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Ann Thorac Surg 1996;61:706-707
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Acute Right Ventricular Failure During Aortic Valvular Operation Due to Mechanical Problem in the Right Coronary Artery

Divisions of Cardiothoracic Surgery, State University of New York at Buffalo and the Buffalo General Hospital, Buffalo, New York, The University G.D'Annunzio, Chieti, Italy, and Bowman Gray School of Medicine, Winston-Salem, North Carolina

Accepted for publication October 24, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
Background. When right ventricular failure occurs during aortic valvular operation, inadequate myocardial protection may be the culprit. However, other causes of right ventricular failure should be considered, such as air or particulate matter embolization. Right ventricular failure unexpectedly occurred during an aortic valvular operation, and the cause was found to be a mechanical problem with the right coronary ostium.

Methods. A mechanical problem with the right coronary artery (RCA) occurred in 9 patients undergoing aortic valvular procedures, which included isolated aortic valve replacement (4 patients), aortic valve replacement and coronary artery bypass (1 patient), Bentall procedure (2 patients), aortic valve reconstruction (1 patient), and double valve replacement and coronary artery bypass (1 patient). Although myocardial protection was considered to be the cause, a mechanical problem was subsequently identified in the RCA, leading that artery to be bypassed with a segment of saphenous vein.

Results. The 1 patient in whom the condition was not recognized at time of aortic valve operation died; at autopsy, a damaged and occluded right ostium was confirmed. The other 8 patients who had the RCA bypassed survived.

Conclusions. We conclude that when right ventricular failure unexpectedly occurs during an aortic valvular operation and does not improve with reperfusion, a mechanical problem in the RCA should be considered. In this situation we recommend that the RCA be bypassed with a segment of saphenous vein graft.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
The right ventricle (RV) is vulnerable to ischemic injury during open heart operations in which cardioplegic arrest is used. It has been confirmed experimentally that underperfusion of the RV may occur during cardioplegic arrest in which retrograde cardioplegia is used [1–3]. Clinically, however, the literature either supports this experimental observation [4] or confirms the efficacy of the technique in humans [5–7], with explanation for the reasons [8] for this discrepancy. When the RV fails and RV distention occurs at the end of cardiopulmonary bypass (CPB), inadequate myocardial protection is usually considered to be the culprit. This may indeed be the case in the majority of patients, and RV function usually improves with reperfusion on CPB. We herein report a clinical observation in 9 patients in whom RV failure occurred and persisted due to a mechanical problem in the right coronary artery (RCA).

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
Patient 1
A 56-year-old man underwent aortic valve replacement for calcific aortic stenosis with a gradient of 110 mm Hg across the valve. Preoperative cardiac catheterization showed normal coronary arteries with a dominant right system, and pulmonary artery pressure of 35/20 mm Hg. At time of operation the aortic leaflets were heavily calcified, with calcium extending into the anterior leaflet of the mitral valve. A no. 23 St. Jude Medical (St. Paul, MN) mechanical prosthesis was inserted. Myocardial protection was via the retrograde route, using initial antegrade arrest and continuous normothermic blood cardioplegia at retrograde flows of 300 mL/min and pressure of 50 mm Hg in the coronary sinus. The aortic cross-clamping time was 58 minutes. The heart resumed spontaneous sinus rhythm immediately after declamping and, although CPB was discontinued, over the next 15 minutes progressive RV distention occurred, necessitating inotropic support. The clinical course continued to deteriorate for no obvious reasons due to RV failure, except for concern of inadequate RV protection. Cardiopulmonary bypass was reinstituted, the heart was rearrested with antegrade and retrograde cardioplegia, and the aorta was opened and inspected. The right coronary ostium was traumatized, likely due to retraction during the valve replacement. A saphenous vein graft was applied to the RCA 4 cm from the ostium. The rearrest period was 20 minutes. Cardiopulmonary bypass was discontinued uneventfully with return of RV function by transesophageal echocardiography. The patient made an uneventful recovery.

Patient 2
A 71-year-old woman was admitted to the hospital with increasing shortness of breath and chest pains. A stress test revealed ischemia in the distribution of the RCA and the circumflex coronary artery. Angiography showed occlusion of the RCA with critical stenosis of the circumflex artery, and severe aortic insufficiency with aneurysmal dilatation of the ascending aorta. At the time of operation, she was found to have a 6-cm aneurysm of the ascending aorta extending to the innominate artery. Cardiopulmonary bypass was instituted at a core temperature of 28°C and myocardial protection was via the retrograde route using cold blood (10°C) cardioplegia. The aorta was cross-clamped, and the aneurysm was resected using a Bentall-type procedure with a homograft and implantation of the right and left coronary ostia. The posterior descending coronary artery was also bypassed using a saphenous vein. The cross-clamping time was 165 minutes. Cardiopulmonary bypass was discontinued uneventfully but, at closure of the sternum, hypotension occurred with poor contraction and dilatation of the right ventricle, unresponsive to inotropic support and intraaortic balloon pumping. The patient was reheparinized and placed on CPB. The graft to the posterior descending artery appeared patent. After resting the heart, CPB was again discontinued but the right ventricle appeared to contract poorly. The RCA was dissected from its ostium distally, and a 1.5-mm right ventricular branch was found and bypassed on a beating heart. This time CPB was discontinued uneventfully and the patient made an uneventful recovery.

Summary of the Other Patients
Seven other patients were encountered in three institutions in whom RV distention and failure occurred at the end of CPB during aortic valvular operations. The patients were undergoing aortic valve replacement (3 patients), reconstruction of the aortic valve (1 patient), Bentall procedure (2 patients), or double valve replacement + three-vessel coronary artery bypass grafting (1 patient). In these patients it was suspected that a mechanical problem had occurred with the RCA. In 1 of them this was confirmed by opening of the aorta and by inspection of the right coronary ostium, which was found to be damaged. In the other patients, bypass of the RCA was performed.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
The right ventricle is vulnerable to ischemia during cardioplegic arrest, irrespective of the type of myocardial protection used. This matter has been of special concern during retrograde continuous normothermic blood cardioplegia, although clinical reports of RV failure in this setting are sparse or nonexistent at present. However, not all cases of RV dysfunction occurring at the end of CPB are due to inadequate RV protection. This preliminary clinical observation suggests that a mechanical problem in the RCA may be the cause. It is possible that retraction of the aorta during aortic valve replacement, failure to bypass an important branch of the RCA, air or particulate matter embolization into the RCA, or a kink during reimplantation of the right ostium may precipitate acute RV failure. If recognized and treated, as in 8 of our patients, successful outcome is possible. Unrecognized, the condition will lead to acute RV failure and eventual death, as in 1 of our patients. Inotropic and intraaortic balloon pump support may temporize the condition, which usually deteriorates with the passage of time. The use of the intraaortic balloon pump for RV failure remains controversial and it was used in desperation, as it was thought that nothing else could be done.

We recognize that the incidence of this complication is very low and that its true incidence remains unknown. Over the last 5 years, 300 aortic valvular operations were performed in one of the institutions, and only 3 patients were identified as having this problem.

In summary, a clinical observation has been made regarding unexpected acute RV failure occurring during aortic valvular operations in 9 patients in three institutions. A mechanical problem in the RCA was found to be the culprit, although inadequate RV protection was also considered at the time. When confronted with this situation, the surgeon should inspect the ostium of the RCA and, if damaged, the RCA should be bypassed. Embolization of particular matter with occlusion of the distal RCA may be difficult to diagnose intraoperatively. We therefore recommend bypassing the RCA distally in any case of aortic valvular operation if RV failure occurs and function does not improve after a period of reperfusion on CPB.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
Address reprint requests to Dr Salerno, Division of Cardiothoracic Surgery, University at Buffalo, State University of New York, 100 High St, Buffalo, NY 14203.

	References

Top Footnotes Abstract Introduction Patients and Methods Comment References

 

1. Partington MT, Acar C, Buckberg GD, et al. Studies of retrograde cardioplegia: I. Capillary blood flow distribution to myocardium supplied by open and occluded arteries. J Thorac Cardiovasc Surg 1989;97:605–12.[Abstract]
2. LeBoutillier M, Grossi E, Steinberg B, et al. Effect of retrograde warm continuous cardioplegia on right ventricular function. Circulation 1993;88(Suppl 1):288.
3. Stirling MC, McClanahan TB, Schott RJ, et al. Distribution of cardioplegic solution infused antegradely and retrogradely in normal canine hearts. J Thorac Cardiovasc Surg 1989;98: 1066–76.[Abstract]
4. Allen BS, Hartz RS, Wiewall J, et al. Retrograde cardioplegia does not reperfuse the right ventricle. J Thorac Cardiovasc Surg 1195;109:1116–24.
5. Salerno TA, Houck J, Barrozo CAM, et al. Retrograde continuous warm blood cardioplegia: a new concept in myocardial protection. Ann Thorac Surg 1991;51:245–7.[Abstract/Free Full Text]
6. Menasché P, Kucharski K, Mundler O, et al. Adequate preservation of right ventricular function after coronary sinus cardioplegia: a clinical study. Circulation 1989;80(Suppl 3): 19–24.
7. Fiore AC, Naunheim KS, Kaiser GC, et al. Coronary sinus versus aortic root perfusion with blood cardioplegia in elective myocardial revascularization. Ann Thorac Surg 1989;47:684–8.[Abstract/Free Full Text]
8. Abbas A, Laks H, Drinkwater DC, et al. Ventricular effluent of retrograde cardioplegia in human hearts has traversed capillary beds. Ann Thorac Surg 1995;60:78–83.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tomas A. Salerno Antonio M. Calafiore Neal D. Kon Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Salerno, T. A. Articles by Bhayana, J. N. Search for Related Content PubMed PubMed Citation Articles by Salerno, T. A. Articles by Bhayana, J. N.