Ann Thorac Surg 1999;67:244-246
© 1999 The Society of Thoracic Surgeons
Case Reports
Repair of an aneurysm of the pulmonary trunk in a 65-year-old patient
Matthias Roth, MDa,
Oliver T. Reuthebuch, MDa,
Wolf-Peter Klövekorn, MDa,
Erwin P. Bauer, MDa
a Department of Thoracic and Cardiovascular Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
Accepted for publication June 20, 1998.
Address reprint requests to Dr Roth, Department of Thoracic and Cardiovascular Surgery, Kerckhoff Clinic, Max Planck Institute, Benekestr. 2-8, D-61231 Bad Nauheim, Germany
e-mail: (matthroth{at}aol.com)
 |
Abstract
|
|---|
The case of a 65-year-old patient with asymptomaticaneurysm of the pulmonary trunk associated with severe insufficiency of the pulmonary valve and symptomatic coronary artery disease is presented. The surgical procedure included coronary artery bypass grafting, aneurysmectomy, and pulmonary artery replacement with implantation of a stentless bioprosthesis and lengthening of the root of the bioprosthesis with a reversed vascular Y prosthesis, which was anastomosed to the left and right pulmonary artery.
|
Introduction
|
|---|
Aneurysms of the pulmonary trunk are rare lesions. They are mainly caused by primary or secondary pulmonary hypertension [1], chronic pulmonary embolism, or pulmonary valve stenosis [2]. Furthermore, they can be associated with systemic disorders, such as Behçet’s syndrome [3] or Osler’s disease, or with other congenital [4] and acquired cardiovascular diseases. Aneurysms of the pulmonary trunk also develop idiopathically, sometimes in combination with pulmonary valve insufficiency [5]. They rarely cause lethal complications, such as rupture [3, 4], dissection, intrapulmonary erosion, or pulmonary embolism, and can provoke compression of the trachea, the bronchi, the superior vena cava, or the recurrent laryngeal nerve as well.
We report a case of an idiopathic aneurysm of the pulmonary trunk associated with severe insufficiency of the pulmonary valve and coronary artery disease. The surgical procedure will be discussed.
A 65-year-old patient was referred to our hospital for progressive symptomatic coronary heart disease. An asymptomatic aneurysm of the pulmonary artery was diagnosed several years ago. The clinical signs were slight exertional dyspnea and pain of the left hemithorax. Right ventriculography through an open foramen ovale showed a dilated, modestly restricted right ventricle, an enlarged pulmonary trunk 7.2 cm in diameter, a severe pulmonary valve insufficiency, and a mild tricuspid valve regurgitation. Magnetic resonance imaging scan showed an aneurysm of the pulmonary trunk with dilatation of both pulmonary arteries (pulmonary trunk, 6.7 x 7.2 cm; right pulmonary artery, 2.4 cm; left pulmonary artery, 2.5 cm) (Fig 1). Left ventriculography demonstrated normal contractility, whereas coronary angiography revealed a 90% stenosis of the left anterior descending coronary artery and a 60% stenosis of the right coronary artery.
View larger version (162K):
[in this window]
[in a new window]
|
Fig 1. Preoperative magnetic resonance imaging of the pulmonary trunk showing the aneurysm of 7.2 cm in diameter.
|
|
The patient was put on extracorporeal circulation and the left anterior descending and right coronary arteries were bypassed. After this procedure the pulmonary artery (Fig 2) was incised. Examination of the pulmonary valve showed dysplasia of the right cusp. The two leaflets of the pulmonary valve were excised, and a 27-mm stentless aortic bioprosthesis (Cryolife-O’Brien, model 400 aortic, Cryolife International Inc., New Market, USA) was implanted. The root of the bioprosthesis then was lengthened with a 26 x 20-mm reversed vascular Y prosthesis (Vascutek Gel Soft, Vascutek Ltd., Ichinnan, Scotland), and the graft legs were anastomosed to the left and right pulmonary arteries (Fig 3). Finally the entire graft was covered with the remaining aneurysmatic tissue.
The patient did well 1 year after the operation. Postoperative angiogram of the right ventricle revealed a modestly enlarged right ventricle with normal contractility. Peak transpulmonary gradient was 10 mm Hg. The right and left pulmonary arteries showed no signs of external compression (Fig 4).
View larger version (147K):
[in this window]
[in a new window]
|
Fig 4. Postoperative angiography of the right ventricle and the pulmonary arteries with demonstration of the pulmonary trunk (bioprosthesis) and both pulmonary arteries (Dacron prosthesis) with normal diameter.
|
|
|
Comment
|
|---|
In cases of peripheral pulmonary artery aneurysms, the common surgical treatment is aneurysmectomy, ligation, segmental resection, lobectomy [3], or pneumonectomy [4]. Various operations are described in the surgical treatment of aneurysms of the pulmonary trunk, which are resection or aneurysmorrhaphy, dilatation of the pulmonary valve, enlargement of the pulmonary annulus or valvulotomy in cases with pulmonary valve stenoses, the interpositioning of a valved conduit [6], or homograft implantation. A pericardial Y graft had been implanted by Jacob and associates [7] in 1986 in 2 patients with a pulmonary aneurysm and pulmonary insufficiency. Fukada and colleagues [8] showed good results after pulmonary valve replacement with second-generation bioprosthesis, especially in adult patients after a mean follow-up of 5.5 years. On echocardiography no bioprosthetic destruction has been observed; these findings were explained with the minimal hemodynamic stress to the pulmonary valve because of the very low transprosthetic pressure gradient. The old age of our patient and the severe pulmonary valve insufficiency were the main reasons why we decided to implant a porcine stentless aortic bioprosthesis. The poor results of mechanical valves in the pulmonary position and the freedom from anticoagulation after implantation of a bioprosthesis were other reasons. We think that such a procedure is a valuable alternative for elderly patients if a pulmonary homograft is not available [6].
|
References
|
|---|
-
Butto F., Lucas R.V., Jr, Edwards J.E. Pulmonary artery aneurysm. A pathologic study in five cases. Chest 1987;91:237-241.[Abstract/Free Full Text]
-
Tami L.F., McElderry M.W. Pulmonary artery aneurysm due to severe congenital pulmonary stenoses: case report and literature review. Angiology 1994;45:383-390.
-
Tuzun H., Hamuryudan V., Yildirim S., et al. Surgical therapy of pulmonary arterial aneurysms in Behçet’s disease. Ann Thorac Surg 1996;61:733-735.[Abstract/Free Full Text]
-
Fukai I., Masaoka A., Yamakawa Y., et al. Rupture of congenital peripheral pulmonary aneurysm. Ann Thorac Surg 1995;59:528-530.[Abstract/Free Full Text]
-
Onorato E., Festa P., Bourlon F., Yves L., Balerini L. Idiopathic right pulmonary aneurysm with pulmonary valve insufficiency. Cathet Cardiovasc Diagn 1996;37:162-165.[Medline]
-
Barbero-Marcial M., Baucia J.A., Jatene A. Valved conduits of bovine pericardium for right ventricle to pulmonary artery connections. Semin Thorac Cardiovasc Surg 1995;7:148-153.[Medline]
-
Jacob J.L., Garzon S.A., Machado N.C., et al. Pulmonary artery aneurysm. Report of two cases. Arq Bras Cardiol 1989;53:33-37.[Medline]
-
Fukada J., Morishita K., Komatsu K., Abe T. Influence of pulmonic position on durability of bioprosthetic heart valves. Ann Thorac Surg 1997;64:1678-1681.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
S. D. Force, C. L. Lau, N. Moazami, E. P. Trulock, and G. A. Patterson
Bilateral lung transplantation and pulmonary artery reconstruction in a patient with chronic obstructive pulmonary disease and a giant pulmonary artery aneurysm
J. Thorac. Cardiovasc. Surg.,
September 1, 2003;
126(3):
864 - 866.
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Kuwaki, K. Morishita, H. Sato, R. Urita, and T. Abe
Surgical repair of the pulmonary trunk aneurysm
Eur. J. Cardiothorac. Surg.,
November 1, 2000;
18(5):
535 - 539.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
