Ann Thorac Surg 2006;82:e17-e18
© 2006 The Society of Thoracic Surgeons
Case report
Unusual Cause of Femorofemoral Cardiopulmonary Bypass Failure
Marek Gwozdziewicz, MD, PhDa,*,
Petr N
mec, MD, PhDa,
Martin Troubil, MDa,
Dan Marek, MD, PhDb
a Department of Cardiac Surgery, University Hospital Olomouc, Olomouc, Czech Republic
b Department of Cardiology, University Hospital Olomouc, Olomouc, Czech Republic
Accepted for publication May 2, 2006.
* Address correspondence to Dr Gwozdziewicz, University Hospital Olomouc, I. P. Pavlova 6, 775 15 Olomouc, Czech Republic. (Email: gwozdziewicz{at}email.cz).
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Abstract
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A case of femorofemoral cardiopulmonary bypass failure in a patient undergoing an emergent operation because of acute aortic dissection is described. The importance of the accurate deduction of preoperative transesophageal echocardiography findings is emphasized.
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Introduction
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Femorofemoral cardiopulmonary bypass (FFB) is a type of partial extracorporeal circulation that is used in cardiothoracic surgery [1]. Apart from its use in surgery on the descending thoracic aorta, it can be used during resuscitation in the cardiac surgery unit [2]. We describe FFB failure in a resuscitated patient during emergent surgery for aortic dissection.
A 70-year-old man was admitted to our department with a diagnosis of type A acute aortic dissection. The patient was transferred to the operating room for emergent surgery. Transesophageal echocardiography was performed after anesthesia induction. The examination revealed no pericardial effusion, good left ventricular function (ejection fraction > .50) and grade I (mild) aortic regurgitation with a 55-mm ascending aorta diameter. No anomalous communications between either heart chambers or great arterial vessels were detected. Echocardiography confirmed an aortic dissection with a false channel that extended proximally along the interventricular septum (Fig 1).
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Fig 1. Transesophageal echocardiography image of acute aortic dissection shows extension of the false lumen of the dissection along the interventricular septum. Ao = ascending aorta; LA = left atrium; LV = left ventricle; RV = right ventricle; IVS = interventricular septum; F = false lumen of the aortic dissection.
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While the right axillary artery was exposed and prepared for cannulation, electromechanical dissociation occurred. External heart massage was started and FFB was introduced through both the left femoral artery and vein. Subsequently, low blood pressure was measured in both radial arteries, which could not be raised either by increasing the pump flow or with vasoactive agents. Moreover, the blood circulating through the venous line was unexpectedly oxygenated. Cannulation of the axillary artery was completed immediately, and cardiopulmonary blood flow was altered to proceed in an antegrade direction. This maneuver did not restore systemic blood pressure to normal levels, however.
The chest was opened, the right atrium was cannulated for venous return, and a cross clamp was applied on the ascending aorta. This process led to normal deoxygenated venous drainage into the cardiopulmonary bypass machine and the reappearance of normal systemic blood pressure. The aorta was opened and the heart was arrested with a selective, antegrade, crystalloid cardioplegic solution.
The entry tear of the dissection was typically localized above the aortic valve in which the cusps appeared normal. The dissection continued proximally with a direct rupture into the right ventricle. Repair of this defect was approached through the right atrium and tricuspid valve with interrupted pledgeted suture. Because of the partial destruction of the aortic root, no attempt was made to preserve the aortic valve. The valve and ascending aorta were replaced with an aortic conduit using a modified Bentall procedure.
The process of weaning from the bypass machine was uneventful, and the patient was subsequently transferred to the intensive care unit. Immediately after surgery, the patient presented with disseminated intravascular coagulopathy and severe renal, liver, and lung dysfunction developed. He died on the second postoperative day from multiorgan failure.
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Comment
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Aortic dissection is a life-threatening disease of the thoracic aorta. Emergent surgery is indicated in patients with type A aortic dissection. FFB is not recommended in patients with aortic dissection because of the risk of brain hypoperfusion, which may be caused by directing cardiopulmonary blood flow into the false lumen of the dissection. Instead, antegrade bypass flow using axillary artery cannulation is currently recommended [3]. However, the use of FFB is an option for stabilizing the hemodynamics of a patient if resuscitation commences before the chest is opened.
The most serious complication of FFB is the retrograde dissection of both the femoral artery and aorta [4]. This problem would present with a decrease in both arterial pressure and venous return after commencing the cardiopulmonary bypass.
In this patient, FFB failure was the result of an aorta–right ventricle fistula caused by the rupture of the false lumen of the aortic dissection into the right ventricle, which occurred during the preparation of the axillary artery. This rupture led to the shunting of oxygenated blood from the aorta through the right ventricle and directly into the venous cardiopulmonary circulation.
A preoperative diagnosis of an aortic dissection rupture into the right ventricle during patient preparation for surgery is difficult. Once suspected, steps should be taken to apply a cross clamp on the ascending aorta as soon as possible after commencing cardiopulmonary bypass to prevent a significant left-to-right shunt of blood flow and to restore systemic blood pressure.
In conclusion, a preoperative echocardiography finding of aortic dissection with false lumen that extends along the interventricular septum should increase awareness of the possibility of an aortic rupture into the right ventricle with a subsequent creation of a hemodynamically significant aorta-to-right ventricle fistula.
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References
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- Coady MA, Mitchell RS. Femoro-femoral partial bypass in the treatment of thoracoabdominal aneurysms Semin Thorac Cardiovasc Surg 2003;15:340-344.[Medline]
- Martin GB, Rivers EP, Paradis NA, Goetting MG, Morris DC, Nowak RM. Emergency department cardiopulmonary bypass in the treatment of human cardiac arrest Chest 1998;113:743-751.[Medline]
- Moizumi Y, Motoyoshi N, Sakuma K, Yoshida S. Axillary artery cannulation improves operative results for acute type a aortic dissection Ann Thorac Surg 2005;80:77-83.[Abstract/Free Full Text]
- Orihashi K, Sueda T, Okada K, Imai K. Detection and monitoring of complications associated with femoral or axillary arterial cannulation for surgical repair of aortic dissection J Cardiothorac Vasc Anesth 2006;20:20-25.[Medline]
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Abstract
Introduction
