JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
Pledget Induced Cardiogenic Shock Following a Minimally Invasive Aortic Valve Replacement
Alexandra E. Tedesco, Victor E. Tedesco IV, MD
Within the last decade, minimally invasive valve replacements have become exceedingly popular, and as a result, sohas the rise of technology aimed at refining and simplifying these techniques. With new technology, new complications are inevitable. We present a routine Minimally invasive aortic valve replacement through a right anterior minithoracotomy complicated by pledget impaction in a coronary artery.
INTRODUCTION
Minimally invasive aortic valve replacement (MIAVR) through a right anterior minithoracotomy has become an increasingly utilized and accepted alternative to traditional sternotomy in patients in need of aortic valve replacement because of the decreased surgical trauma and more favorable cosmetic outcomes. 1 Furthermore, MIAVR has been associated with lower perioperative morbidity and comparable long term survival rates. 1,2 We provide an account of a MIAVR case complicated by pledget induced cardiogenic shock. To the best of our knowledge, this report is the first of its kind within the literature.
arterial, and venous cannulae were removed. Transesophageal echocardiogram revealed normal left ventricular function and no evidence of a paravalvular leak. The cardiopulmonary bypass and aortic cross-clamp times were 81 minutes and 61 minutes, respectively. After approximately 15 minutes of being off cardiopulmonary bypass, with the wounds essentially closed, the patient suddenly became hemodynamically unstable and developed significant dysrhythmias. The patient’s systolic arterial blood pressure dropped to the 50s, and she subsequently became asystolic. We quickly began CPR. The femoral artery and vein was re-exposed and the patient was re- hepariniazed. The patient was placed back on cardiopulmonary bypass. At this point, transesophageal echo revealed severe global left ventricular dysfunction with an ejection fraction of around 10%. At this point, we were concerned that were was potentially something wrong with coronary flow and the decision was made to convert to a sternotomy. The aorta was crossclamped and cold blood cardioplegia again given through the aortic root. The aortotomy was reopened and examination of the coronary ostia revealed a pledget lodged within the left main coronary artery. The pledget was removed. A thorough search revealed the source of the pledget. A suture tied with the assistance of the COR-KNOT device had popped with the suture still intact in its location, but only half of the suture was in the aortic annulus and the valve sewing ring. A new valve suture was placed to cover this location. The aorta was reclosed in the same manner described previously. The patient was weaned off the cardiopulmonary bypass and wounds were closed in the usual fashion. Transesophageal echocardiogram revealed no aortic insufficiency, and left ventricular function returned to normal. The patient left the operating room in guarded but stable condition. Postoperative care was uneventful, and the patient recovered well.
CASE REPORT
A 67-year-old woman presented to the hospital complaining of severe dyspnea on exertion. Physical exam revealed a 4/6 mid- systolic ejectionmurmur over the right second intercostal space. An echocardiogram revealed severe aortic stenosis with 68mm gradient and a .9 cm 2 aortic valve area with good left ventricular function. The patient also had mild mitral regurgitation. A coronary artery angiogram was normal. These findings were indicative of symptomatic critical aortic stenosis and a MIAVR was planned. During the surgery, femoral cannulation was used for cardiopulmonary bypass. An incision was made anteriorly over the right, third rib. The aorta was exposed through the second interspace. CO 2 was infused into the pericardial well, and antegrade cold blood cardioplegia given through the aortic root. A transverse aortotomy was made and the calcified valve excised. Pledgeted sutures were attached to the aortic annulus and the sewing ring of a mosaic porcine valve (21 mm), and the valve parachuted into position. Each suture was tied with the COR-KNOT device and deemed to be intact. The aorta was closed in a standard fashion. The crossclamp removed and patient rewarmed. The patient quickly returned to a sinus rhythm and subsequently was easily weaned from cardiopulmonary bypass. Following Protamine administration, the femoral,
94 J La State Med Soc VOL 169 JULY/AUGUST 2017
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