Ann Thorac Surg 1999;68:575-576
© 1999 The Society of Thoracic Surgeons
Case Reports
An unusual iatrogenic cause of right coronary air embolism
Robert C. Baker, FRCSa,
Alastair N.J. Graham, FRCSa,
Anne S. Phillips, MDb,
Gianfranco Campalani, MDa
a Cardiac Surgery, Royal Victoria Hospital, Belfast, Ireland
b Anesthesia, Royal Victoria Hospital, Belfast>, Ireland
Address reprint requests to Dr Campalani, Department of Cardiac Surgery, Royal Victoria Hospital, Grosvenor Rd, Belfast BT12 6BA, Northern Ireland
e-mail: gianfranco.campalani{at}general.rght.n-i.nhs.uk
 |
Abstract
|
|---|
A 62-year-old woman undergoing redo mitral valve replacement was noted to have persistent intracardiac air following standard deairing procedures. Transesophageal echocardiography (TEE) identified air bubbles entering the left atrium from the right superior pulmonary vein. Exploration of the pleural cavity revealed a fistula between the pulmonary parenchyma and the right superior pulmonary vein caused by the atriotomy closure suture transfixing the edge of the lung, which was repaired with immediate disappearance of the air emboli. This demonstrates that transesophageal echocardiography is an invaluable aid to ensuring complete deairing after open heart procedures.
|
Introduction
|
|---|
The adverse consequences of air embolism following cardiac surgery are well recognized. Air embolism is usually a result of residual air following intracardiac procedures or malfunction of the pump oxygenator system. We have encountered a case of persistent intracardiac air as a result of a fistula created between the right superior pulmonary vein and anterior hilar margin of the right lung, the diagnosis of which was greatly aided by transesophageal echocardiography (TEE).
A 62-year-old female underwent redo mitral valve surgery, having undergone closed valvotomy 23 years earlier and open mitral valvotomy 3 years previously with the latter giving a good echocardiographic and symptomatic result. However, her symptoms returned and investigations confirmed severe mitral regurgitation. Reoperation was performed through the previous median sternotomy with dissection difficult due to dense adhesions, although neither pleural cavity was opened. Cardiopulmonary bypass was instituted using bicaval cannulation, with antegrade crystalloid cardioplegia, systemic cooling to 28° C, and topical ice slush applied to the heart. The left atrium was opened anterior to the right pulmonary veins and the anterior leaflet of the mitral valve excised. A size 29 Prosthesis Mechanical Mitral Valve (St. Jude Medical, Inc, St. Paul, MN) was inserted using multiple continuous 2-O polypropilene sutures. The left atriotomy was closed with 3-O polypropilene continuous suture.
Deairing was carried out prior to cross clamp removal in the following manner. The patient was placed in the Trendelenberg position and venous return to the pump was partially occluded. The ventricular apex was stabbed with the site allowed to bleed freely, and the left atriotomy vented while the anesthetist manually ventilated the lungs. A 19-gauge needle on a syringe was used to aspirate the roof of the left atrium and left atrial appendage. Prior to removal of the cross clamp the needle was left in place in the ascending aorta.
On attempting to wean from bypass, it was noted that the right ventricle was contracting poorly and becoming dilated, with ST segment elevation apparent on continuous electrocardiogram monitoring.
Right coronary air embolism was suspected and, therefore, the aorta was partially cross-clamped, bypass reinstituted, and further deairing performed. Air bubbles could still be seen emerging from the aortic root. TEE showed a continuous stream of air bubbles emerging from the right superior pulmonary vein into the left atrium (Fig 1).
View larger version (82K):
[in this window]
[in a new window]
|
Fig 1. Transesophageal echocardiograph showing air emerging from the right superior pulmonary vein (a) into the left atrium.
|
|
The right pleura was opened and the right superior pulmonary vein inspected. The atriotomy closure suture was found to be transfixing the anterior hilar margin of the lung to the right superior pulmonary vein, thus causing an alveolar-venous fistula. (This had happened because, in order to reinforce the suture line in correspondence of the right superior pulmonary vein, the suture needle was passed through the pericardium into the pleural cavity and then back to continue the atriotomy suture). The lung was disconnected from the pulmonary vein that was oversewn with 4-O polypropilene.
TEE showed an immediate cessation of air entering the left atrium. Following this, deairing was repeated with the same techniques, with TEE confirming no significant residual intracardiac air or influx of air bubbles. Discontinuation of cardiopulmonary bypass was uneventfulwith extubation possible 17 hours later. There was no detectable neurological deficit, pneumothorax or cardiac enzyme rise, and the patient had a good recovery.
|
Comment
|
|---|
Air embolism from a fistula between the pulmonary vein and a bronchus, following left atrial pressure line insertion [1] and penetrating chest trauma [2, 3], has previously been described. Although TEE has shown air streaming from the pulmonary veins for up to 28 minutes following cardiopulmonary bypass [4], we do not believe this to be the explanation in our patient because a fistulous communication between the lung and pulmonary vein was found by the surgeon. In addition, after disconnection of the fistula and suture of the vein, the streaming of air bubbles immediately ceased. In addition to air bubbles, pools of air have been observed in the pulmonary veins following valve replacement [5, 6]. However, an experienced echocardiographer using TEE observed no pools of air in our patient.
|
References
|
|---|
-
Becker R.M., Gabbay S., Frater R.W.M. Pulmonary venous-bronchial fistula following left atrial pressure line insertion. Chest 1982;81:378-380.[Abstract/Free Full Text]
-
Meier G.H., Wood W.J., Symbas P.N. Systemic air embolization from penetrating lung injury. Ann. Thoracic Surg. 1979;27:161-168.[Abstract]
-
Thomas A.N., Roe B.B. Air embolism following penetrating lung injuries. J Thorac Cardiovasc Surg 1973;66:533-540.
-
Tingleff J., Joyce F.S., Pettersson G. Intraoperative echocardiographic study of air embolism during cardiac operation. Ann Thorac Surg 1995;60:673-677.[Abstract/Free Full Text]
-
Orihashi K., Matsuura Y., Sueda T., Shikata H., Mitsui N., Sueshiro M. Pooled air in open heart operations examined by transoesophageal echocardiography. Ann Thorac Surg 1996;61:1377-1380.[Abstract/Free Full Text]
-
Orihashi K., Matsuura Y., Hamanaka Y., et al. Retained intracardiac air in open heart operations examined by transesophageal echocardiography. Ann Thorac Surg 1993;55:1467-1471.[Abstract]
Accepted for publication January 16, 1999.
This article has been cited by other articles:
|
|
|
|
 
T. Carrel, L. Beyeler, A. Schnyder, P. Zurmuhle, P. Berdat, J. Schmidli, and F. S. Eckstein
Reoperations and late adverse outcome in Marfan patients following cardiovascular surgery
Eur. J. Cardiothorac. Surg.,
May 1, 2004;
25(5):
671 - 675.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
