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J Thorac Cardiovasc Surg 1994;107:640-0641
© 1994 Mosby, Inc.

Letters to the Editor

Ascending aortic aneurysm eroding the chest wall: Repair avoiding a median sternotomy

K. R. Balakrishnan, MS, MCh, Adarsh Koppula, MS, MCh

Department of Cardiac Surgery
Railway Hospital, Perambur
Madras, India

To the Editor:

Median sternotomy is the standard approach for most heart operations.Go 1 Aneurysms of the ascending aorta and aortic arch are now operated on with good results.Go 2 However, especially in developing countries, we continue to see aortic aneurysms so late that they are eroding through the anterior chest wall and are about to rupture (Fig. 1). The major problem in tackling such aneurysms is that median sternotomy is impossible without entering and rupturing the aneurysm. Cardiopulmonary bypass therefore is established by peripheral cannulation and the chest must be opened after the patient is cooled to 18° C and the circulation is stopped. The repair is then done in the usual manner. The problem with this approach in our hands has been that closure of the sternum is extremely difficult because the entire upper sternum has been destroyed by the aneurysm. Most patients therefore have mediastinitis. To overcome this problem, we decided to avoid the median sternotomy incision.



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  		Fig. 1. Erosion of aortic aneurysm through chest wall.

 
A 28-year-old man came to us with an aneurysm eroding through the anterior chest wall as a result of syphilitic aortitis. The innominate artery was not involved and there was no aortic leak. The approach was through a bilateral transverse thoracotomy through the fifth intercostal space, cutting across the sternum. Bypass was established with femoral arterial and right atrial cannulation. The left side of the heart was vented through the right superior pulmonary vein. With the patient at a rectal temperature of 18° C, the circulation was stopped and the aorta, which was easily accessible, was opened. The ascending aorta was replaced with a preclotted, woven graft. The circulation was stopped for 10 minutes to do the distal anastomosis only. The patient was extubated the next morning and discharged on the seventh day. The defect in the upper sternum was left untouched. At 3 months of follow-up, that area had healed nicely and was indistinguishable from the rest of the sternum. There seem to be significant advantages with this approach as compared with median sternotomy in dealing with this difficult situation.

First, incision through the destroyed sternum is avoided, with consequent better healing. Second, with a median sternotomy, the chest can be opened only under circulatory arrest after cooling the patient. This means that venous drainage has to be established with the femoral or jugular vein. With the groin approach, drainage is often problematic. Many of these aneurysms are already obstructing jugular venous drainage, making such drainage impossible. Also, if there is aortic leakage, as is extremely common, this could be a dangerous situation because there is no way to vent the heart percutaneously and avoid left ventricular distention without opening the chest. With this transsternal approach, however, bypass can be established with a regular right atrial cannula. The left side of the heart is easily vented and the aorta can even be clamped when gross aortic leakage is present.

References

  1. Crawford FA, Kratz JM. Thoracic incisions. In: Sabiston DC Jr, Spencer FC, eds. Gibbon's surgery of the chest, vol 1. 4th ed. Philadelphia: WB Saunders, 1983:143-54.
  2. Cooley DA. Ascending aorta and sinuses of Valsalva. In: Cooley DA. Surgical treatment of aortic aneurysms. Philadelphia: WB Saunders, 1986:17-34.



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 Ann. Thorac. Surg.Home page
R. Lorusso, G. Coletti, P. Totaro, R. Maroldi, and M. Zogno
Treatment of giant aortic aneurysm with tracheal compression and sternal erosion without circulatory arrest
Ann. Thorac. Surg., January 1, 2000; 69(1): 275 - 278.
[Abstract] [Full Text] [PDF]

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