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Ann Thorac Surg 1999;67:1162-1163
© 1999 The Society of Thoracic Surgeons

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Case Reports

Shunt control of bleeding after homograft replacement of the ascending aorta

^a Department of Surgery, Louisiana State University Medical Center, Shreveport, Louisiana, USA

Accepted for publication September 24, 1998.

Address reprint requests to Dr Mancini, Department of Surgery, Louisiana State University Medical Center, 1501 Kings Highway, Shreveport, LA 71130
e-mail: mmanci{at}lsumc.edu

	Abstract

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Homograft replacement of the ascending aorta with replacement of the coronary arteries often is accompanied by significant postoperative bleeding from the suture lines that often requires a second exploratory operation. These events occur despite a meticulous operative technique and pharmacologic hemostatic agents. We used hemostatic material to cover the homograft as patch to create a watertight seal and placed a left-to-right shunt to control bleeding.

	Introduction

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A 15-year-old boy with idiopathic dilation of the aortic root presented with symptoms consistent with class II congestive heart failure. On examination he was found to have significant aortic regurgitation. Two-dimensional echocardiography demonstrated a 60-mm aortic root with aortic insufficiency. Cardiac catheterization confirmed severe aortic insufficiency and an aortic root measuring 54 mm at the level of the coronary sinuses and 33 mm proximal to the innominate artery. Results of evaluation for Marfan syndrome were negative. The patient was referred for aortic root replacement.

Aortic root replacement was completed with a 24-mm valved aortic homograft conduit with reimplantation of the coronary arteries. Intraoperative transesophageal echocardiography showed satisfactory valvular function. Six hours postoperatively cardiac tamponade developed requiring emergency exploration, in which an anastomotic leak was found at the valvular anastomosis of the homograft. Because direct suture repair of the leak was ineffective in controlling the bleeding, an aorta-to-right atrial fistula was proposed. There was insufficient native aorta to wrap around the homograft to create the fistula. To create a watertight seal around the homograft without compromising flow through the coronary arteries, a portion of a 22-mm Hemashield (Meadox Corp., Oakland, NJ) tube graft was fashioned as an on-lay patch to the native aorta to provide hemostatic closure over the homograft (Fig 1). A 6-mm Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) graft was anastomosed to the Hemashield patch and then to the right atrium to create the left-to-right shunt. The hemorrhage was controlled successfully, and the patient was returned to the intensive care unit in stable condition. The patient had a subsequent uneventful postoperative course. Follow-up echocardiography showed the shunt to remain patent for about 1 week postoperatively followed by spontaneous thrombosis. Thrombus was observed in the plane between the homograft and the Hemashield patch by color-flow Doppler echocardiography. Valve function was normal.

View larger version (57K): [in this window] [in a new window]   Fig 1. Hemashield (Meadox Corp., Oakland, NJ) patch sewn to native aorta covering the homograft replacement of the ascending aorta. The 6-mm Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) graft connects the Hemashield patch to the right atrium forming the left-to-right shunt. (A-V = aorto-venous).

	Comment

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The prosthetic material used allowed the patch to be tailored over the homograft so that coronary flow would not be obstructed. A Hemashield patch was chosen because of its hemostatic property as well as pliability. With the construction of the patch, a watertight seal was obtained around the homograft insuring hemostasis around the root and flow through the left-to-right shunt. Complications from thrombus accumulation beneath the prosthetic material were not observed, and echocardiographic follow-up has not demonstrated compression of the homograft. The 6-mm shunt was chosen to minimize the risk of cardiac failure from rapid shunt flow but still allow for adequate drainage of the area around the homograft.

Although there is no substitute for meticulous surgical technique in aortic root operations, anastomotic bleeding remains a problem despite good technique and pharmacologic hemostatic agents. The use of the shunt should not replace standard operative procedures but does allow for control of hemorrhage in seemingly irreparable situations even when a homograft replacement of the aortic root is used.

	References

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1. Cabrol C., Gandjbakhch I., Cham B. [Anverismes de l’aorte ascendante. remplacement total avec reimplantation des arteres coronaires]. Nouv Presse Med 1978;7:363-365.[Medline]
2. Hoover E.L., Hsu H.K., Ergin A., et al. Left-to-right shunts in control of bleeding following surgery for aneurysms of the ascending aorta. Chest 1987;91:844-849.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Mary C. Mancini Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mancini, M. C. Articles by Cush, E. M. Search for Related Content PubMed PubMed Citation Articles by Mancini, M. C. Articles by Cush, E. M. Related Collections Related Article