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J Thorac Cardiovasc Surg 2007;134:1379
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Vascular obstruction related to mediastinal fibrosis: An interesting clinical entity

Department of Cardiac Surgery, Prince Charles Hospital, Chermside, Queensland, Australia

To the Editor:

We read with interest the article published by Zhang and associates.¹ They have presented an interesting clinical scenario in which tuberculosis caused encasement of the aorta, pulmonary arteries, and coronary arteries owing to mediastinal fibrosis. They treated their patient surgically to relieve the mediastinal vascular occlusion. We would like to share our clinical experience with this rare clinical entity.²

Myocardial ischemia was the presenting symptom in our patient with a background of long-term use of methysergide for migraine. There was prominent involvement of the aorta with thickening of the wall and of the left and right coronary artery ostia. Preoperatively, an accurate diagnosis could not be established. The diffuse fibrotic process was found to involve the ascending aorta and proximal aortic arch intraoperatively. The coronary ostial occlusion was obviously due to the extreme thickening of the ascending aorta. We used circulatory arrest to replace the ascending aorta and performed partial arch replacement with saphenous vein grafting of the left anterior descending and right coronary arteries.

Coronary artery involvement may be in the form of stenosis of the origin of left and right coronary arteries or there may be diffuse involvement of coronary arteries owing to extensive fibrosis of the wall. Overall mediastinal fibrosis is an extremely uncommon indication for coronary artery bypass surgery.^3,4

We agree with the authors that there are two important points to consider in these patients regarding surgical management. Operative intervention is required to relieve the vascular obstruction and to establish the diagnosis. The role of specific medical treatment is evident from the case reported by Zhang and associates.¹ The coronary artery occlusion along with the involvement of other great vessels disappeared with antitubercular treatment on postoperative follow-up.

We congratulate the authors on the successful management of a difficult case and emphasize that surgery should be performed earlier in suspected cases presenting with mediastinal fibrosis with vascular occlusion to treat potentially treatable causes like mycobacterial infection, to discontinue an offending drug, and to establish the diagnosis of malignancy.

References

1. Zhang C, Yao M, Yu Z, Jian L, Jiang X, Ni Y. Rare fibrosing granulomatous mediastinis of tuberculosis with involvement of the transverse sinus. J Thorac Cardiovasc Surg 2007;133:836-837.[Free Full Text]
   
2. Saxena P, Tesar PJ. Mediastinal fibrosis causing myocardial ischemia. Ann Thorac Surg 2005;80:2368-2370.[Abstract/Free Full Text]
   
3. Cochrane A, Warren R, Mullerworth M, Manolas E. Fibrosing mediastinitis with coronary artery involvement. Ann Thorac Surg 1991;51:652-654.[Abstract/Free Full Text]
   
4. Aleksic I, Saldaña F, Busch T, Basenau D, Sîrbu H, Schauer A, et al. Unsuspected idiopathic mediastinal fibrosis complicating coronary bypass operation. Ann Thorac Surg 1999;67:224-225.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pankaj Saxena Peter J. Tesar Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Saxena, P. Articles by Tesar, P. J. Search for Related Content PubMed Articles by Saxena, P. Articles by Tesar, P. J. Related Collections Cardiac - other Coronary disease Related Article