We present the case of a 65 years old patient, initially hospitalized at Regional Pneumology Clinic with marked fatigue, severe pulmonary symptoms (suddenly developed severe resting dyspnea, orthopnea, irritating cough), loss of appetite, weight loss and dysphagia. Chest radiography raises the suspicion of giant ascending aortic aneurysm. Echocardiography confirms the presence of the aneurysm, but CT scan with contrast and angiography showed a giant pseudoaneurysm of ascending aorta with severe local compression of the right lung hilum and right main bronchus and in posterior on the esophagus. Coronary angiography also shows significant compression and deformation of the left main coronary artery. Echocardiography reveals marked dilated ascending aorta in the suprabulbar portion without aortic insufficiency. Replacement of the ascending aorta was performed in extracorporeal circulation with a impregnated Dacron prosthesis. Because of technically difficult approach, the ascending aorta ( being the right anterolateral wall of the pseudoaneurysm) was incanculated via right axillary artery, the aortic crossclamp was performed initially transluminal with Foley catheter and later with classical metallic instruments, and myocardial protection was achieved initially by retrograde administration of cardioplegic solution with monitoring of lactic acid, pH and base excess simultaneous from coronary sinus and the coronary ostia during administration of cardioplegic solution. The postoperative evolution was favorable, the weaning from extracorporeal circulation was succeeded without inotropics, with a 48 hours length of stay in ICU, and the patient was discharged after 8 days postoperatively.
Bicoronary - pulmonary artery fistulae are rare conditions. Their association with mitral valve prolapse is even rarer and randomly reported. This association is important to be recognized in clinical practice because of the differential diagnose problems. Closing the coronary fistulae and mitral valve replacement during the same surgical procedure is probably the optimal management of these patients. We report a case involving the correction of congenital bicoronarypulmonary artery fistulae and mitral valve replacement within the same surgical procedure in a 56 years old female patient with angina and clinical signs of left ventricular failure associating the fistulae to severe mitral regurgitation due to mitral valve prolapse. Past medical history revealed autoimmune thyroiditis, atrial fibrillation, mitral and tricuspid valve regurgitation. At admission physical examination revealed stable vital signs, irregular tachycardia with significant pulse and a mitral regurgitation systolic murmur. ECG showed atrial fibrillation, no ischemia. Echocardiography revealed severe mitral regurgitation, prolapse of anterior and posterior mitral leaflets, moderate tricuspid valve regurgitation, and mild pulmonary hypertension. Coronary angiogram showed no significant lesions of the epicardial vessels but high flow congenital bicoronary-pulmonary fistulae (right coronary artery and left coronary artery to main pulmonary artery). Surgical correction of the congenital bicoronarypulmonary fistulae was performed simultaneously with mitral valve replacement in the same session. Postsurgical evolution was uneventful. Post-procedural ECG showed atrial fibrillation with a controlled heart rate, postoperative echocardiography showed normal functional and normal positioned prosthetic mitral mechanical valve, and rather normal left ventricle function. Coexistence of bicoronary-pulmonary fistulae and mitral valve insufficiency due to prolapse in a symptomatic patient with angina pectoris is a very rare clinical entity. Solving both abnormalities within the same surgical procedure was the optimal management for this patient.
Introduction. Perioperative myocardial injuries are one of the most frequent causes of morbidity and mortality after cardiac surgery, the most common etiology being the poor myocardial protection during aortic crossclamp. During aortic crossclamp progressive accumulation of lactate and intracellular acidosis are well-known phenomena, and are associated with alteration of myocardial contractile function. Our objective was to study the coronary sinus lactate levels as a predictor of postoperative hemodynamic outcome in open-heart surgical patients.
Material and methods. We performed a prospective clinical trial, including 142 adult patients with elective cardiac surgery. Anterograde cardioplegia was administered in 82 patients, retrograde cardioplegia in 60 (in 30 patients it was administrated intermittently and in 30 continuously). Blood was collected simultaneously from the aortic cardioplegic line (inflow) and from coronary sinus or the aortic root (outflow) before aortic crossclamp, after crossclamp at every 10 minutes and after crossclamp removal at 0 and 10 minutes. All patients were operated on cardiopulmonary bypass with cardiac arrest, using warm-blood cardioplegia for cardioprotection.
Results. Lactate levels showed increasing values during aortic crossclamp, and a rapid decline after crossclamp removal. The incidence of low cardiac output was significantly higher in patients with lactate levels that exceeded 4 mmol/L. In patients who died in the postoperative period, lactate level was even higher (5 mmol/L), with only a modest recovery after crossclamp removal.
Conclusion. Monitoring lactate level in coronary sinus blood is a reliable method and has a good prognostic value regarding postoperative morbidity and mortality in open heart surgery