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Ann Thorac Surg 2004;78:1827-1829
© 2004 The Society of Thoracic Surgeons

Case report

Aortopulmonary Fistula Due to Perforation of the Aortic Wall of a Freestyle Stentless Valve

Yoichi Kameda, MD*,a, Kazumi Mizuguchi, MDa, Toshiyuki Kuwata, MDa, Tohru Mori, MDa, Shigeki Taniguchi, MDb

a Department of Cardiovascular Surgery, Ishinkai Yao General Hospital, Yao, Osaka, Japan
b Department of Thoracic and Cardiovascular Surgery, Nara Medical University, Kashihara, Nara, Japan

Accepted for publication July 21, 2003.

* Address reprint requests to Dr Kameda, Department of Cardiovascular Surgery, Nara Medical University, Shijo-Cho 840, Kashihara, Nara 634-8522, Japan
ykameda{at}naramed-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Aortopulmonary fistula occurring as a result of a rupture of the aortic wall of a stentless valve has not been previously reported. A 71-year-old woman suffered aortopulmonary fistula 15 months after replacement of the aortic root with a Freestyle stentless valve (Medtronic, Inc, Minneapolis, MN) and Dacron graft extension to replace the aortic valve and the ascending aorta to the aortic arch. We describe the successful repair of the fistula and simultaneous mitral valve replacement. The cause of deterioration of the aortic wall of the stentless valve, which gradually developed and ruptured, may have been primarily structural injury at the previous operation, with additional insult from the surgical adhesive used.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
The porcine stentless bioprosthesis has gained favor in comparison with its stented counterparts due to its excellent hemodynamic performance and, in the elderly population, its promised durability [1]. In cases of an ascending aortic aneurysm with aortic valve regurgitation, a full root replacement using a stentless valve benefits elderly patients, as anticoagulant therapy is unnecessary [2, 3]. We report the case of an uncommon complication in which the aortic wall of the stentless valve (used for a full root replacement) perforated, resulting in a fistula to the pulmonary artery.

A 70-year-old woman with an aneurysm involving the ascending aorta to the aortic arch and severe aortic valve regurgitation underwent surgery on November 28, 2001. To replace the aortic valve and the ascending aorta to the aortic arch, a full root replacement was carried out using a 23-mm Freestyle stentless valve (Medtronic, Inc, Minneapolis, MN) with 120° rotation technique and with continuity to a Dacron graft (UBE shield graft [Ube Industries LTD, Yamaguchi, Japan]). The proximal anastomosis was performed using a continuous 4-0 polypropylene suture with autologous pericardium strip as an external reinforcement. The pulmonary artery was injured when the aneurysm was dissected, and some sutures were necessary for hemostasis. After the operation, the patient underwent mediastinal re-exploration for bleeding that was found around the pulmonary artery and at an anastomotic site. Complete hemostasis was obtained by compression using biological glue (Biobond [Mitsubishi Pharma Corp, Osaka, Japan]) and a fibrillar absorbable hemostat (Surgicel [Johnson & Johnson]). Additional sutures were not required. Thereafter, the patient's postoperative course was uneventful. After discharge, she visited our outpatient department monthly for regular follow-ups, including serial echocardiography and chest roentgenograms, because of mild congestive heart failure (New York Heart Association class II) attributable to moderate mitral valve regurgitation, which had developed postoperatively in contrast to mild regurgitation preoperatively.

On February 13, 2003, the patient presented with general fatigue, chest pain, and back pain. Her blood pressure was 90/50 mm Hg, and she was in a pre-shock state with anuria. The chest roentgenogram showed a widened mediastinal shadow, compared with the scan from 3 months previously. An echocardiogram demonstrated a para-aortic fluid collection, and color Doppler echocardiography showed a turbulent flow jet, originating from the posterior wall of the Freestyle prosthesis (Medtronic, Inc). Severe mitral regurgitation was also demonstrated. Contrast computed tomography confirmed a para-aortic hematoma with leakage of contrast medium from the ascending aortic prosthesis. It also suggested low cardiac output, as contrast enhancement beyond the descending aorta was very slow (Fig 1).



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  		Fig 1. Contrast-enhanced computed tomography confirmed a para-aortic hematoma with leakage of contrast medium from the ascending aortic wall of the prosthesis.

 
Emergency surgery was performed with mitral valve replacement and repair of the perforated Freestyle stentless valve (Medtronic, Inc). Intraoperatively, the hematoma was found to be encapsulated by thick fibrous tissue. After opening the capsule and removing the thrombus debris, the posterior wall of the Freestyle conduit (Medtronic, Inc) was inspected through transection of the Dacron graft (UBE shield graft [Ube Industries LTD, Yamaguchi, Japan]). Two holes (5 x 7 mm and 3 x 5 mm in size) were found in the Freestyle aortic wall (Medtronic, Inc) about 1 cm distal to the left coronary orifice anastomosis, and about 5 mm proximal to the anastomotic line between the Freestyle graft and prosthetic vascular graft (Medtronic, Inc), which was at the noncoronary sinus of the Freestyle valve (Medtronic, Inc) (Fig 2). A hole in the pulmonary artery with a diameter of 1 cm was found. Some sutures were also found near the hole; therefore the hole was considered to be made at the time of the previous operation. Accordingly, we were convinced that this patient's compromised state was caused by the fistula between the Freestyle valve (Medtronic, Inc) and the pulmonary artery. The hole in the pulmonary artery was closed with a Dacron patch. The tissue at the site of the perforation in the Freestyle conduit (Medtronic, Inc) was friable, and it was resected as much as possible and was replaced with a new Dacron graft. The proximal portion of the graft was prepared by cutting a scallop to match the remaining Freestyle wall and was reinforced by a polytetrafluoroethylene felt strip. Mitral valve replacement was performed with a 25-mm bioprosthesis (Carpentier-Edwards Perimounted Pericardial Bioprosthesis [Edwards Lifesciences LLC, Irvine, CA]).



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  		Fig 2. Two holes (5 x 7 mm and 3 x 5 mm) were found in the Freestyle aortic wall about 1 cm distal to the left coronary orifice, about 5 mm proximal to the anastomotic line between the Freestyle graft and prosthetic vascular graft (Medtronic, Inc, Minneapolis, MN). The forceps have been inserted into one of the holes.

 
An intraaortic balloon pump was necessary to allow discontinuation of cardiopulmonary bypass support and continuous hemodialysis was required postoperatively for 2 days.

Pathologic findings of the resected Freestyle wall showed interrupted media, and the medial fibers were disarrayed and torn. No inflammatory changes were observed (Fig 3). Postoperative computed tomography demonstrated no leakage of contrast medium. The patient was discharged on postoperative day 46 without any complications.



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  		Fig 3. Microscopic appearance of the resected Freestyle wall: the media is interrupted and the medial fibers are disarrayed and torn. There is no infiltration of inflammatory cells. (Elastica van Gieson's stain; x100.)

 

   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Although there is one report of the need for reoperation for a Freestyle valve (Medtronic, Inc) for infective endocarditis or leaflet deterioration [4], we believe reoperation for aortic wall rupture of a Freestyle valve (Medtronic, Inc) has never been reported. Unfortunately, in our case, an aortopulmonary fistula developed secondary to injury of the pulmonary artery at the previous operation, and emergent surgery was required because the patient fell into a state of shock.

The definite cause of the wall disruption of the Freestyle prosthesis (Medtronic, Inc) remains uncertain, but we speculate the following may have happened: The aortic wall of the Freestyle valve (Medtronic, Inc) may have suffered some structural injury due to possible pinching of forceps during the previous operation, the lesion gradually developed over time, and the wall finally ruptured. Because the noncoronary sinus of the Freestyle conduit (Medtronic, Inc) is one of the thinnest parts and is sometimes diaphanous, this part may be easily injured by manipulations. The patient's own healing mechanism may not function to repair the Freestyle valve (Medtronic, Inc), which is a porcine xenograft. In addition, reports of reoperation on a Freestyle valve (Medtronic, Inc) indicate that it can be accessed and divided with ease due to only mild adhesion to the surrounding tissues [4]. Pathologic findings implicate these factors, because there were no inflammatory changes, no infiltration of macrophages or fibroblasts, and the layers of the media were disarrayed and interrupted.

The patient underwent re-exploration for bleeding, and hemostasis was achieved by compression using biological glue (Biobond [Mitsubishi Pharma Corp, Osaka, Japan]) and a fibrillar absorbable hemostat (Surgicel [Johnson & Johnson]). The use of this adhesive may have affected the aortic wall of the Freestyle valve (Medtronic, Inc). Biobond is a plastic fixation material, which is a mixture of methyl 2-cyanoacrylate monomer, polyisocyanate, and nitrometane solution of nitrile rubber. Methyl 2-cyanoacrylate, the main ingredient of this adhesive, has been reported as a possible cause of fusiform dilatation of middle size arteries (carotid, femoral, and axillary arteries) of mongrel dogs due to infarction of the arterial wall. However, none of the vessels was disrupted because of maintenance of the elastic tissues that apparently gave the arterial strength. This infarction was described as the disappearance of nuclei from the media and severe inflammatory change in the media [5]. Accordingly, it was uncertain that this adhesive truly affected the Freestyle valve (Medtronic, Inc).

Although we could have completely removed the damaged Freestyle valve (Medtronic, Inc), the leaflets of the valve had no lesions, and the residual aortic wall after resection of the deteriorated tissue appeared to be durable. Therefore we preserved the undamaged part of the Freestyle valve (Medtronic, Inc) as much as possible, and we replaced the ascending aorta with a Dacron graft. Because of the patient's serious condition and the necessity for mitral valve replacement, we had to perform the simplest operation possible to repair the fistula.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Neal DK, Robert DR, Sandy MA, Dalane WK, Robert C. Eight-year results of aortic root replacement with the Freestyle porcine aortic root bioprosthesis. Ann Thorac Surg. 2002;73:1817–1821[Abstract/Free Full Text]
  2. Belhhan A, Mustafa G, Saide A, Ilhan S, et al. The use of stentless valves for root replacement during repair of ascending aortic aneurysms with aortic valve regurgitation. Heart Surg Forum. 2002;5:52–55[Medline]
  3. Markowitz A. Utility of the full root bioprosthesis in surgery for complex aortic valve-ascending aortic disease. Semin Thorac Cardiovasc Surg. 2001;13(4 Suppl 1):12–15[Medline]
  4. Deeb GM, Smolens IA, Bolling SF, Eppinger MJ, Pagani FD, Prager RL. Re-operation for Freestyle stentless aortic valves. Semin Thorac Cardiovasc Surg. 2001;13(4 Suppl 1):16–23[Medline]
  5. Weissberg D, Goetz RH. Necrosis of arterial wall following application of methyl 2-cyanoacrylate. Surg Gynec Obstet. 1964;119:1248–1252



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