Ann Thorac Surg 2004;78:1825-1827
© 2004 The Society of Thoracic Surgeons
Case report
Mitral Valve Replacement in a Patient With a Collapsed Lung and a Giant Abscess
Tetsuya Horai, MD*,a,
Keita Tanaka, MDa,
Makoto Takeda, MDa
a Department of Cardiovascular Surgery, Teikyo University Ichihara Hospital, Ichihara City, Chiba, Japan
* Address reprint requests to Dr Horai, Department of Cardiovascular Surgery, Teikyo University Ichihara Hospital, 3426-3 Anesaki, Ichihara City, Chiba 299-0111, Japan
thourai-tky{at}umin.ac.jp
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Abstract
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Mitral valve replacement was performed on a 75-year-old man with a history of pulmonary tuberculosis. Computed tomography showed a collapsed left lung and counterclockwise rotation of the heart due to a hard abscess. Surgery was performed through a median sternotomy, and extensive pericardial suspension was useful for obtaining an adequate view. Despite poor pulmonary function, the patient was extubated on the day of surgery and had an uneventful postoperative course. Cardiac surgery can be performed in patients with a single functional lung if their preoperative respiratory function is good enough to have daily life without dyspnea.
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Introduction
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Cardiac surgery is rarely performed in patients with a single functional lung. Several patients who have undergone cardiac surgery after pneumonectomy [1–5] or with one collapsed lung due to tuberculosis [6] have been reported. We report a patient with a collapsed lung and a giant abscess due to tuberculosis who underwent successful mitral valve replacement.
A 75-year-old man was admitted to our hospital with dyspnea and edema of the legs, and he was found to have mitral regurgitation and congestive heart failure. He had been diagnosed with pulmonary tuberculosis 50 years ago, but he had not suffered from any medical complaints during daily life before the mitral regurgitation had developed. A grade 3 systolic murmur was heard along the left sternal boarder and at the apex. Chest roentgenogram revealed a giant abscess with fluid collection, which caused almost total collapse of the left lung and hyperinflation of the right lung (Fig 1). Computed tomography showed deformity of the left chest wall and a giant abscess with a calcified shell and fluid collection in the left chest cavity. The left lung had collapsed and the heart had been rotated counterclockwise around its long axis due to the hard abscess (Fig 2). Pulmonary function tests revealed severe obstructive and restrictive lung disease. His vital capacity was 1.80 L (55.6% of the predicted value), and the forced expiratory volume in 1 second was 0.86 L (36.9% of the predicted value), which increased to 1.15 L after bronchodilator inhalation. The room-air arterial blood gases showed a normal pH with hypercapnia and hypoxemia; the carbon dioxide tension (PaCO2) was 52.6 mm Hg, and the oxygen tension (PaO2) was 75.1 mm Hg. Echocardiography confirmed severe mitral regurgitation due to prolapse of the anterior leaflet. Electrocardiography showed atrial fibrillation, and coronary angiography showed normal coronary arteries.
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Fig 2. Computed tomography showing a collapsed lung and a hard abscess with counterclockwise rotation of the heart.
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Surgery was performed through a median sternotomy. The right pleura, which crossed the midline, was carefully peeled away from the pericardium so as not to open the right pleural cavity. The heart was rotated counterclockwise, placing the right atrium in a more posterior position than usual. Only the right side of the posterior pericardium was elevated extensively, and the right atrial appendage could be seen.
Cannulation for cardiopulmonary bypass was achieved. An arterial cannula was inserted into the ascending aorta and two venous cannulas were directly inserted into the superior vena cava and through the right atrium with forceful retraction of the aorta and right ventricle into the inferior vena cava. The aorta was cross clamped and the heart was arrested using warm blood cardioplegia. The mitral valve was exposed through a transseptal superior approach, and the exposure was facilitated by stay sutures around the margin of the incision. The valve was replaced with a bi-leaflet mechanical prosthesis (27 mm) (CarboMedics). Weaning from cardiopulmonary bypass was easily achieved.
The patient was extubated on the day of the operation with intravenous administration of aminophylline. Postoperative recovery was uneventful, and results of the pulmonary function tests at 1 month postoperatively were almost the same as those before surgery.
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Comment
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When performing cardiac surgery in patients with a single functional lung, there are two problems. The first is anatomic changes in the thoracic cavity, and the second is respiratory tolerance for cardiac surgery. There are several reports of cardiac surgery in patients with previous pneumonectomy or a single collapsed lung. In cases after left pneumonectomy [3–5] or with a left collapsed lung [6], the heart is rotated clockwise due to deformity of the left chest wall and absence of the left lung. In our patient, who not only had a collapsed lung with chest deformity, but also a giant abscess, the heart was rotated counterclockwise around its long axis. Using a retractor for harvesting of the internal mammary artery as previously described [5, 6], did not help expose the right atrium. Extensive suspension of the posterior pericardium was useful for obtaining an adequate view. Another author described a case of mitral valve replacement after right pneumonectomy that resulted in counterclockwise rotation of the heart [2]. In that case, the mitral valve was approached through the left atrial appendage. In our patient, this approach was not chosen because the left atrial dilation was mild.
Hockmuth and Mills [7] recommended accepting patients for cardiac surgery with cardiopulmonary bypass if their forced expiratory volume in 1 second was greater than 40% of the predicted value and not less than 800 mL, and if resting PaCO2 was less than 50 mm Hg. Our patient did not meet these criteria. But his forced expiratory volume in 1 second increased to 1.15 L after inhalation of a bronchodilator. We decided to perform surgery with the administration of a bronchodilator. Aminophylline was administered after extubation. In addition, extensive respiratory cleansing and early mobilization were carried out to reduce pulmonary complications. Previous literature suggests that the longer the cardiopulmonary bypass time, the more the lung is injured [8]. We chose mitral valve replacement because it requires a shorter cardiopulmonary bypass time than mitral valve repair. We believe that our perioperative management contributed to uneventful recovery of this patient who had not met the criteria for this type of surgery.
In summary, mitral valve replacement was successfully performed in a patient with a collapsed lung and a giant abscess due to tuberculosis. Extensive pericardial suspension was useful for obtaining an adequate view. We think it is possible to perform cardiac surgery in patients with a single functional lung if they have no respiratory symptoms during their daily life.
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References
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Abstract
Introduction
