CASE REPORT KONSTANTINOV ET AL PERICARDIAL FLAP AFTER SLIDE TRACHEOPLASTY IN PA SLING COMPLEX
If the clinical suspicion of an aortopulmonary fistula arises, Doppler echocardiography is a useful method to visualize the shunt. Cardiac catheterization can confirm the diagnosis. However, in the present case, the sequence of diagnostic procedures was inadvertently inverted with regard to this logical approach, because balloon dilatation of the pulmonary stenosis was the procedure that initially disclosed the presence of the unsuspected fistula. Probably this supravalvular stenosis created a “high pressure chamber” in the proximal neopulmonary artery, avoiding the left-to-right shunt and protecting the patient from pulmonary over circulation. In conclusion, even though aortopulmonary fistula as a complication of the ASO is now reported for the first time, it has to be kept in mind as a possible cause of heart failure developing in the postoperative course of these patients. Depending on the size and characteristics of the fistula, it could be closed with a device in the catheterization laboratory. When this is not possible, prompt surgical closure is mandatory. Repair through a pulmonary arteriotomy offers an excellent approach in these patients, in whom a Lecompte maneuver has been previously performed.
References 1. Williams WG, McCrindle BW, Ashburn DA, Jonas RA, Mavroudis C, Blackstone EH. Outcomes of 829 neonates with complete transposition of the great arteries 12–17 years after repair. Eur J Cardiothorac Surg 2003;24:1–10. 2. Prifiti E, Crucean A, Bonacchi M, et al. Early and long term outcome of arterial switch operation for transposition of the great arteries: predictors and functional evaluation. Eur J Cardiothorac Surg 2002;22:864 –73. 3. Serraf A, Roux D, Lacour-Gayet F, et al. Reoperation after the arterial switch operation for transposition of the great arteries. J Thorac Cardiovasc Surg 1995;110:892–9. 4. Massetti M, Babatasi G, Rossi A, et al. Aortopulmonary fistula: an uncommon complication in dystrophic aortic aneurysm. Ann Thorac Surg 1995;59:1563– 4. 5. Piciche M, De Paulis R, Chiariello L. A review of aortopulmonary fistulas in aortic dissection. Ann Thorac Surg 1999;68: 1833– 6.
Interposition Pericardial Flap After Slide Tracheoplasty in Pulmonary Artery Sling Complex Igor E. Konstantinov, MD, PhD, Yves d’Udekem, MD, PhD, and Pankaj Saxena, MCh, DNB Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, Australia
Children undergoing an extensive tracheoplasty, particularly those with associated cardiovascular anomalies, Accepted for publication May 26, 2009. Address correspondence to Dr Konstantinov, Royal Children’s Hospital, Flemington Rd, Parkville, VIC 6009, Australia; e-mail: igor.
[email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
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may require long cardiopulmonary bypass, prolonged ventilatory support, subsequent tracheostomy, and multiple reinterventions on the trachea. Thus, these rare patients are at risk of mediastinitis. With tracheal erosion into the adjacent vessels and tracheal perforation during subsequent bronchoscopic interventions. Herein we describe a simple technique of interposition pericardial flap that provides an effective seal and isolation of the tracheoplasty site. (Ann Thorac Surg 2010;89:289 –91) © 2010 by The Society of Thoracic Surgeons
P
ulmonary artery (PA) sling complex is a spectrum of anomalies that commonly includes left PA sling, patent ductus arteriosus, hypoplastic right lung, and severe long-segment tracheal stenosis [1]. In addition, approximately 12% of these patients have direct origin of the right epi-arterial bronchus, also known as “bronchus sui” or “pig bronchus” from the trachea [2, 3]. During the last decade slide tracheoplasty appears to have become a method of choice in repairing severe long-segment tracheal stenosis [4, 5]. However, less than 250 children underwent slide tracheoplasty worldwide. The operative mortality in a larger series of these patients reported during the last decade ranged from 5% to 33% [4, 5]. The PA sling complex and other concomitant cardiovascular anomalies add to complexity and risk of slide tracheoplasty. An 8-month-old baby boy with a history of frequent respiratory tract infections was admitted to the intensive care unit in severe respiratory distress that required intubation. A chest roentgenogram demonstrated bilateral patchy atelectases. A computed tomographic scan demonstrated PA sling complex and severe longsegment tracheal stenosis of the bridging bronchus between the blunt stump of the rudimentary pig bronchus and the carina, as well as right lung hypoplasia (Fig 1A). Both bridging bronchus and right main bronchus collapsed without positive pressure ventilation. After 1 month of treatment for a respiratory infection and failure to decrease ventilatory support, the patient was referred for surgery. This surgery was performed through a midline sternotomy with cardiopulmonary bypass on the beating heart. An intraoperative examination confirmed the diagnosis of PA sling complex (Fig 1B) with left ligamentum arteriosum, severe ostial stenosis of the right PA, and tracheobronchial compression and malacia. The left PA was divided and reimplanted to the main PA. The stenotic segment of the right PA was resected and was re-anastomosed to the main PA. Cardiopulmonary bypass time was 190 minutes. Although the compression was effectively relieved, severe tracheomalacia persisted. In 1 week, after failure to wean the patient off ventilatory support, a slide tracheoplasty was performed with an extension into the right main bronchus (Fig 2A). Care was taken to avoid damage to the recurrent nerves. Division of the left pulmonary ligament, incision of the posterior 0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.05.080
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CASE REPORT KONSTANTINOV ET AL PERICARDIAL FLAP AFTER SLIDE TRACHEOPLASTY IN PA SLING COMPLEX
Ann Thorac Surg 2010;89:289 –91
Fig 1. (A) Computed tomographic scan demonstrates long-segment tracheobronchial narrowing with rudimentary stump of the bronchus sui, and (B) the pulmonary artery sling complex. The left pulmonary artery sling in combination with left ligamentum arteriosus caused compression of the trachea.
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pericardial reflection inferiorly, and hilar release contributed significantly to mobilization of the trachea, and allowed a tension-free anastomosis. The tracheobronchial tree was separated from the vascular structures by a flap of the anterior pericardium that was passed through the transverse sinus underneath the aorta and pulmonary artery (Figs 2B and 2C). Cardiopulmonary bypass time was 134 minutes. No cardiac arrest was required. Postoperatively, the patient required bronchoscopic resection of the granulation tissues above the surgical anastomosis at the site of endotracheal tube placement and tracheostomy, which was removed 6 months after the surgery. The bronchoscopy at that time demonstrated widely open airways and a stable tracheobronchial tree without stenoses. The patient was doing well at 8 months after surgery.
Comment A recent study of 40 children (11 of them had left PA sling) demonstrated that preoperative mechanical ventilatory support and duration of cardiopulmonary bypass were risk factors for prolonged postoperative ventilatory support [5]. Repairing PA sling complex and other cardiovascular anomalies increases complexity of surgery and duration of cardiopulmonary bypass, thus putting these patients at an even higher risk of prolonged post-
Fig 2. (A) Division of the ligamentum arteriosus and reimplantation of both branch pulmonary arteries into the main pulmonary artery. (B) A broad flap of the anterior pericardium was harvested and passed through the transverse sinus, and (C) partially wrapped in front of the trachea, separating the tracheobronchial tree from the brachiocephalic artery, left carotid artery, ascending aorta, and pulmonary arteries.
operative ventilatory support. Patients with PA sling complex and tracheomalacia who require prolonged ventilatory support often have excessive endotracheal granulation tissue that develops at the site of mechanical irritation by the endotracheal tube. The granulation tissue requires bronchoscopic resection and dilation, and in severe cases also a temporary stenting [4, 5]. Subsequent bronchoscopic intervention and stenting carry the risk of perforation or erosion into the adjacent vessels (ie, a rare, but life-threatening complication). A spontaneous erosion of the trachea into the adjacent blood vessels after tracheoplasty may rarely occur in the absence of bronchoscopic intervention [2, 5]. Slide tracheoplasty itself, as well as subsequent interventions on the trachea after slide tracheoplasty, carries a risk of mediastinitis. In fact, some surgeons routinely irrigate the chest for 48 hours with povidone-iodine antiseptic on the assumption that the open tracheal surgery creates a latent mediastinitis [5]. Covering the trachea with the interposition pericardial flap after a tracheoplasty (as described herein) is a simple procedure that might be helpful in high-risk patients to re-enforce tracheal anastomotic seal, prevent mediastinitis, and prevent tracheal erosion into the blood vessels, as well as making subsequent bronchoscopic interventions safer.
References 1. Chen SJ, Lee WJ, Lin MT, Wang JK, Chang CI, Chiu IS, Wu MH. Left pulmonary artery sling complex: computed tomography and hypothesis of embryogenesis. Ann Thorac Surg 2007;84:1645–50. 2. Gikonyo BM, Jue KL, Edwards JA. Pulmonary vascular sling: report of seven cases and review of the literature. Pediatr Cardiol 1989;10:81–9. 3. Loukanov T, Sebening C, Springer W, Hagl S. A case of pulmonary artery sling associated with long-segment funnel trachea and bronchus suis. Ann Thorac Surg 2004;78:1839 – 42. 4. Manning PB, Rutter MJ, Border WL. Slide tracheoplasty in infants and children: risk factors for prolonged postoperative ventilatory support. Ann Thorac Surg 2008;85:1187–91. 5. Elliott M, Hartley BE, Wallis C, Roebuck D. Slide tracheoplasty. Curr Opin Otolaryngol Head Neck Surg 2008;16:75– 82.
Video-Assisted Thoracoscopic Lobectomy for Pulmonary Aspergilloma After Life-Threatening Hemoptysis in a Patient With Lupus Kathryn L. Parker, BS, Michael D. Zervos, MD, Farbod Darvishian, MD, and Costas S. Bizekis, MD Division of Thoracic Surgery, Department of Cardiothoracic Surgery, and Department of Pathology, New York University Langone Medical Center, New York, New York
Open thoracotomy procedures serve as the mainstay for surgical resection of pulmonary aspergilloma. These procedures are considered among the most challenging for thoracic surgeons, and postoperative morbidity and mortality rates are high. Here, we present patient who underwent video-assisted thoracoscopic lobectomy for aspergilloma. Based on the success of the operation, we suggest that video-assisted thoracoscopic surgical resection be considered as an option for pulmonary aspergilloma. (Ann Thorac Surg 2010;89:291–2) © 2010 by The Society of Thoracic Surgeons
CASE REPORT PARKER ET AL VATS LOBECTOMY FOR ASPERGILLOMA
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fully resected through a video-assisted thoracoscopic surgical (VATS) lobectomy. In January 2009, a 57-year-old woman was hospitalized for life-threatening hemoptysis out of a previously placed tracheostomy. Her medical history included systemic lupus erythematosus (SLE) complicated with Pneumocystis carinii pneumonia (PCP) and subsequent respiratory failure. She was receiving long-term immunosuppression therapy with mycophenolate and prednisone. After an emergency bronchoscopy was performed to remove a 6.5 ⫻ 2.5 ⫻ 1 cm clot embedded in both her right and left mainstem bronchi, a computed tomography (CT) scan revealed a very large, 7 cm right upper lobe fungus ball cavity (Fig 1). A bronchial artery embolization was performed to prevent future hemoptysis (Fig 2), and treatment with voriconazole was started. After a brief period of stabilization, she underwent surgical resection. Initially, an exploratory VATS using two lower thorascopic ports was performed. Adhesions between the upper lobe and the chest wall were identified and taken down endoscopically with a harmonic scalpel. An anterior access incision was then created in the fifth intercostal space. Owing to the size and location of the mass, a lobectomy would be necessary for resection. The hilum was carefully dissected, and the vessels and bronchus to the right upper lobe were individually ligated with endoscopic stapling devices to free the lobe. No surgical complications were noted, and the patient made an uneventful recovery. Macroscopic examination of the surgical specimen revealed a cavitary, brown-red mass containing soft and friable material. Microscopically, this material consisted of concentric aggregates of hyphae that were rimmed by an incomplete fibrous capsule and focal abscess formation. On high magnification, the hyphal elements of the fungus ball were uniform, septated at regular intervals, and branching at 45° angles. These features were consistent with aspergilloma. A Gomori methenamine silver (GMS) stain highlighted the fungal structures and supported the diagnosis (Fig 3).
A
spergillus is a ubiquitous saprophytic fungus usually found in damp areas or on decaying plants [1]. Each day, humans inhale an average of 15 to 30 of these spores without disease developing. In some people, however, especially in immunocompromised individuals, severe and life-threatening infections result. Aspergilloma is the most common type of infection caused by Aspergillus and consists of a round fungus ball that colonizes in preexisting lung cavities, such as those caused by tuberculosis. The most common presenting symptom is hemoptysis, and current literature recommends surgical intervention because antifungal therapy is unreliable. We report a case of aspergilloma discovered in a patient with massive hemoptysis that was successAccepted for publication June 16, 2009. Address correspondence to Dr Bizekis, 530 First Ave, Skirball 9 9V, New York, NY 10016; e-mail:
[email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. A transverse computed tomography scan shows the large aspergilloma fungus ball in the right upper lobe. 0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.06.084
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