

Left Ventricular Apex Venting in High-Risk Redo Sternotomy With Severe Aortic Insufficiency

A Case Report

Wakefield, Brett J. MD*; Leone, Alexander J. MD*; Sale, Shiva MD

doi: 10.1213/XAA.0000000000000623
Case Reports: Case Report
Free
SDC

Redo cardiac surgery in patients with severe aortic insufficiency can present unique challenges to the anesthesiologist. We report a case highlighting the challenge and importance of interdisciplinary planning between cardiothoracic surgeons and anesthesiologists prior to high-risk surgery. Failure to place an endoaortic balloon and percutaneous coronary sinus catheter due to anatomical abnormalities prompted the adoption of an alternate technique involving apical ventricular venting to assist sternal reentry. Apical left ventricular venting was successfully used to prevent ventricular dilation and dysfunction during institution of cardiopulmonary bypass with significant aortic regurgitation and hypothermia-induced ventricular fibrillation.

From the Departments of *Anesthesiology and Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, Ohio.

Accepted for publication July 12, 2017.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Brett J. Wakefield, MD, Department of Anesthesiology, Cleveland Clinic, 9500 Euclid Ave, E30-R, Cleveland, OH 44195. Address e-mail to wakefib@ccf.org.

Redo sternotomy presents unique challenges to the anesthesiologist. The proximity of the aortic or cardiac structures to the sternum can mandate institution of cardiopulmonary bypass before sternotomy. It is important for cardiac anesthesiologists to develop a plan with the cardiac surgeons prior to these difficult cases. We present such a case of a fourth-time reoperation complicated by severe aortic insufficiency (AI) and a graft attached to the retrosternum requiring closed chest cardiopulmonary bypass (CPB) and alternative left ventricular venting. Written informed consent was obtained for publication of this case report.

Back to Top | Article Outline

CASE DESCRIPTION

A 44-year-old morbidly obese male, body mass index 40 kg/m2, with atrial fibrillation and severe AI presented to the operating room for a fourth-time redo sternotomy with aortic valve and root replacement and aortic hemiarch repair. Bicuspid aortic valve was diagnosed at the age of 4 years. He subsequently underwent an aortic valvuloplasty at the age of 12 years, aortic valve repair and ascending aortic replacement at the age of 19 years, and aortic arch repair at the age of 25 years. In the preceding year, he had experienced worsening shortness of breath, wheezing, dizziness, fatigue, palpitations, and chest pain with exertion. Transthoracic echocardiography demonstrated severe aortic regurgitation with significant holodiastolic flow reversal in the proximal descending aorta with normal left ventricular systolic function. Computed tomography (CT) revealed a dilated 5.6-cm aortic root and an ascending graft adhered to the posterior table of the sternum (Figure 1). The preoperative surgical plan included sternotomy under low-flow CPB with right axillary cannulation and moderate systemic hypothermia in addition to an endoaortic balloon clamp and cardioplegia delivered via percutaneous coronary sinus catheter in anticipation of high-risk sternal reentry caused by the immediate proximity of the ascending aortic graft and the manubrium.

Figure 1

Figure 1

On arrival at the operating room, a left brachial arterial line was placed and anesthesia and muscle relaxation were induced. Following endotracheal intubation, a transesophageal echocardiography (TEE) probe was placed confirming a previously repaired bicuspid aortic valve with moderate to severe stenosis and severe eccentric aortic valvular regurgitation. Considering the patient’s severe AI in addition to the anatomic uncertainty brought on by the 3 previous aortic procedures, the anesthesia team discussed alternative strategies for safe conduct of the surgery with the surgical team. As a result of the discussion, the cardiac apex was mapped out with transthoracic echocardiography on the operating room table before incision in case apex access was warranted for left ventricular venting (Supplemental Digital Content 1, Figure 1, http://links.lww.com/AACR/A124).

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

Figure 5

Figure 5

The patient’s altered anatomy precluded placement of the 9F percutaneous coronary sinus catheter (ProPlege; Edwards Lifesciences, Irvine, CA) (Supplemental Digital Contents 2 and 3, Figure 2, http://links.lww.com/AACR/A125, Video 1, http://links.lww.com/AACR/A126). CPB was established without difficulty after right axillary artery and right femoral venous cannulation. Attempts to pass a 10.5F intra-aortic occlusion device (IntraClude; Edwards Lifesciences, Irvine, CA) into the ascending aorta failed secondary to kinking of the ascending aortic graft (Figure 2; Supplemental Digital Contents 4–6, Figure 3, http://links.lww.com/AACR/A128, Videos 2 and 3, http://links.lww.com/AACR/A127, http://links.lww.com/AACR/A129). Due to failure of the original management plan and the high risk of hypothermia-induced ventricular arrhythmias impairing myocardial preservation and causing pulmonary edema secondary to ventricular distention in the setting of moderate to severe aortic regurgitation, the cardiac apex was exposed via left thoracotomy. Following 20 minutes of cooling, ventricular fibrillation ensued, and a 13F left ventricular DLP vent (Medtronic Inc, Minneapolis, MN) was placed through the cardiac apex as a left ventricular vent to decompress the left ventricle (Figures 3 and 4). The surgeon proceeded with sternotomy under low systemic flow (Supplemental Digital Content 7, Figure 4, http://links.lww.com/AACR/A130). As expected, the graft was attached to the manubrium, and the aorta was entered. Following the disruption of the aortic graft, a 10F balloon catheter (Coda; Cook Medical Inc, Bloomington, IN) was placed in the distal ascending aortic graft under TEE guidance (Figure 5; Supplemental Digital Content 8, Figure 5, http://links.lww.com/AACR/A131) to allow cardiac isolation. Right axillary pump line pressures indicated no occlusion of the innominate artery. Antegrade ostial cardioplegia was delivered by direct ostial feeders, and the heart was arrested. A successful aortic root and hemiarch replacement with a 27-mm On-X mechanical valve (On-X Life Technologies, Inc, Austin, TX) with CPB and 15 minutes of deep hypothermic circulatory arrest proceeded. Postoperative TEE showed a well-seated prosthetic aortic valve with trivial aortic regurgitation. Following the procedure, the patient was taken intubated to the intensive care unit with norepinephrine, epinephrine, and vasopressin infusions. He was extubated on postoperative day 2 and discharged after a 10-day hospital stay. Six months postoperatively the patient’s aortic graft was stable with no signs or symptoms of heart failure.

Back to Top | Article Outline

DISCUSSION

Sternal reentry in a patient with multiple previous aortic surgeries and severe AI presents unique challenges to the surgical and anesthetic teams. Redo operations can be complicated by increased arrhythmias, bleeding, ischemia, and injury to structures directly adjacent to the sternum. Roselli et al1 demonstrated a 7% rate of intraoperative adverse events in patients undergoing resternotomy. Aside from bypass grafts, the most commonly injured structures were the right atrium (12%) and the aorta (13%). Of these events, 23% occurred upon resternotomy, and the majority (39%) took place during prepump dissection. In addition to the increased risk of intraoperative events, mortality following redo aortic procedures is between 11.5% and 13.8%.2 Considering these risks, planning is of paramount importance.

Safe practices for redo sternotomy have been established including preoperative CT scans and institution of peripheral CPB.3,4 Preoperative CT scans can assess the possibility of sternotomy-related complications, particularly bleeding.4 Typically, CPB with peripheral cannulation can be accomplished before sternotomy via femoral or axillary access. However, in the case of a severely regurgitant aortic valve, the regurgitant fraction increases due to the increased afterload of CPB and can result in ventricular distention if ventricular ejection is compromised by decreased contractility or arrhythmia. This increased left ventricular volume does not pose a risk to the patient in the setting of a perfusing rhythm and normal cardiac contractility. The increased left ventricular distension during fibrillation, however, could lead to increased oxygen requirements, subendocardial ischemia, decreased recovery of ventricular performance in the post-CPB period, and pulmonary edema.5,6

The original plan called for peripheral CPB cannulation with endoaortic balloon clamp occlusion for isolation of the heart and retrograde cardioplegia delivered via a percutaneous coronary sinus catheter. This plan would have allowed closed chest cardioplegic cardiac arrest facilitating sternal opening with the adherent proximal aortic graft. The endoaortic balloon clamp would have prevented ventricular distension. This device (IntraClude) is a triple lumen catheter deployed through the femoral artery (Figure 6). One lumen is used to inflate the balloon, while the other 2 lumens are used to deliver antegrade cardioplegia and vent the aortic root. Bentala et al7 reported the failure of endoaortic balloon clamping in 6% of minimally invasive mitral valve procedures. In this case, a kink in the aortic graft prevented successful placement. A coronary sinus catheter can be inserted via the right internal jugular vein with TEE guidance and fluoroscopic confirmation.8 Success rates are between 87.5% and 89.1%.8,9 However, as in this case, anatomic reasons, such as acute angulation, may make cannulation difficult or impossible.

Figure 6

Figure 6

Due to concerns regarding altered anatomy, the anesthesiology and surgical teams discussed alternative strategies before induction. The decision was made to map out the left ventricular apex with transthoracic echocardiography prior to the incision in case the original plan failed. Transapical left ventricular venting via lateral thoracotomy has previously been described in surgical literature.6,10 However, left ventricular venting is not without risks. There are reports of left ventricular false aneurysm formation, left ventricular ischemia, and mural thrombus formation resulting in stroke.11,12 The strategy implemented in this patient likely contributed to the lack of subendocardial ischemia and pulmonary edema caused by left ventricular distention secondary to fibrillation prior to cardiac arrest, thereby allowing improved myocardial preservation.

In this case with severe aortic regurgitation, an alternative left ventricular venting plan proved critical in the setting of failed endoaortic balloon clamp and coronary sinus catheter placement. Left ventricular venting is required in cases of severe AI during closed-chest CPB due to concern for left ventricular dilation and pulmonary venous congestion. This strategy of apical venting is an important option in the cardiothoracic anesthesiologist’s armamentarium when presented with challenging redo aortic operations in the setting of significant AI.

Back to Top | Article Outline

DISCLOSURES

Name: Brett J. Wakefield, MD.

Contribution: This author helped complete the manuscript.

Name: Alexander J. Leone, MD.

Contribution: This author helped complete the manuscript.

Name: Shiva Sale, MD.

Contribution: This author helped complete the manuscript.

This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.

Back to Top | Article Outline

REFERENCES

1. Roselli EE, Pettersson GB, Blackstone EHAdverse events during reoperative cardiac surgery: frequency, characterization, and rescue. J Thorac Cardiovasc Surg. 2008;135:316–323, 323.e1.
2. Keeling WB, Leshnower BG, Thourani VH, Kilgo PS, Chen EPOutcomes following redo sternotomy for aortic surgery. Interact Cardiovasc Thorac Surg. 2012;15:63–68.
3. Maselli D, Santise G, Montalto A, Musumeci FEndovascular aortic clamping for pseudoaneurysms of the aortic root with aortic regurgitation. Ann Thorac Surg. 2005;80:1303–1308.
4. Morishita K, Kawaharada N, Fukada J, et alThree or more median sternotomies for patients with valve disease: role of computed tomography. Ann Thorac Surg. 2003;75:1476–1480.
5. Lucas SK, Gardner TJ, Elmer EB, Flaherty JT, Bulkley BH, Gott VLComparison of the effects of left ventricular distention during cardioplegic-induced ischemic arrest and ventricular fibrillation. Circulation. 1980;62:I42–I49.
6. Tempe DK, Khanna SK, Banerjee AImportance of venting the left ventricle in aortic valve surgery. Indian Heart J. 1999;51:532–536.
7. Bentala M, Heuts S, Vos RComparing the endo-aortic balloon and the external aortic clamp in minimally invasive mitral valve surgery. Interact Cardiovasc Thorac Surg. 2015;21:359–365.
8. Lebon JS, Couture P, Rochon AGThe endovascular coronary sinus catheter in minimally invasive mitral and tricuspid valve surgery: a case series. J Cardiothorac Vasc Anesth. 2010;24:746–751.
9. Hanada S, Sakamoto H, Swerczek M, Ueda KInitial experience with percutaneous coronary sinus catheter placement in minimally invasive cardiac surgery in an academic center. BMC Anesthesiol. 2016;16:33.
10. Ito K, Yaku H, Shimada Y, Kawata M, Kitamura NLeft ventricular apex venting during deep hypothermia in a case of difficult re-entry into the mediastinum. J Cardiovasc Surg (Torino). 2001;42:493–494.
11. Murphy DA, Krause VWFatal cerebral embolus—a complication of left ventricular venting. Can J Surg. 1976;19:228–230.
12. Bizzarri F, Rose D, Frati G, Muzzi LLeft ventricular postoperative false aneurysm following apical venting. J Cardiothorac Surg. 2006;1:41.

Supplemental Digital Content

Back to Top | Article Outline
© 2018 International Anesthesia Research Society