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Ann Thorac Surg 1996;62:889-891
© 1996 The Society of Thoracic Surgeons

Case Report

Closure of Ruptured Coronary Sinus by a Pericardial Patch

Seyedhossein Aharinejad, MD, PhD, Helmut Baumgartner, MD, Aurelia Miksovsky, MD, Werner Mohl, MD, PhD

Departments of Anatomy, Thoracic and Cardiac Surgery, and Cardiology, University of Vienna, Vienna, Austria

Accepted for publication April 8, 1996.


   Abstract
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We report on a case of coronary sinus rupture that happened during placement of a cardioplegia balloon catheter and its subsequent repair. First, the defect was oversewn, however, not successfully. Under cardiopulmonary bypass and cardioplegic arrest, a pericardial patch was used to reconstruct the coronary sinus. Six months after the operation, blood drained during diastole into the right atrium but the flow was partially reversed during systole.


   Introduction
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I n our department, we routinely use cannulation of the coronary sinus to administer cardioplegic solution retrogradely. The positive effect of this method on myocardial protection during open heart operation, that is, reduction of the extent of the ischemic injury, associated with advances in manufacturing of coronary sinus cannulas have resulted in a worldwide application of this technique to cardiac operations with a relatively low incidence of complications [1–3]. However, evidence is accumulating suggesting that the rate of coronary sinus rupture might be increasing [4, this study]. Recently, Weiss [4] reported on a difficult coronary sinus rupture in a 70-year-old man and its management with Gore-Tex patch (W.L. Gore & Associates, Flagstaff, AZ) and a conduit to the right atrium.

We report on a 37-year-old woman who was hospitalized to undergo cardiac operation because of a severe endocarditis and insufficiency of her mitral valve. The case history went back to her childhood, when she suffered from an insufficiently treated rheumatic fever. The echocardiogram before operation showed severe mitral valve insufficiency of New York Heart Association functional class IV.

Intraoperatively, the pericardium was opened and a 5 x 3-cm large block of the pericardium was isolated and fixed with glutaraldehyde for valve reconstruction. Both caval veins and the aorta were cannulated as usual and a standard coronary sinus retrograde catheter was tried to be introduced into the coronary sinus through the closed right atrium using a pursestring suture at the free wall of the atrium. This maneuver was problematic and resulted in rupture of the sinus (Fig 1Go). The balloon catheter was withdrawn and the rupture was first oversewn with continuous 5.0 Prolene suture (Ethicon, Somerville, NJ). Then, the aortic root was cannulated and cardiopulmonary bypass was started. A second attempt was made to introduce the coronary sinus catheter. The right atrium was opened and a membrane closing the coronary sinus orifice was incised. The coronary sinus catheter was then placed successfully. The body temperature was lowered to 28°C, the aorta was cross-clamped and 800 mL of cold cardioplegia was administered through the catheter into the aortic root and through the coronary sinus. The left atrium was then opened and the mitral valve was inspected. Because both leaflets were highly damaged, it seemed unlikely that valvular reconstruction would suffice. Therefore, we implanted a 27-mm Carpentier-Edwards biologic prosthesis, drained air from the left atrium, and closed the latter. Thereafter, the aortic cross-clamp was released.



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  		Fig 1. . Reconstruction of the coronary sinus using a pericardial patch: step 1, rupture of the coronary sinus by the balloon catheter (top inset); step 2, the reconstruction of the coronary sinus using a pericardial patch (middle inset); and step 3, the reconstructed coronary sinus (bottom inset).

 
At that time, bleeding began at the site of the oversewn coronary sinus. An approximately 16-mm defect was found, starting at the level of inferior vena cava directed toward the left atrium. A maneuver to directly oversew the defect was not successful. Thus, we again cross-clamped the aorta, lowered the patient's body temperature again down to 28°C and administered 1,000 mL of cold cardioplegia through the aortic root catheter. An elongated triangular patch was made using the fixed pericardium to reconstruct the coronary sinus as follows. The free wall of the coronary sinus was incised (and the damaged tissue partly removed) from its right atrial origin to the merging site of the great cardiac vein. Now we realized that the myocardial aspect of the coronary sinus near to the inferior vena cava had been damaged and was the site of bleeding. We therefore searched for myocardial tissue areas that would allow repair of the coronary sinus. Using a 6.0 Prolene suture, the triangular pericardial patch was anastomosed with the remainder of the coronary sinus free wall (1.5 cm) and then with the unaffected myocardial part of the sinus, resulting in a tubelike flap. The bottom of the pericardial tube was anastomosed to the septal aspect of the right atrium, forming a new base of Koch's triangle, and the roof of the tube was anastomosed with the free wall of the right atrium (Fig 1Go). The middle cardiac vein now opened through an undamaged part of the myocardial aspect of the coronary sinus into the pericardial tube.

The right atrium was closed, the body temperature was increased to 37°C, and the aortic cross-clamp was released. The heart started to beat spontaneously with a sinus rhythm. After 10 minutes of reperfusion, we weaned the patient from cardiopulmonary bypass. Heparin was reversed by systemic administration of protamine but bleeding from the posterior interventricular vein near to the patch did not cease. We used fibrin glue and Tachocomb and managed to stop the bleeding without changing the venous drainage. Hemostasis was gained at that time. External pacemaker wires were implanted onto the right ventricle. We closed the pericardium using a Gore-Tex patch (W.L. Gore & Associates).

Intraoperative transesophageal echocardiography showed normal function of the valve prosthesis, normal flow within the reconstructed coronary sinus, as well as normal left ventricular function. The hospitalization period was otherwise uneventful and two echocardiographic examinations showed normal flow inside the coronary sinus. The patient was discharged from hospital 10 days after operation. Six months postoperatively, the patient was examined again by echocardiography. The mitral valve prosthesis worked normally; however, blood flow inside the coronary sinus was intermittent. Blood was drained from the coronary sinus during the diastole into the right atrium whereas during systole, temporarily, flow was reversed (Fig 2Go).





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  		Fig 2. . Color-coded echocardiographic images of the heart: (A) Shows the location of the coronary sinus (arrows) and the heart chambers, (B) Shows the red-colored flow (ie, from the coronary sinus toward the right atrium), and (C) Shows the blue-colored flow (ie, from the right atrium toward the coronary sinus [flow reversal]). (LV = left ventricle; RA = right atrium; RV = right ventricle.)

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
The present contribution reports on a patient in whom primary repair of the ruptured coronary sinus with fine suture [5] was frustrating. Furthermore, the pericardial patch seems to have successfully covered the defect in the coronary sinus, although blood flow within the reconstructed sinus was shown to be intermittently reversed 6 months after the operation. The reason for this intermittent flow might be explained as follows. A part of the venous blood is normally drained directly into the right ventricle through the thebesian veins. In this patient because of a membrane at the coronary sinus orifice, alternate drainage pathways formed and carried most of the venous blood into the atria and ventricles. Shortly after the operation, with a long cardioplegic arrest and operative time, the right ventricular pressure increases and is higher than the opening pressure of the thebesian veins. This, in turn, results in higher venous backflow through venous anastomoses toward the coronary sinus. As the right ventricular function is improved after operation, the pressure and flow moments in the thebesian veins normalize, and these competitive routes again carry blood to the alternate pathways. Because the flow was fully physiologic during the first 10 days, and because intermittent flow emerged 6 months after the procedure without visible changes at the repaired site, it seems unlikely that changes in the flow patterns were attributable to sewing technique. It is rather fair to assume that stabilization and normalization of ventricular function after operation resulted in "normal" drainage for this particular patient.

During the reviewing process of this report, we had a similar case of a ruptured coronary sinus; however, only the free wall of the sinus was injured. Therefore, it was much easier to handle the situation, that is, this time we used a rhomboid saphenous vein patch and anastomosed it with the free coronary sinus wall using a 6.0 Prolene suture, under cardioplegic arrest.


   Footnotes
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 References
 
Address reprint requests to Dr Mohl, Department of Cardiac and Thoracic Surgery, General Hospital of Vienna, Währingergürtel 18–20, A-1090 Vienna, Austria (E-mail: werner.mohl{at}akh-wien.ac.at).


   References
Top
 Footnotes
 Abstract
 Introduction
 Comment
 References
 

  1. Menasché P, Subayi JB, Piwnica A. Retrograde coronary sinus cardioplegia for aortic valve operations: a clinical report on 500 patients. Ann Thorac Surg 1990;49:556–64.
  2. Menasché P. Coronary sinus retroperfusion for myocardial protection: pragmatic observations and caveats based on a large experience. In: Karp RB, Laks H, Wechsler AS, eds. Advances in cardiac surgery. Vol. 4. St. Louis: Mosby-Year Book, 1993:157–72.
  3. Geha AS, Lee JH. Retrograde cardioplegia cannulation during cardiopulmonary bypass. Ann Thorac Surg 1993;55:175–6.
  4. Weiss SJ. Management of difficult coronary sinus rupture. Ann Thorac Surg 1994;58:548–50.
  5. Panos AL, Ali IS, Birnbaum PL, Barrozo CAM, Al-Nowaiser O, Salerno TA. Coronary sinus injuries during retrograde continuous normothermic blood cardioplegia. Ann Thorac Surg 1992;54:1137–8.[Abstract/Free Full Text]



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