Ann Thorac Surg 2009;87:e16-e17. doi:10.1016/j.athoracsur.2008.09.043
© 2009 The Society of Thoracic Surgeons
Case Reports
Neonatal Bronchial Reconstruction After Norwood Procedure for Hypoplastic Left Heart Syndrome
Colleen B. Gaughan, MD,
Dao Nguyen, MD,
Marco Ricci, MD*
Division of Cardiothoracic Surgery, Sections of Pediatric Cardiac Surgery and Thoracic Surgery, Holtz Children's Hospital/Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida
Accepted for publication September 11, 2008.
* Address correspondence to Dr Ricci, Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, University of Miami, Holtz Center 3072 (R-114), 1611 NW 12th Ave, Miami, FL 33136 (Email: mricci{at}med.miami.edu).
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Abstract
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Left bronchial obstruction is a rare complication after neonatal aortic arch reconstruction. This article describes the surgical management of a neonate with hypoplastic left heart syndrome who underwent a stage 1 Norwood reconstruction. A mediastinal infection developed with an abscess that caused left bronchial obstruction and disruption. The left bronchus was repaired successfully by using a pedicle intercostal muscle flap that was used to cover the defect.
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Introduction
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Left bronchial obstruction is a rare complication after neonatal aortic arch reconstruction [1]. Various techniques to relieve the vascular compression resulting in obstruction of the left bronchus have been described [2]. In this article we report the management of the left bronchus after bronchial erosion and injury. This article describes the case of a 5-week-old boy with hypoplastic left heart syndrome (HLHS) who underwent a stage 1 Norwood procedure with aortic arch reconstruction by using a homograft patch at age 1 week. A postoperative mediastinal infection developed. This involved the presence of a large abscess underneath the reconstructed aortic arch that caused near complete obstruction of the left mainstem bronchus (Fig 1), partial lung collapse, and significant hypoxemia. We describe the surgical management of this unusual and serious complication.
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Fig 1. (A, B) Preoperative chest computed tomography angiography shows multiple mediastinal abscesses (white arrows) causing compression of the left main stem bronchus.
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After delineating the vascular and airway anatomy by computed tomography angiography (CTA; Fig 1), a left thoracotomy in the fifth intercostal space was used to enter the left pleural space and drain multiple abscess cavities in the posterior mediastinum, the largest one of which caused compression of the left bronchus (Fig 1). One of the mediastinal cultures obtained from the surgical field came back positive for Staphylococcus aureus. Cultures from the tracheobronchial lavage obtained before the operation were negative for any organism and showed a moderate amount of white blood cells.
As the infected material was removed, it was found that the abscess had eroded through the cartilaginous portion of the left bronchus, resulting in a large area of bronchial wall injury and significant air leak (Fig 2). This was a spontaneous rupture and not iatrogenic. The edges of the bronchial injury were relatively smooth and thinned out. The reconstructed aortic arch appeared not to play a role in causing bronchial compression.
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Fig 2. Schematic illustration of the operation conducted through a left thoracotomy shows the reconstructed aortic arch (Ao), the previous right ventricle-to-pulmonary artery (RV-PA) conduit used for the Norwood procedure, and the intercostal muscle flap pedicle. The arrow indicates the left bronchus with a large area denuded and injured. The intercostal muscle flap was used to cover the defect and reconstruct the cartilaginous portion of the left bronchus.
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The air leak from the left bronchus caused a significant loss in tidal volume and affected ventilation. Owing to the infected field and thin and friable bronchial wall, we decided to reconstruct the left bronchus with a pedicle of intercostal muscle flap that was developed from the intercostal space below the incision, as shown in Fig 2. The muscle flap was adequately mobilized and sutured to the bronchial wall and surrounding tissues with 6-0 monofilament suture, thereby covering completely the bronchial defect. This resulted in effective control of the air leak, adequate left lung expansion, and stabilization of the patient. Biologic glue was not used because it was felt not to be needed and potentially dangerous (leak into the airway).
The infant was treated with high-frequency oscillatory ventilation (HFOV) for 2 weeks, and continued to have a small but persistent air leak. The air leak was managed by chest tube thoracostomy and finally resolved after 4 weeks of conservative management. A follow up chest CT scan performed 3 weeks after the operation confirmed the adequacy of the repair with an unobstructed left bronchus (Fig 3).
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Fig 3. (A, B) A postoperative chest computed tomography angiography shows resolution of the mediastinal abscesses and adequate left bronchial repair.
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The patient received 6 weeks of intravenous antibiotic treatment with vancomycin and was discharged home in stable condition more than 9 weeks after the operation. Further follow-up at age 6 months revealed that the child has no symptoms related to airway obstruction. He is scheduled to undergo bidirectional Glenn shunt in the near future.
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Comment
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Left bronchial stenosis due to vascular compression is a rare but well recognized postoperative complication of aortic arch reconstructive procedures [3, 4]. In our patient the aortic arch did not appear to play a role in causing bronchial compression. However, CTA demonstrated that a large abscess cavity resulted in severe left bronchial stenosis, lung collapse, and injury to the left bronchus that became apparent after complete mediastinal débridement.
The management of bronchial injuries in children is challenging. In our patient we elected to perform a bronchial repair by using a pedicle of viable intercostal muscle flap to cover the area corresponding to the bronchial injury. Because of the friability of the bronchial tissue, this flap was secured mostly to the surrounding tissues and allowed bronchial healing.
Postoperative management included HFOV, which minimized mean airway pressure, reduced the risk of flap dehiscence, and facilitated bronchial healing. Long-term antibiotic therapy as well as adequate enteral nutrition also contributed to the patient's metabolic and nutritional recovery. The surgical strategy described herein allowed us to manage a very challenging complication involving left bronchial disruption in a small infant. In this situation, other options such as stenting of the bronchus would have been undesirable for the small size of the airway as well as the presence of an infection.
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References
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- Sakai T, Miki S, Ueda Y, et al. Left main bronchus compression after aortic reconstruction for interruption of aortic arch Eur J Cardiothorac Surg 1995;9:667-669.[Abstract/Free Full Text]
- Yamaguchi M, Ohashi H, Hosokawa Y, Oshima Y, Tsugawa C, Kimura K. Surgical treatment of airway obstruction associated with congenital heart disease in infants and small children Eur J Cardiothorac Surg 1991;5:479-485.[Abstract/Free Full Text]
- Mitchell MB, Campbell DN, Toews WH, Khan TZ. Autograft aortic arch extension and sleeve resection for bronchial compression after interrupted aortic arch repair Ann Thorac Surg 2002;73:1969-1971.[Abstract/Free Full Text]
- Kim YM, Yoo SJ, Kim WH, Kim TH, Joh JH, Kim SJ. Bronchial compression by posteriorly displaced ascending aorta in patients with congenital heart disease Ann Thorac Surg 2002;73:881-886.[Abstract/Free Full Text]
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Abstract
Introduction
