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Ann Thorac Surg 2000;69:927-929
© 2000 The Society of Thoracic Surgeons

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Case Reports

Uncommon complication of arterial switch operation: tracheobronchial compression

^a Department of Thoracic and Cardiovascular Surgery, University of Istanbul, Istanbul Medical School, Istanbul, Turkey

Address reprint requests to Dr Toker, nönü Cad Yildiz Sok STFA B-6 Blok Daire: 13, Kozyatai, stanbul 81090, Turkey
e-mail: korkutbostanci{at}superonline.com

	Abstract

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We describe 2 patients in whom symptoms of airway compression developed after arterial switch operation for correction of the transposition of the great arteries. The clinical features, diagnosis, management, and proposed mechanisms of this complication are described.

	Introduction

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Compression of the tracheobronchial tree by vascular structures is a well-known pathology. Tracheobronchial compression after operation for congenital heart diseases is a rare entity and only a few cases have been reported [1–4].

	Case reports

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Patient 1
A female newborn was diagnosed to have transposition of the great arteries (TGA). Arterial switch operation was performed on the 7th day of life by means of a technique described by Quaegebeur and colleagues [5]. Lecompte maneuver was performed to bring the neopulmonary artery in front of the neoaorta. The patient suffered no postoperative complication and was extubated on the 3rd postoperative day. The day after extubation the patient had sudden severe respiratory distress that almost caused pulmonary arrest and she was reentubated. A chest roentgenogram revealed left lung atelectasis. After hemodynamic stabilization of the patient, bronchoscopic examination was performed with an open-tube rigid bronchoscope with 3.3 mm outer diameter (OD). A tracheal stenosis 6 cm from the mouth was noticed and it was impossible to pass the bronchoscope through the stenotic segment. A tracheogram revealed tracheal stenosis and filling defect of the left main bronchus (Fig 1). Though hemodynamically stable, without inotropic medication, the patient could not be weaned from the mechanical ventilator. Weekly rigid bronchoscopic examinations and tracheal dilatations with the broncoscope with an increasing OD were performed. During these procedures the left lung began to aerate. On the 4th week, bronchoscopic examination revealed no tracheal stenosis but 30% obstruction of the left main bronchus confirmed by tracheography (Fig 2). The patient still could not be weaned from the mechanical ventilator and tracheostomy was performed. The patient was kept on mechanical ventilation for 1 more month. On control bronchoscopic examination, the left main bronchus was noticed to be completely normal. She was gradually separated from the mechanical ventilation. The tracheostomy cannula was taken out and the patient was discharged with normal chest roentgenogram findings. She is 18 months old and lives symptom free.

View larger version (63K): [in this window] [in a new window]   Fig 1. (Patient 1.) Tracheogram showing tracheal stenosis and filling defect of the left main bronchus in anteroposterior (A) and left lateral (B) views.

View larger version (169K): [in this window] [in a new window]   Fig 2. (Patient 1.) Tracheogram revealing no tracheal stenosis but 30% obstruction of the left main bronchus after tracheal dilatation.

View larger version (88K): [in this window] [in a new window]   Fig 3. (Patient 2.) Thoracic computed tomographic scan showing that the left main bronchus is left to cross a space that is very narrow between the vertebral body and ascending aorta.

	Comment

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Another very uncommon complication of the procedure is tracheobronchial compression [3, 4]. Worsey and colleagues [3] and Robotin and colleagues [4] reported a total of four cases in which tracheobronchial compression was noticed at 4, 5, 12, and 20 weeks after operation. Our 2 patients presented with these symptoms on the 4th day and in the 3rd month.

We believe that tracheal stenosis in patient 1 aggravated the symptoms and caused early diagnosis of this complication. Nonetheless, we do not believe that the tracheal stenosis was due to the procedure itself or that it was congenital. Probably it was because of early granulation tissue due to intubation. If it had been a congenital stenosis, it would have been impossible to dilate the trachea. Patient 2 presented at week 12, which was similar to other cases in the literature [3, 4]. Symptoms of presentation were the same, eg, severe and sudden onset. Bronchoscopic examination was performed as a first-line diagnostic tool and compression of the left main bronchus was visualized in patient 2. Tracheography in patient 1 helped us to notice the hidden left main bronchial stenosis. Thus we agree with Corno and associates [2] that tracheography is one of the most useful diagnostic methods in congenital heart disease and coexisting airway obstruction. However, the hemodynamic status of the patient must be well enough to tolerate the procedure.

As presented in other reports, airway obstruction is believed to be the result of compression of the left main bronchus between the neoaorta and descending aorta. We performed high transection on the great arteries and Lecompte maneuver in the last 10 TGA cases and did not see this complication. We performed high transection because we believed the root of the neoaorta was preserved and the anastomotic region stayed above the left main bronchus level. In the 2 patients presented here, we had mobilized the pulmonary arteries including their bifurcations and divided the patent ductus arteriosus, but we had not used the high transection and anastomosis technique. The neoaorta anastomotic line stayed in the lower position causing compression of the left main bronchus, and the bronchus was trapped between the neoaorta, descending aorta, and vertebrae (Fig 3). Patient 1 did not have the chance to present with symptoms of bronchial stenosis as she had symptoms of tracheal stenosis. We managed both of her problems simultaneously. The left main bronchus stayed open, which might have been due to increased endobronchial pressure and increased cartilaginous ability to resist the arterial pressure. We did not consider aortopexy and left main bronchus liberalization operation for patient 1 after the tracheal stenosis had been managed, because the tracheobronchogram showed only 30% obstruction of the left main bronchus. As patient 2 did not have additional tracheal stenosis, we planned aortopexy and left main bronchus liberalization operation for him.

In conclusion, left main bronchus compression after arterial switch operation is a complication of the procedure itself. Compression of the bronchus is not only between the ascending and descending aortas but also the vertebrae. Though we do not feel that prolonged mechanical ventilation is the preferred method of treatment, it may be helpful in bronchial stenoses with additional tracheobronchial pathologies. Patients who are believed to have respiratory problems in the postoperative period should be evaluated endobronchially with rigid bronchoscopy for left main bronchus compression.

	References

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1. Leijala M., Sairanen H., Makinen L., Maunuksela E.L., Louhimo I. Iatrogenic, unexpected and other vascular rings in children. Eur J Cardiothorac Surg 1989;57:125-129.
2. Corno A., Giamberti A., Giannico S., et al. Airway obstruction associated with congenital heart disease in infancy. J Thorac Cardiovasc Surg 1990;109:1-8.
3. Worsey J., Pham S.M., Newman B., Park S.C., del Nido P.J. Left main bronchus compression after an arterial switch for transposition. Ann Thorac Surg 1994;57:1320-1327.[Abstract/Free Full Text]
4. Robotin M.C., Bruniaux J., Serraf A., et al. Unusual forms of tracheobronchial compression in infants with congenital heart disease. J Thorac Cardiovasc Surg 1996;112:415-423.[Abstract/Free Full Text]
5. Quaegebeur J.M., Rohmer J., Ottenkamp J., et al. The arterial switch operation. J Thorac Cardiovasc Surg 1986;92:361-384.[Abstract]
6. Castañeda A. Management of complications related to surgery for transposition of the great vessels. In: Waldhausen J., Orringer M., eds. Complications in cardiothoracic surgery. St. Louis: Mosby, 1991:195-201.

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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): Alper Toker Korkut Bostanci Enver Dayioglu Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Toker, A. Articles by Dayioglu, E. Search for Related Content PubMed PubMed Citation Articles by Toker, A. Articles by Dayioglu, E. Related Collections Related Article