Excision of a recurrent mediastinal cyst through mid sternotomy with high thoracic epidural anesthesia as the sole anesthetic—A case report

Abstract

A 62-year-old lady, weighing 65 kilos presented to the hospital with complaints of breathlessness, palpitation and chest pain for the past 3 months. She was a hypertensive on treatment with atenalol 50 mg daily. Her heart rate was 62 beats/minute, blood pressure 160/90 mm Hg, auscultation of the chest revealed no abnormality. Electrocardiogram and echocardiogram were normal; chest X ray showed the presence of a recurrent mediastinal mass, which was confirmed by computerized tomographic (CT) scan. The mass was a well-circumscribed cystic attenuating lesion seen in the superior mediastinum extending in to anterior mediastinum on the right side. The lesion extended from the level of aortic arch up to the level of right cardiophrenic recess and the lesion abutted the right atrium. The lesion measured 6 cm anteroposteriorly and 3 cms transversely. There was no evidence of calcification or mural nodule. There was no compression of superior vena cava. Since the tumor did not show evidence of any attachment to major anatomical structure, it was decided to aspirate it percutaneously under imag control. There was no history of muscular weakness or fatigue. Lung function test was normal. In view of the mediastinal swelling, neurologist's consult & electromyogram were obtained and there was no evidence of myasthenia gravis (MG). As per the plan, she underwent a percutaneous aspiration of a mediastinal cyst from the right parastemal space guided by CT scan and the aspirate 9 IJTCVS 097091341931103/009 was clear fluid through most of the procedure. Towards the end, the aspirate from the cyst turned blood stained; therefore she was kept in the hospital for observation and discharged from the hospital the same evening after confirming that there was no hematoma by a check X ray. After a month the patient had recurrence of symptoms; a repeat chest X ray showed recurrence of the mediastinal mass and therefore repeat CT scan was performed. This scan showed that the mass had not only increased in size but also had inhomogeneous shadow which raised the suspicion of hematoma or organized clot within the cyst thus precluding us from a repeat aspiration of the cyst. There were no communication with either the vascular or the airway structures; therefore it was decided to excise the recurrent cyst via mid stemotomy and we suggested about the possibility of performing the surgery with high thoracic epidural anesthesia (HTEA), as the sole anesthetic. The patient was also informed that she would remain arousable during the surgery and she had the right to reject the proposal. At our unit we have already performed several minimally invasive direct coronary artery bypass surgery, off pump coronary artery bypass surgery under HTEA as the sole anesthetic, hence we were confident of performing this surgery also under similar anesthetic technique. To our suggestion of performing the surgery with HTEA as the sole anesthetic, the patient agreed; therefore the patient's consent and the hospital ethics committee clearance were obtained. Preoperative ...