David's procedure for pulmonary artery aneurysm

J Card Surg. 2020;35:942–945. wileyonlinelibrary.com/journal/jocs

942

|

C A S E R E P O R T

David's procedure for pulmonary artery aneurysm

Renda Circi MD

| Emre Boysan MD

| Bulent Behlul Altunkeser MD

| Nazif Aygul

|

Kumral Cagli

| Kerim Cagli MD

| Erol Sener MD

1

Department of Cardiovascular Surgery, Liv Hospital, Ankara, Turkey

2

Department of Cardiology, Selcuk University, Konya, Turkey

3

Department of Cardiology, Ankara City Hospital, Ankara, Turkey

Correspondence

Kumral Cagli, MD, Ankara City Hospital, Universiteler Mah. Bilkent Cad., No: 1 06800, Cankaya/Ankara, Turkey.

Email:kumralcagli@yahoo.com

Abstract

Pulmonary artery aneurysm (PAA) is a rare entity with fatal complications. Its

silent course contributes to large aneurysms with compression symptoms. We

present a 39

‐year‐old female idiopathic pulmonary arterial hypertension

patient with a giant PAA causing severe pulmonary regurgitation (PR) and

symptomatic left main coronary artery compression (LMCA). Since she had a

failed LMCA stenting attempt, she underwent surgery. A valve

‐sparing

David

‐like pulmonary trunk reconstruction and coronary artery bypass were

performed. This case illustrates that David

‐like reconstruction procedure can

be applied to the PAA with severe PR.

K E Y W O R D S

pulmonary artery aneurysm, pulmonary hypertension, reconstruction

1 | I N T R O D U C T I O N

Pulmonary artery aneurysm (PAA) is defined as a focal dilatation of the pulmonary artery greater than 1.5 times the normal diameter.1_{A true PAA involves all three layers of the vessel wall}

in the main pulmonary artery and/or its branches. It is a rare abnormality and infrequently diagnosed but may represent potentially life‐threatening conditions.2,3PAA may be idiopathic or secondary to an underlying disease including congenital heart diseases, pulmonary hypertension, Behcet's disease, syphilis, tuberculosis, Marfan's syndrome, and vasculitis.4 _Clinical

manifestations of PAA are mostly nonspecific and most patients with PAA remain undiagnosed, even those with large PAAs, because of its silent course. Because of the infrequency of the disease the optimal treatment of PAA remains uncertain with limited experience of surgical or endovascular therapy.3

Idiopathic pulmonary arterial hypertension (IPAH) is an important cause of PAA formation.5_{In IPAH patients PAA may}

result in dissection, rupture, or compression of adjacent structures such as the left main coronary artery (LMCA), main bronchi, or the recurrent laryngeal nerve.5 _{In this report, we}

describe our surgical approach to a patient with IPAH and a giant_{‐size PAA complicated with severe pulmonary regurgitation} (PR) and symptomatic LMCA compression.

2 | C A S E P R E S E N T A T I O N

A 39‐year‐old woman with the diagnosis of IPAH and symptomatic LMCA compression by a PAA was referred to our institution for surgical therapy. She had been diagnosed with IPAH 10 years ago at another institution and was on pulmonary arterial hypertension (PAH)_{‐specific therapy (bosentan plus sildenafil) since then. In May} 2018 she was evaluated for exertional angina. A true PAA of 58 mm compressing the LMCA was detected and the LMCA was percuta-neously stented at the same institution. One year after the percutaneous intervention, she had a control angiography due to recurrent angina pectoris. Control angiography showed 90% stenosis of the LMCA caused by compression and possible restenosis (Figure1A). Computed tomography showed that the main PA was 80 mm in size with the right and left PA's of 30 and 50 mm, respectively (Figure1B). At admission her WHO functional class was II. Physical examination revealed an accentuated pulmonary component of the second heart sound, a III/IV diastolic murmur at the left upper sternal border, and mild hepatomegaly. Electrocardiography was consistent with right ventricular strain. Transthoracic echocardiography revealed a huge PAA (the main PA 78 mm) (Figure 1C), systolic pulmonary artery pressure of 58 mm Hg, and severe PR caused by annular dilation. Right ventricular function was found to be preserved with tricuspid annular plane systolic excursion of 18 mm

and fractional area change of 39%. After evaluation by a Heart Team, she was scheduled for surgical correction of PAA and PR along with the revascularization of the left coronary system.

The right femoral artery and femoral vein were cannulated for cardiopulmonary bypass (CPB). Following a median sternotomy, the left internal mammary artery (LIMA) graft was harvested. Pulmonary artery, aorta, and superior vena cava were dissected (Figure1D). After initiating CPB, further dissection was carried out, the aortic arch and the pulmonary artery branches were thoroughly freed from surrounding tissues. The cross_‐clamp was applied, 20 mL/kg Custadiol (Dr. Franz Köhler GmbH, Switzerland) solution was administered and cardiac arrest was established. PAA was resected proximally about 3 cm above the leaflet level. Both the right and the left PA dissection was extended 1.5 cm laterally from the phrenic nerve. The right PA was fully separated from ascending aorta and superior vena cava. Both PA stumps were circumferentially reinforced with PTFE teflon felts. Main PA was skeletonized. Three subcommissural annuloplasty sutures were placed using 2/0 pledgeted polyester stitch. Six sutures were placed on the root level (primary suture

line, three subcommissural, and three subvalvular). A 30 mm Dacron (Flow Weave BIOSEAL, JOTEC) graft was used for replacement. David's reimplantation technique, which is applied to the aorta is adapted for the PA.6 The pulmonary root was implanted in the graft and the primary sutures were replaced. Then the free vessel wall remnants were sutured to the greft (secondary suture line) using three running 4/0 prolenes. A brief saline test was visually applied (Figure2). Another 30 mm Dacron graft was anatomosed to the right PA using a running 5/0 prolene. The graft was anastomosed to the first graft in an end‐to‐side fashion passing underneath the superior vena cava and the aorta with a 4/0 running prolene. The first graft was anastomosed to the left PA stump with a 5/0 prolene. A biological glue was applied to both branch anastomoses. LIMA was then anastomosed to the left anterior descending artery using 8/0 prolene (Figure 3A‐D). Cross‐clamp was removed. Sinus rhythm was recovered spontaneously. She was taken to the intensive care unit with prophylactic venoarterial extracorporeal membrane oxygenation (ECMO) support. Positive inotropic agents and intravenous sedatives were administered and she was F I G U R E 1 A, Typical ''slit‐like'' compression (arrow) of the left main coronary artery. B, Computerized tomography showing giant pulmonary artery aneurysm (PAA). C, Transthoracic echocardiography, short_{‐axis image showing aneurysm of the main pulmonary artery (MPA),} left pulmonary artery (LPA), and right pulmonary artery (RPA). D, Direct vision of the pulmonary artery aneurysm

entubated for 72 hours. Her oral PAH‐specific medications were continued during the perioperative period and she did not need any parenteral PAH‐specific drugs. She was extubated and ECMO was weaned on the third postoperative day. She was transferred to ward on the fifth postoperative day after an uneventful follow_{‐up. Control echocardiography showed intact pulmonary} artery grafts, mild‐to‐moderate PR, and unchanged right ventricular function (Figure 3E‐G). She was discharged on the tenth postoperative day.

3 | D I S C U S S I O N

This case shows that David's procedure is feasible in patients with IPAH, PAA, and severe PR. Although there is no clear guideline for the best treatment of PAA, surgery is indicated in patients with pulmonary trunk aneurysyms > 5.5 cm.7 Compression of adjacent structures and verification of PAH as in our patient are other recommended indications to relieve symptoms and to diminish the risks of fatal complications.7_{However, patients with PAH may be}

challenging for surgery with very high surgical risk. These patients

must be evaluated by an experienced Heart Team and operated by surgeons familiar with the valve repair/replacement techniques. Double‐lung or heart‐lung transplantation are other possible approaches in these patients.5

Options in PAA surgery include aneurysmorraphy or aneur-ysmectomy.7,8_{For patients with focal aneurysm, aneurysmorraphy}

with excision of the excessive vessel wall is a simple and fast technique but in patients with inflammatory disease and PAH, complete replacement of the entire pulmonary trunk is recommended.4_{This case underlines that another possible surgical}

approach is David's procedure like valve_{‐sparing surgery. This} approach may eliminate the hemodynamic burden of PR on the right ventricle and the vessel wall. Any type of surgery except for double‐lung and heart‐lung transplantation is not curative in IPAH patients but a giant_{‐size PAA with coronary compression,} especially with a failed initial stenting, may force you to take the risks of aneurysm surgery. Interdisciplinary perioperative management is crucial in these patients and may include appropriate anesthesia, careful intraoperative monitoring, prophylactic ECMO, extended ventilatory support, and use of inotropic and vasoactive drugs if needed.

F I G U R E 2 A, Pulmonary root dissection. B, Placement of subcommissural annuloplasty sutures. C, Primary sutures on the root level. D, Saline control

O R C I D

Kumral Cagli http://orcid.org/0000-0002-2632-907X

R E F E R E N C E S

1. Truong QA, Massaro JM, Rogers IS, et al. Reference values for normal pulmonary artery dimensions by noncontrast cardiac computed tomography: the Framingham Heart Study. Circ Cardiovasc Imaging. 2012;5:147‐154.

2. Deterling RA Jr, Clagett OT. Aneurysm of the pulmonary artery; review of the literature and report of a case. Am Heart J. 1947;34: 471‐499.

3. Park HS, Chamarthy MR, Lamus D, Saboo SS, Sutphin PD, Kalva SP. Pulmonary artery aneurysms: diagnosis & endovascular therapy. Cardiovasc Diagn Ther. 2018;8:350‐361.

4. Hou R, Ma GT, Liu XR, et al. Surgical treatment of pulmonary artery aneurysm: an institutional experience and literature review. Interact Cardiovasc Thorac Surg. 2016;23:438‐442.

5. Galiè N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2016;37:67_‐119.

6. David TE, Feindel CM. An aortic valve‐sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103:617_‐621.

7. Kreibich M, Siepe M, Kroll J, Höhn R, Grohmann J, Beyersdorf F. Aneurysms of the pulmonary artery. Circulation. 2015;131:310‐316. 8. Reisenauer JS, Said SM, Schaff HV, Connolly HM, Maleszewski JJ,

Dearani JA. Outcome of surgical repair of pulmonary artery aneur-ysms: a single‐center experience with 38 patients. Ann Thorac Surg. 2017;104:1605_‐1610.

How to cite this article: Circi R, Boysan E, Behlul Altunkeser B, et al. David's procedure for pulmonary artery aneurysm. J Card Surg. 2020;35:942–945.https://doi.org/10.1111/jocs.14480

F I G U R E 3 Left (A) and right (B) pulmonary artery stumps, reinforced with Teflon strips. C, Direct vision after graft implantation. D, Left internal mammary artery (LIMA) to left anterior descending artery anastomosis. E, Postoperative echocardiographic short‐axis view showing the pulmonary artery graft. F, Preoperative transthoracic echocardiography, short_{‐axis image demonstrating severe pulmonary regurgitation} (arrows). G, Postoperative significantly decreased pulmonary regurgitation. LPA, left pulmonary artery; MPA, main pulmonary artery; RPA, right pulmonary artery