Balloon closure of a surgical aorto-atrial communication.

Abstract

SUMMARY Surgical repair of an extensive dissection of the proximal aorta (Shumway type A or DeBakey type I) was complicated by persistent haemorrhage from the surgical suture lines and via the false lumen. This was controlled by closing the aortic adventitia round the repaired aorta and by creating an anastomosis between the subadventitial space and the right atrial appendage. Though the haemorrhage was contained, the left to right (aorto-atrial) shunt led to a severe low output state, which was corrected by percutaneous closure of the fistula with a detachable balloon. A year after operation computed axial tomographic scanning showed the balloon in place though the paraaortic space persisted and communicated freely with the aorta.Case report A 72 year old woman was referred from another London centre. Two days before she had been admitted with a seven hour episode of severe retrostemal chest pain that culminated in collapse. There was a history of treated hypertension, cigarette smoking, and airways obstruction. She was in pain and drowsy with a systolic blood pressure of 80 mm Hg. Heart sounds were soft and pulses were normal. The initial chest radiograph showed mediastinal widening and a left pleural effusion. Serial electrocardiograms showed inverted T waves and ST segment depression in the anterolateral leads. The concentration of blood urea was 8-7 mmol/l, serum creatinine was 75 pmol/l, haemoglobin was 10-4 g/dl, and the cell white count was 9-2 x 109/1. A computed tomographic scan showed a Shumway type A dissection of the aorta extending from the annulus of the aortic valve to the descending thoracic aorta, with a small pericardial effusion.Because of a rapid rise in blood pressure she was treated with hypotensive agents but the aorta continued to widen. At operation, the arterial pressure was controlled with nitroprusside and the left atrial pressure was monitored indirectly. An atriofemoral bypass was established, the patient was cooled to 18 C, and thiopentone (2 g) was administered for cerebral protection. Total circulatory arrest lasted 35 minutes. When the aortic dissection sac, which affected the entire thoracic aorta, was incised an unusual longitudinal intimal entry tear was identified quite high in the ascending aorta. The ascending aorta was replaced with 24 mm Meadox hemishield, and the repair was wrapped in adventitia.2 The aorta distal to the repair continued to distend and a further large intimal tear in the arch slightly distal to the left subclavian origin (the probable reentry site) was located and treated by the insertion of buttressed sutures. Despite these measures profuse haemorrhage continued via the adventitia enclosing the ascending aorta. This was consistent with one or more defects of the suture line, and a fatal outcome seemed probable. As a lifesaving measure, the haemorrhage was controlled by fashioning a communication between the subadventitial space and the right atrial appendage; this decompressed the paraaortic lumen by allowing blood to return to the venous circuit. Wit...