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Ann Thorac Surg 2002;73:296-297
© 2002 The Society of Thoracic Surgeons
a Long Island Jewish Medical Center, North Shore—LIJ Health System, New Hyde Park, New York, USA
Accepted for publication April 26, 2001.
* Address reprint requests to Dr Graver, Long Island Jewish Medical Center, Rm 2123, 270-05 76th Ave, New Hyde Park, NY 11040, USA
e-mail: Graver{at}lij.edu
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Abstract |
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A 73-year-old woman who presented with severe mitral regurgitation and coronary artery disease underwent coronary artery bypass and mitral valve repair. Routine transesophageal echocardiography (TEE) at the beginning of the operative procedure demonstrated mitral annular dilatation and a dilated left atrium. A patent foramen ovale (PFO) was noted with a small left-to-right shunt early in the operative procedure. Minimally invasive harvest of the greater saphenous vein was performed simultaneous with sternotomy and takedown of the internal thoracic artery as is our routine. Using our routine MIVH technique, the greater saphenous vein (GSV) was identified 2 cm inferior to the tibial plateau through a 2-cm incision. The working endoscope was used to bluntly dissect the surrounding tissue from the GSV. Carbon dioxide (CO2) was insufflated at 12 Torr to develop a subcutaneous tunnel around the vein. Side branches of the GSV were identified and divided using bipolar cautery shears. Dissection was continued to the junction of the GSV and the common femoral vein where a counter-incision was made and the GSV was ligated proximally and divided. During the division of the side branches of the GSV, the anesthesiologist noted gas emboli entering the right ventricle and, subsequently, the left atrium and left ventricle. There was clear-cut passage of bubbles across the PFO and subsequent macroembolization to the systemic arterial system. The right ventricle exhibited acute failure with elevation of the central venous pressure and increased right-to-left shunting across the PFO. Despite cessation of the CO2 insufflation, the gaseous embolic process continued for several minutes. Treatment consisted of placing the patient in Trendelenburg position, rapid systemic heparinization, and pharmacological elevation of the systemic blood pressure with an alpha-adrenergic agonist.
With subsequent recovery of right ventricular contraction, the patient was carefully placed on cardiopulmonary bypass and underwent coronary bypass using the left internal thoracic artery to the left anterior descending coronary artery, and reversed saphenous vein graft to the posterior descending coronary artery. The mitral valve was repaired using an annuloplasty ring. The PFO was closed through the left atriotomy with a single figure-of-eight suture.
Postoperatively, the patient had an uneventful course. She was extubated approximately 24 hours after surgery. No focal or diffuse neurologic sequelae were noted, and she was discharged to home on the 6th postoperative day.
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The routine use of TEE during cardiovascular procedures should make early detection of micro- and macroembolization of CO2 prompt and easier. Absent the availability of TEE monitoring, it might perhaps be prudent to either forgo the use of MIVH or use an alternative technique which does not require gas insufflation.
Microembolization of CO2 to the right-sided chambers should be well tolerated due to the rapid and complete solubility of CO2 in the circulation. The presence of a PFO makes the occurrence of micro- and macroembolization a great deal riskier as illustrated in this case. Significant embolization of gas into the left heart can be associated with acute right-sided (and if severe, left-sided) cardiac decompensation. The resulting elevations of right-sided filling pressures will generally exacerbate the problem by further increasing right-to-left interatrial shunting. We now consider the presence of a PFO to be a relative contraindication to MIVH. Whether or not there is an obvious PFO, we are vigilant for gas embolization on the TEE during harvest of the conduit with minimal access techniques requiring CO2 insufflation. In addition, we now use the lowest possible insufflation pressure during MIVH and are careful not to exceed 12 Torr.
Management of this problem in the setting of a cardiac surgical procedure should include: rapid heparinization, Trendelenburg positioning, and pharmacological elevation of the blood pressure. CO2 insufflation is ceased at the earliest sign of right-sided embolization. If cardiovascular collapse progresses, it is reasonable to consider needle aspiration of the right atrium, left ventricle, and aorta. Alternatively, rapid institution of cardiopulmonary bypass may ultimately be necessary.
Increased interest in minimal access conduit harvesting (including the radial artery and the gastroepiploic artery) will undoubtedly uncover previously unanticipated technical complications such as pneumoperitoneum, pneumothorax, venous and pulmonary gas embolism, subcutaneous emphysema, and hypercarbia. The cardiac surgical team needs to remain vigilant to prevent these technical issues from becoming life threatening when they do occur.
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