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J Thorac Cardiovasc Surg 1997;114:493-495
© 1997 Mosby, Inc.
BRIEF COMMUNICATIONS |
Seattle, Wash.
Received for publication Sept. 17, 1996; accepted for publication Nov. 19, 1996. Address for reprints: Jeffrey P. Morray, MD, Department of Anesthesia and Critical Care, Children's Hospital and Medical Center, P.O. Box 5371, Seattle, WA 98105.
A case is presented in which suture closure of a secundum atrial septal defect in a 4-year-old child resulted in narrowing of the coronary sinus, which produced acute my cardial failure after discontinuation of cardiopulmonary bypass. The problem was diagnosed by transesophageal echocardiography (TEE) and corrected after a return to cardiopulmonary bypass. Myocardial function improved, and the patient was successfully weaned from bypass. The remainder of the perioperative course was benign, and the patient made a normal recovery from the operation.
Clinical summary.
An otherwise healthy 4
-year-old girl weighing 16.5 kg needed repair of an asymptomatic secundum atrial septal defect and supravalvular pulmonic stenosis. Induction of anesthesia, intubation of the trachea, and placement of arterial and central venous catheters were uneventful. Transesophageal echocardiography was performed with a Siemens SI-1200 ultrasound system (Siemens Corp., Union, N.J.) with a 5 mHz biplane TEE probe, which was inserted without difficulty. The atrial septal defect was unusual in that the superior aspect of the defect was at the level of a secundum defect, but the eustachian valve was inserted on the inferior aspect of the defect, posteriorly, near the coronary sinus (Fig. 1). Ventricular contractility appeared normal. After incision and sternotomy, heparin was administered, and arterial and venous bypass cannulas were placed without difficulty. Cardiopulmonary bypass was initiated at full calculated flows, and the patient was cooled to 28° C (esophageal temperature). Pulmonary valvotomy through a pulmonary arteriotomy and suture closure of the atrial septal defect through an atriotomy were performed after aortic cross-clamping and administration of cardioplegic solution. During bypass, mean arterial pressure was 45 to 55 mm Hg and central venous pressure was 13 to 15 mm Hg. After a cardiopulmonary bypass time of 60 minutes and an aortic crossclamp time of 14 minutes, cardiopulmonary bypass was discontinued at an esophageal temperature of 36° C and a rectal temperature of 34.5° C. Shortly after discontinuation of bypass, analysis of an arterial blood sample revealed oxygen tension, carbon dioxide tension, pH, and ionized calcium all within the normal range. The hematocrit value was 19 mg/dl. Arterial blood pressure declined from 90/50 to 50/30 mm Hg, central venous pressure increased from 14 to 19 mm Hg, and sinus rhythm deteriorated into sinus bradycardia with T-wave depression. The heart appeared to be contracting poorly. An infusion of epinephrine was started at a rate of 0.1 µg/kg per minute without improvement in blood pressure or heart rate.
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This is the first report of iatrogenic narrowing of the coronary sinus diagnosed though the use of TEE, without which the need to return to bypass for immediate relief of the obstruction may not have been considered or would have been delayed.
A variety of other causes of low output state were considered and ruled out. It was not until the dilated coronary sinus was seen that the true diagnosis was considered and then corrected. Coronary sinus narrowing probably produced myocardial failure by elevating coronary venous pressure, thereby reducing net coronary perfusion pressure. Although congenital coronary sinus atresia is compatible with life because of the development of collateral drainage,
1 collateral channels probably could not provide adequate decompression in the setting of acute coronary sinus occlusion.
In recent years, intraoperative TEE has become increasingly popular in the evaluation of repair of congenital heart defects. TEE can identify residual defects that otherwise would have been undetected 2-4 In several large series, 7% to 12% of patients had immediate successful revision of their procedure in the same operative setting based on TEE evaluation after the initial repair. 2,3 Like wise, 15% to 25% of patients have alteration of ventricular function immediately after bypass, some with a definable and treatable cause. 3 However, none of the studies on the utility of TEE for intraoperative evaluation of repair of congenital heart defects lists coronary sinus occlusion as a cause of post bypass ventricular dysfunction.
In summary, we report a case of iatrogenic coronary artery stenosis during repair of an atrial septal defect in a child in which TEE was instrumental in making the diagnosis and in confirming correction. TEE contributed to a favorable outcome in the surgical management of this most straightforward of congenital heart lesions.
Footnotes
From the Department of Anesthesia and Critical Care,a Division of Cardiology, Surgery, Department of Pediatrics,b Division of Cardiac Surgery, Department of Surgery,c Department of Anesthesia and Critical Care,d Children's Hospital and Medical Center, and University of Washington School of Medicine, Seattle, Wash. 
References
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