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J Thorac Cardiovasc Surg 1996;112:1406-1407
© 1996 Mosby, Inc.
LETTERS TO THE EDITOR |
Wessex Cardiac Centre
Southampton General Hospital
Southampton, Hants, United Kingdom
To the Editor:
In 1992 in this Journal we
1 reported on an operative technique used in two patients with complex coronary artery anatomy undergoing the arterial switch procedure. The operation involved the construction of an aortopulmonary fenestration with a bovine pericardial tunnel to allow perfusion of the coronary arteries from the neoaorta. We report a late death after coronary occlusion in a subsequent child in whom this procedure was undertaken.
The patient was a female infant who was born with cyanosis, tachypnea, and a systolic murmur. Echocardiography revealed double-outlet right ventricle with transposition of the great arteries and a subpulmonary ventricular septal defect. She underwent cardiac catheterization and a balloon atrial septostomy at 3 days of age. The coronary arteries arose from a single origin. Congestive cardiac failure developed as a result of excessive pulmonary blood flow, and she underwent pulmonary artery banding at 29 days old. A pericardial effusion then developed, which was drained when she was 40 days of age.
Symptoms of congestive cardiac failure continued, and anatomic correction was planned. However, after median sternotomy, asystole occurred after broad complex brady-cardia and necessitated 4 minutes of internal cardiac massage. Therefore full correction was not attempted at this time and the pulmonary artery band was tightened.
Anatomic correction was performed at 15 months of age, involving an arterial switch, closure of the ventricular septal defect, and pulmonary artery reconstruction. The coronary arteries arose from the left posterior facing sinus via three ostia, as in case 2 of the original report. The right and circumflex arteries arose from the middle of the sinus and the left anterior descending artery arose eccentrically adjacent to the commissure between the left posterior and right posterior facing sinuses. She initially was easily weaned from bypass, but then the cardiac output dropped suddenly, necessitating a further short period of bypass as the heart was stunned. This was attributed to an air embolus in a coronary artery.
The initial postoperative period was uneventful. She received epinephrine at a maximum dose of 0.08 µg/kg per minute for 19 hours and dobutamine at a maximum dose of 7 µg/kg per minute for 44 hours. She had no episodes of hypotension or bradycardia, and echocardiography showed good function of the left ventricular posterior wall and apex. She was extubated 19 hours after the operation and was discharged from the hospital 9 days after the operation.
Four months after the operation she became nonspecifically unwell at home over a 48-hour period. She had a cardiac arrest and resuscitation was unsuccessful.
Postmortem examination revealed some evidence of viral infection with mild generalized lymphadenopathy. Examination of the heart revealed large amounts of fibrous adhesions on the epicardial surface of the heart, especially at the base. The lumen of the aortopulmonary tunnel was almost totally occluded by white old organized thrombus extending to the coronary ostia and through the full length of the baffle into the lumen of the aorta. The myocardium of the left ventricle showed a subendocardial layer of pallor that may have represented old fibrosis.
This patient died of sudden cardiac arrest, probably after 2 days of cardiac ischemia, because of obstruction of the pericardial tunnel. We believe that the viral infection is coincidental. The autopsy showed the obstruction to be due to old thrombus, despite the fact that she had been well since the operation, with no evidence of ischemia clinically and no abnormalities on a resting electrocardiogram 4 weeks before she died. We speculate that the old subendocardial fibrosis was due to the episode of cardiac arrest and cardiac massage when the pulmonary artery band was tightened. It is unclear when the baffle thrombosis occurred, and the episode of loss of output when she was being weaned from bypass must be suspected. However, this theory is not supported by the uncomplicated postoperative course, the evidence of good biventricular function on echocardiography, and the lack of ischemic changes on the postoperative electrocardiogram.
In view of this case we must recommend close postoperative follow-up and early angiography after this procedure to investigate baffle patency, even in the absence of any evidence of ischemia. Reassuringly, the two patients reported on originally are doing well. They have had cardiac catheterizations 25 and 28 months postoperatively that have confirmed baffle patency (Fig. 1).
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This article has been cited by other articles:
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  M. Yamagishi, K. Shuntoh, K. Fujiwara, T. Shinkawa, T. Miyazaki, and N. Kitamura "Bay window" technique for the arterial switch operation of the transposition of the great arteries with complex coronary arteries Ann. Thorac. Surg., June 1, 2003; 75(6): 1769 - 1773. [Abstract] [Full Text] [PDF]
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 A. J. Parry, M. Thurm, and F. L. Hanley The use of 'pericardial hoods' for maintaining exact coronary artery geometry in the arterial switch operation with complex coronary anatomy Eur J Cardiothorac Surg, February 1, 1999; 15(2): 159 - 165. [Abstract] [Full Text] [PDF]
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