CASE REPORT MITROPOULOS ET AL AORTO-LEFT VENTRICULAR TUNNEL: AN ALTERNATIVE SURGICAL APPROACH
graphic scan and the catheterization carefully and decided that although the RVOT and the internal mammary artery were both close to the chest wall, they were to the left of the sternum making peripheral cannulation unnecessary. It is of course critically important to make these considerations beforehand and have ready plans of action for different scenarios. Radical debridement of all infected tissue including the sternum allowed primary healing of the heart and the sternum.
References 1. Tulan M, Clarke S, Schofield P, Wells C. Homograft replacement of fungal endocarditic pulmonary valve. Eur J Cardiothorac Surg 1995;9:528 –30. 2. Edmond JJ, Eykyn SJ, Smith LD. Community acquired staphylococcal pulmonary valve endocarditis in non-drug users: case report and review of the literature. Heart 2001;86:E17. 3. Davlourosa PA, Polyzogopouloub EV. Syrokostac I, Alexopoulosa D, Gogosc CA, Manolisa AS. Pulmonary valve staphylococcal endocarditis in a nondrug addict with alcoholic cirrhosis. Int J Cardiol 2004;97:575– 6. 4. Shimazaki Y, Blackstone EH, Kirklin JW. The natural history of isolated congenital pulmonary valve incompetence— surgical implications. Thorac Cardiovasc Surg 1984;32:257–9. 5. Llosa JC, Gosalbez F, Cofino JL, Naya JL, Valle JM. Pulmonary valve endocarditis: mid-term follow up of pulmonary valvectomies. J Heart Valve Dis 2000;9:359 – 63. 6. Willems TP, Bogers AJJC, Cromme-Dijkhuis AH, et al. Allograft reconstruction of the right ventricular outflow tract. Eur J Cardio-thorac Surg 1996;10:609 –15. 7. Albert JD, Bishop DA, Fullerton DA, Campbell DN, Clarke DR. Conduit reconstruction of the right ventricular outflow tract: lessons learned in a twelve-year experience. J Thorac Cardiovasc Surg 1993;106:228 –36. 8. Arbulu A, Gursel E, Camero LG, Asfaw I, Stephenson LW. Spontaneous right ventricular rupture after sternal dehiscence: A preventable complication? Eur J Cardiothorac Surg 1996;10:110 –5.
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reported in the English literature so far. This technique may minimize the risk of aortic valve (AV) injury. A 10-day-old twin boy, was born by a cesarean delivery after an uncomplicated full-term pregnancy. A persistent systolic murmur (1/6) was detected and a transthoracic echocardiogram showed a large ALVT. The aortic orifice was distal to the sinuses of Valsalva and the coronary ostia were not involved. The anterior leaflet of the mitral valve opened poorly, secondary to the jet created by the regurgitated blood flow from the ALVT. The left ventricle was mildy dilated with a fraction shortening of 30% and a mild aortic leaflet prolapse (right coronary cusp). There was also a patent ductus arteriosus. Catheterization confirmed the echocardiographic findings (Fig 1). After opening the pericardium, on the anterior aspect and leftwards of the aorta, there was a large tunnel emptying to the left ventricle below the AV (Fig 2). The ductus arteriosus was ligated. The patient was placed on cardiopulmonary bypass and after the heart was arrested, the ALVT was opened in a longitudinal fashion. Stay stitches were placed on either side to keep the tunnel open. The aortic opening of the tunnel appeared to be above the sinotubular junction. Pericardium treated with 6% glutaraldehyde was used to close the aortic orifice through the open tunnel. Then the ventricular orifice was patched with tanned pericardium through the open tunnel with extra care not to injure the AV (Figs 3A, B). The atrioseptal defect was also closed primarily and the patient was weaned from cardiopulmonary bypass without difficulty. The intraoperative transesophageal echocardiogram showed complete closure of the tunnel with no aortic valve regurgitation.
Aorto-Left Ventricular Tunnel: An Alternative Surgical Approach Fotios A. Mitropoulos, MD, PhD, Hillel Laks, MD, Meletios A. Kanakis, MD, and Daniel Levi, MD University of Athens, School of Medicine, Athens, Greece; David Geffen School of Medicine at UCLA, Los Angeles, California
A 10-day-old infant was diagnosed with aorto-left ventricular tunnel. An alternative surgical approach is described. This technique may minimize the risk of aortic valve injury. (Ann Thorac Surg 2006;82:1113–5) © 2006 by The Society of Thoracic Surgeons
A
orto-left ventricular tunnel (ALVT) is a rare congenital paravalvar communication between the aorta and the left ventricle. It was first described in 1963 by Levy and colleagues [1]. We describe a new surgical approach to correct this malformation, which we believe has not been Accepted for publication Dec 20, 2005. Address correspondence to Dr Mitropoulos, University of Athens School of Medicine, Monastiriou 8, Thracomacedones, Athens, 13676 Greece; e-mail:
[email protected].
© 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Aorto-left ventricular tunnel (ALVT) as depicted from the lateral view on the cardiac angiogram. (A ⫽ ALVT; B ⫽ ascending aorta; C ⫽ right coronary artery.) 0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2005.12.072
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Ann Thorac Surg 2006;82:1113–5
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CASE REPORT MITROPOULOS ET AL AORTO-LEFT VENTRICULAR TUNNEL: AN ALTERNATIVE SURGICAL APPROACH
Ann Thorac Surg 2006;82:1113–5
excision and reimplantation of the coronary button before closing the aortic orifice. There is also a case of ALVT with severe aortic stenosis that was treated with replacement of the aortic root with an aortic homograft [8]. The closure of the aortic orifice is typically performed by opening the ascending aorta. There is a risk of AV injury, especially if trying to close the ventricular opening through this approach. Serino and colleagues [9] support that closing the aortic defect by direct suture distorts the cusps by pulling them toward the weak aortic wall, which remains unsupported within the dilated aortic sinus. In that way, the aortic regurgitation may persist and progress even if repaired in infancy [9]. From this point of view, the patch technique is believed to reduce that risk. The goal is to close the communication by distorting the
FEATURE ARTICLES
Fig 2. Picture as seen from the surgeon’s view after opening the pericardium. (A ⫽ pulmonary artery; B ⫽ aorto-left ventricular tunnel; C ⫽ aorta; D ⫽ right atrium; E ⫽ right ventricle.)
Comment Aorto-left ventricular tunnel is often diagnosed in infancy, but in some patients it is recognized later. The ALVT can be considered a defect of the aortic root affecting the interleaflet triangle [2]. Diagnosis has been reported in utero [3]. Cases diagnosed in utero are more severe and have a worse outcome [3]. Hovaguimian and colleagues [4] proposed a classification of four anatomic types. They described a slit-like opening at the aortic end with no valve distortion in 24% of the cases (type 1), a large extracardiac aneurysm in 44% (type 2), intracardiac aneurysm of the septal portion of the tunnel, with or without right ventricular outflow tract obstruction in 24% (type 3), and a combination of types 2 and 3 in 8% (which is type 4). In our case, the ALVT belonged to type 2. Echocardiography can identify the ALVT, although some may recommend catheterization to separate the ALVT from AV regurgitation and to identify associated lesions [5]. Surgical closure has been recommended at the time of diagnosis, including asymptomatic patients, due to inadequacy of medical therapy, risk of developing severe aortic regurgitation, and the excellent surgical results [5]. The goal of any treatment modality is to obliterate the tunnel [3]. The techniques that have been described are summarized as follows: (1) closure of the aortic orifice of the tunnel with or without a patch (Dacron, pericardium, Teflon); (2) closure of the ventricular end of the tunnel; (3) obliteration of the tunnel (ie, ligation of the tunnel, or partial resection of the tunnel, or filling of the tunnel with gel-foam); and (4) closure of both orifices (aortic and ventricular) [4 – 6]. Surgical repair undoubtedly needs to be tailored for each case. Rarely, the coronary ostium may arise from the tunnel itself, and closure of the orifice of the tunnel would compromise the patency of the coronary artery. Horvath and colleagues [7] described
Fig 3. (A) Schematic representation of the surgical anatomy. (Aa ⫽ ascending aorta; LAA ⫽ left atrial appendage; PA ⫽ pulmonary artery; RA ⫽ right atrium; SVC ⫽ superior vena cava.) (B) After the tunnel has been opened, the aortic and the ventricular orifices are seen through the tunnel. (A ⫽ aortic orifice; B ⫽ ventricular orifice; C ⫽ tunnel opened; D ⫽ aortic cannula; E ⫽ venous cannula.)
Ann Thorac Surg 2006;82:1115–7
References 1. Levy MJ, Lillehei CW, Anderson RC, Amplatz K, Edwards JE. Aortico-left ventricular tunnel. Circulation 1963;27:841–53. 2. Ho SY, Muriago M, Cook AC, Thiene G, Anderson RH. Surgical anatomy of aorto-left ventricular tunnel. Ann Thorac Surg 1998;65:509 –14. 3. Sousa-Uva M, Touchot A, Fermont L, et al. Aortico-left ventricular tunnel in fetuses and infants. Ann Thorac Surg 1996;61:1805–10. 4. Hovaguimian H, Cobanoglu A, Starr A. Aortico–left ventricular tunnel: a clinical review and new surgical classification. Ann Thorac Surg 1988;45:106 –12. 5. Martins JD, Sherwood MC, Mayer JE JR, Keane JF. Aorticoleft ventricular tunnel: 35-year experience. J Am Coll Cardiol 2004;44(2):446 –50. 6. Levy MJ, Schachner A, Blieden LC. Aortico-left ventricular tunnel: collective review. J Thorac Cardiovasc Surg 1982;84: 102–9. 7. Horvath P, Balaji S, Skovranek S, Hucin B, de Leval MR, Stark J. Surgical treatment of aortico-left ventricular tunnel. Eur J Cardiothorac Surg 1991;5:113–7. 8. Weldner P, Dhillon R, Taylor JFN, de Leval MR. An alternative method for repair of aortico-left ventricular tunnel associated with severe aortic stenosis presenting in a newborn. Eur J Cardiothorac Surg 1996;10:380 –2. 9. Serino W, Andrande JL, Ross D, de Leval MR, Somerville J. Aorto-left ventricular communication after closure: later postoperative problems. Br Heart J 1983;49:501– 6.
Successful Reoperation After 17 Years in a Case of Endomyocardial Fibrosis Sanjay Mammen Cherian, MS, Baylal Ragavendra Jagannath, DNB, Sushma Nayar, MD, and Kotturathu Mammen Cherian, FRACS Departments of Cardiovascular Surgery and Pathology, Frontier Lifeline, International Centre for Cardiothoracic and Vascular Diseases & Dr KM Cherian Heart Foundation, Chennai, India
Endomyocardial fibrosis is an uncommon cause of congestive cardiac failure characterized by severe diffuse thickening of the endocardium, and the overall long-term prognosis of this disease is generally considered poor. We report a case of endomyocardial fibrosis that was Accepted for publication Dec 8, 2005. Address correspondence to Dr Cherian, Frontier Lifeline, International Centre for Cardiothoracic and Vascular Diseases & Dr KM Cherian Heart Foundation, R-30-C, Ambattur Industrial Estate Rd, Mogappair, Chennai, 600101 India; e-mail:
[email protected].
© 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
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initially treated by endocardial resection and mitral valve replacement, which was regularly followed-up. The patient underwent successful repair of a paravalvular leak after a period of 17 years. The treatment of left ventricular endomyocardial fibrosis with associated mitral valve disease by endocardial resection and mitral valve replacement is a good surgical option that provides good long-term results. (Ann Thorac Surg 2006;82:1115–7) © 2006 by The Society of Thoracic Surgeons
E
ndomyocardial fibrosis (EMF) is an uncommon idiopathic disorder characterized by severe diffuse thickening of the endocardium causing obliteration of the ventricular cavity, restricted ventricular filling, and congestive cardiac failure [1]. The fibrotic process is usually located at the apex of the affected ventricle, and involvement of the chordae tendinea may cause mitral or tricuspid valve dysfunction, or dysfunction of both valves simultaneously. The treatment of EMF is primarily surgical, and the overall long-term prognosis in severe cases is poor [2]. We report a case of EMF involving the left ventricle and mitral valve, initially treated by endocardial resection and prosthetic valve replacement, which was regularly followed-up, and underwent successful repair of a paravalvular leak after 17 years. A 26-year-old man presented to us in November 1987 with symptoms suggestive of class III dyspnea. His pulse was regular with a rate of 106 per minute. Systemic blood pressure was 140/100 mm Hg. Transthoracic echocardiography revealed thickening of the inferior and basal ventricular wall, apical obliteration, a restrictive left ventricular filling pattern, severe mitral regurgitation, thickening of the anterior and posterior mitral leaflets, and moderate pulmonary artery hypertension. The left ventricular end-systolic volume was 39 mL, left ventricular end-diastolic volume was 176 mL, and the ejection fraction was 78%. No cardiac catheterization was performed. On table inspection, diffuse fibrosis of the left ventricular endocardium and chordae tendinea was revealed. The mitral valve was fibromyxomatous with spotty calcification, and repair of the valve was not feasible due to the extensive fibrosis. On excision of the valve, a welldefined plane of cleavage was observed between the endocardium and myocardium. This permitted excision of the fibrous tissue starting from the mitral valve annulus to the apex of the left ventricle. The weight of the excised tissue was approximately 8 to 10 grams. After endocardial resection, the mitral valve was replaced using a 25-mm Bjork Shiley (Shiley Inc, Irvine, CA) mechanical valve. His postoperative course was uneventful. Histopathologic examination of the endocardial tissue revealed endomyocardial fibrosis. Postoperatively, he was treated with anticoagulants and diuretics, and he was on a regular annual follow-up. He remained asymptomatic for 16 years. He had atrial fibrillation develop during that year for which he was 0003-4975/06/$32.00 doi:10.1016/j.athoracsur.2005.12.041
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cusps as little as possible, reduce the size of the aneurysmal sinus and aortic root, and reinforce the aortic wall in the same region. This eliminates the risk of aortic regurgitation [9]. We believe that by using the direct approach through the tunnel and closing both ostia with pericardial patches avoids distortion of the AV while supporting the aortic wall, and this is easier to perform. In addition, the risk of injury to the AV leaflets while trying to close the ventricular end is minimized.
CASE REPORT CHERIAN ET AL REOPERATION IN ENDOMYOCARDIAL FIBROSIS
