초록접수 현황
| 15F-264 | 포스터 발표 |
Aorto-mediastinal Fistula after Aortic and Mitral Valve Replacement
조상호¹, 김대현¹, 박주철¹, 윤효철², 김수철², 김범식², 곽영태¹
Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Gangdong-gu, Republic of Korea¹, Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea²
Background : Aorto-mediastinal fistula following surgical procedures of the aorta is rare complication with potentially fatal results that require rapid diagnosis and urgent surgical treatment. We report here a case of aorto-mediastinal fistula of the ascending aorta in a 60-year-old woman after aortic and mitral valve replacement.
Methods : A 60-year-old woman underwent aortic and mitral valve replacement for rheumatic valve disease. 2 weeks after operation, she suddenly developed a transient loss of consciousness and became lethargic. She immediately recovered well by volume administration. Her chest X-ray showed enlargement of the heart and the superior mediastinum. Enhanced computed tomography (CT) of the chest disclosed hemopericardium and a 60×35 mm enhanced retrosternal mass adjacent to the ascending aorta. Color Doppler echocardiography revealed a fistula between the aortic lumen and retrosternal mass (pseudoaneurysm with high flow velocity inside).
Results : The patient was taken to the operating room. Before sternotomy, cardiopulmonary bypass (CPB) was instituted by means of axillary and femoral artery perfusion and femoral venous drainage. When the body's temperature falls below 32 °C, the chest was opened through the previous scar. Immediately after the sternotomy, the rupture of pseudoaneurysm and massive bleeding occurred. In order to avoid exsanguination and to enable the lysis of mediastinal adhesion for the better surgical view, perfusion pressure and flow were stopped almost completely for 6 minutes. Intermittent axillary arterial perfusion for the support of cerebral circulation was performed during circulatory arrest. Afterwards, full-flow CPB was resumed by placing a cross-clamp on the distal ascending aorta just below the brachiocephalic artery. Retrosternal false aneurysm was encapsulated hematoma in communication with the aortic lumen. The fistula was seen to arise from the suture line of aortotomy for aortic valve replacement. Because the fistula was very friable and near to the right coronary ostium, resection and graft replacement of the ascending aorta was performed using a 24 mm woven Dacron tube graft. The patient’s postoperative course was uneventful, and she was discharged from the hospital on postoperative day 20. She was followed up at an outpatient clinic for 12 months.
Conclusion : After surgeries of the heart or aorta, mediastinal pseudoaneurysm and aorto-mediastinal fistula are very rare complications with a high degree of mortality. They usually occur on graft suture lines, aortotomy site, and cannulation sites. Graft infection or mediastinitis, Marfan syndrome, previous acute aortic dissection, trauma, chronic hypertension, and aorta calcifications have been defined as predisposing factors. As in other aortic aneurysms, they may cause life threatening complications such as rupture, compression of adjacent organs, thrombosis, and embolism, So, prompt investigation, and consideration of early surgical intervention are essential. We describe a case of the patient with aorto-mediastinal fistula of the ascending aorta on aortotomy after aortic and mitral valve replacement.
Methods : A 60-year-old woman underwent aortic and mitral valve replacement for rheumatic valve disease. 2 weeks after operation, she suddenly developed a transient loss of consciousness and became lethargic. She immediately recovered well by volume administration. Her chest X-ray showed enlargement of the heart and the superior mediastinum. Enhanced computed tomography (CT) of the chest disclosed hemopericardium and a 60×35 mm enhanced retrosternal mass adjacent to the ascending aorta. Color Doppler echocardiography revealed a fistula between the aortic lumen and retrosternal mass (pseudoaneurysm with high flow velocity inside).
Results : The patient was taken to the operating room. Before sternotomy, cardiopulmonary bypass (CPB) was instituted by means of axillary and femoral artery perfusion and femoral venous drainage. When the body's temperature falls below 32 °C, the chest was opened through the previous scar. Immediately after the sternotomy, the rupture of pseudoaneurysm and massive bleeding occurred. In order to avoid exsanguination and to enable the lysis of mediastinal adhesion for the better surgical view, perfusion pressure and flow were stopped almost completely for 6 minutes. Intermittent axillary arterial perfusion for the support of cerebral circulation was performed during circulatory arrest. Afterwards, full-flow CPB was resumed by placing a cross-clamp on the distal ascending aorta just below the brachiocephalic artery. Retrosternal false aneurysm was encapsulated hematoma in communication with the aortic lumen. The fistula was seen to arise from the suture line of aortotomy for aortic valve replacement. Because the fistula was very friable and near to the right coronary ostium, resection and graft replacement of the ascending aorta was performed using a 24 mm woven Dacron tube graft. The patient’s postoperative course was uneventful, and she was discharged from the hospital on postoperative day 20. She was followed up at an outpatient clinic for 12 months.
Conclusion : After surgeries of the heart or aorta, mediastinal pseudoaneurysm and aorto-mediastinal fistula are very rare complications with a high degree of mortality. They usually occur on graft suture lines, aortotomy site, and cannulation sites. Graft infection or mediastinitis, Marfan syndrome, previous acute aortic dissection, trauma, chronic hypertension, and aorta calcifications have been defined as predisposing factors. As in other aortic aneurysms, they may cause life threatening complications such as rupture, compression of adjacent organs, thrombosis, and embolism, So, prompt investigation, and consideration of early surgical intervention are essential. We describe a case of the patient with aorto-mediastinal fistula of the ascending aorta on aortotomy after aortic and mitral valve replacement.
책임저자: 곽영태
Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Gangdong-gu, Republic of Korea
연락처 : 조상호, Tel: 02-440-6158 , E-mail : sinan75@khnmc.or.kr
