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Ann Thorac Surg 2006;81:1275-1278
© 2006 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Management of Central Coronary Sinus Ruptures Using the Pericardial Patch Repair Technique

Department of Cardio-Thoracic Surgery, Medical University of Vienna, Vienna, Austria

Accepted for publication November 22, 2005.

^_* Address correspondence to Dr Mohl, Department of Cardiothoracic Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (Email: werner.mohl{at}meduniwien.ac.at).

	Abstract

Top Abstract Introduction Material and Methods Patients and Results Comment References

 
BACKGROUND: Intraoperative coronary sinus rupture is a rare event; however, it carries potential mortality and its' management is technically challenging. A repair technique should provide adequate bleeding control while avoiding narrowing or stricture of the coronary sinus.

METHODS: We retrospectively review our experience with a new pericardial patch repair technique. From January 1996 to May 2005 four cases of intraoperative coronary sinus injury were identified. Three female patients and one male patient with a mean age of 74 ± 4 years underwent valve replacement and/or coronary artery bypass on cardiopulmonary bypass. A double pericardial patch technique sandwiched with human fibrin glue was used to cover the defect.

RESULTS: In all patients treated with this method, the injury could be treated successfully. All patients were extubated on the first postoperative day and median intensive care unit stay was 3 days. Drains could be removed after 4 days median. Median hospital stay was 13 days. After a median follow-up of 33 months all patients are alive without any echocardiographic signs of impairments of the coronary sinus.

CONCLUSIONS: We conclude that the pericardial patch technique is a safe and technically feasible technique for repair of central coronary sinus ruptures. Excellent bleeding control and, in our experience, no consecutive complications were observed.

	Introduction

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Intraoperative coronary sinus rupture or injury is a rare event [1, 2], which nonetheless carries potential mortality and management is technically challenging. Main risk factor is the insertion of a coronary sinus catheter for retrograde cardioplegia. Administration of retrograde cardioplegia through the coronary sinus is a widespread method. Main indications are patients with coronary artery disease or aortic valve insufficiency. Primary suture of the coronary sinus frequently led to stricture; thus, various technical solutions to prevent this problem were developed. We reported an initial case of pericardial patch repair of a ruptured coronary sinus [3]. Our series were corroborated by other groups. Since 1996 this approach has been applied and has been further developed in our cardiac surgical patient collective in the event of intraoperative coronary sinus injury.

	Material and Methods

Top Abstract Introduction Material and Methods Patients and Results Comment References

 
We retrospectively reviewed our experience with the pericardial patch repair technique for coronary sinus rupture. From January 1996 to May 2005 four cases of intraoperative coronary sinus injury were identified. Three female and 1 male patients with a mean age of 74 ± 4 years underwent valve replacement and/or coronary artery bypass on cardiopulmonary bypass. A pericardial patch was used in all patients to cover the defect. The patch was secured with nonresorbable Prolene sutures (either 4-0 or 5-0; Ethicon, Somerville, NJ). Additionally, a layer of fibrin sealant was used underneath the patch to prevent small leakages. Thereafter, a second (slightly larger) patch was placed over the first one again with a fibrin layer underneath (Fig 1). The reported 4 cases represent an incidence of 0.053% of coronary sinus injury in our experience with retrograde cardioplegia. Written informed consent was obtained by all patients.

View larger version (97K): [in this window] [in a new window]   Fig 1. Technique of pericardial patch placement. (Top) Situs of a central coronary sinus rupture. (Bottom, from left to right) Sagittal section of ruptured coronary sinus; fibrin glue is placed underneath the first pericardial patch; a second pericardial patch is placed over the first one with an additional layer of fibrin glue in between; final situs.

	Patients and Results

Top Abstract Introduction Material and Methods Patients and Results Comment References

Initial postoperative course was uncomplicated. The patient could be extubated on the first postoperative day and after weaning from catecholamine support was transferred to the surgical ward on the second postoperative day. Chest drainages placed in the right pleural cavity and in the anterior mediastinum produced, in total, 1,500 mL and were removed on the third postoperative day. During hospital stay the patient received four erythrocyte concentrates due to a decrease in hematocrit and hemoglobin; however, neither chest x-ray nor echocardiography revealed any effusion. The patient was discharged on the 13th postoperative day. After a follow up of 39 months the patient is doing well without any restrictions in normal activity and echocardiography does not reveal any irregularities with regard to the coronary sinus.

Patient 2
A 78-year-old female with a severe aortic valve stenosis (valve area 0.8 cm²) underwent surgery for valve replacement. As concomitant disease a moderate chronic obstructive pulmonary disease was known. After installation of cardiopulmonary bypass and antegrade and retrograde delivery of cardioplegia a 23-mm porcine valve was implanted in the aortic position. The implantation itself was uneventful. After completion of the implantation during retrograde delivery of cardioplegia no pressure elevation was noted. At inspection of the coronary sinus a dislocation and perforation of the tip in the proximal part of the coronary sinus was detected. An autologous pericardial patch was secured with a running 5-0 Prolene suture in the same fashion as described in patient 1 in the surrounding epicardium and after adding a layer of fibrin glue a second patch was put in place. Thereafter no bleeding from the coronary sinus was observed. Total operative time was 2 hours and 50 minutes.

The patient was extubated on the first postoperative day. The weaning from catecholamine support was prolonged due to a new onset of atrial fibrillation. Two electrical cardioversions were unsuccessful; finally, conversion to sinus rhythm was achieved with antiarrhythmic medication. After 9 days intensive care unit (ICU) stay the patient could be transferred to the normal ward. Chest drainages placed in the right pleural cavity, retrocardial and in the anterior mediastinum were left in situ for 10 days and produced, in total, 6,700 mL. After removal of chest drainages, bilateral pleural punctures were necessary due to effusions detected on chest x-ray, which produced 500 mL serous effusion on each side. After prolonged mobilization due to weak muscular status the patient was discharged on the 31st postoperative day. After a follow-up of 33 months the patient is doing well without any restrictions in normal activity and echocardiography does not reveal any irregularities with regard to the coronary sinus.

Patient 3
A 72-year-old female with severe aortic stenosis (valve area 0.6 cm²) and single-vessel disease of the left anterior descending (LAD) coronary artery underwent aortic valve replacement and a single coronary artery bypass using the left internal mammary artery. The procedure itself was uneventful. After weaning from cardiopulmonary bypass and venous decannulation venous bleeding was observed. At inspection of the coronary sinus a rupture close to the right coronary artery was detected. Again venous cannulation was performed and cardiopulmonary bypass installed. After aortic cross clamping and superficial adaption of the rupture a pericardial patch was secured over the rupture site using a running Prolene 4-0 suture. Fibrin glue was additionally sprayed underneath the patch. For additional tamponade two Tabotamp (Johnson&Johnson; Ethicon, Sommerville, NJ) were placed in situ. Total operative time was 4 hours and 20 minutes with 3 hours 0 minutes on cardiopulmonary bypass. One erythrocyte concentrate had to be substituted intraoperatively.

The patient could be weaned from the respirator within 1 day and transferred from the ICU on the third postoperative day. Drainages in the left pleural cavity and in the anterior mediastinum could be removed on the fourth postoperative day and produced 1,200 mL in total. The further postoperative course was uneventful and the patient was discharged from hospital on the 12th postoperative day. Due to the aortic valve replacement using a porcine valve the patient was put on anticoagulation using phenprocoumon for 3 months. After a follow-up of 5 months the patient is doing well without any restrictions in normal activity and echocardiography does not reveal any irregularities with regard to the coronary sinus.

Patient 4
A 69-year-old male with a history of NSTEMI (non-ST elevation myocardial infarction), who developed ischemic cardiomyopathy with a left ventricular ejection fraction of 0.15, was scheduled for a coronary artery bypass procedure. During cannulation of the right atrium the venous cannula was initially misplaced and perforated the proximal coronary sinus. A pericardial patch was used to control bleeding and again anchored in the surrounding epicardium using a running 4-0 Prolene suture together with fibrin sealant. Thereafter a double coronary artery bypass was performed uneventfully. Weaning from cardiopulmonary bypass was prolonged due to the preexisting cardiomyopathy; however, it was achieved with the use of levosimendan and high doses of dobutamine and norepinephrine. No further bleeding from the coronary sinus rupture site was observed.

The patient was extubated on the first postoperative day and transferred from ICU on the second postoperative day. The anterior mediastinal chest drain was removed on the second postoperative day and produced only 400 mL in total. The patient was discharged 2 weeks after the operation after uneventful postoperative recovery. After a follow-up of 2 months echocardiography shows no irregularities of the coronary sinus.

	Comment

Top Abstract Introduction Material and Methods Patients and Results Comment References

 
We report on the results of a modification of our previously published method [3] to correct coronary sinus injuries. The methodology involves a double patch technique sandwiched with human fibrin glue. In all patients treated with this method, the injury could be treated successfully. The techniques to treat coronary sinus ruptures are technically demanding to allow sufficient drainage through the coronary veins together with a complete hemostasis. Other successful techniques are also in use; however, with the reported modified technique all patients could be treated successfully.

The use of retrograde cardioplegia is a well-established technique that provides excellent myocardial protection with low complication rates [2]. Coronary sinus rupture is a rare event; thus, large numbers of a distinct repair technique are rarely reported. The main risk factor certainly remains the catheter delivering retrograde cardioplegia; however, even with a misplaced venous cannula a coronary sinus lesion can be inflicted in case of an unfavorable anatomic configuration as reported in patient 4. Left ventricular and septal hypertrophy represent risk factors for coronary sinus injuries [4, 5]. In high risk patients transesophageal echocardiography might help in placing catheters securely [6].

At the present time coronary sinus catheter placements are very popular, considering electrophysiologic therapies as well as placement of electrodes. Injuries occur in about 10% of the cases which are clinically silent and do not require additional surgical treatment. It is, however, important to establish a clinically feasible routine to correct these injuries [7].

The exact location of the rupture often indicates the potential mechanism of the injury [5]. Proximal injuries are mainly either due to direct perforation of the catheter tip or due to hyperinflation of the compliant balloon, which ruptures the wall due to a surplus of endovascular volume. A direct fine suture repair of such injuries has been suggested [5, 8]. However, stricture or distortion is a potential complication when using a direct suture increasing the risk for coronary sinus thrombosis. The on-lay pericardial patch technique in our opinion represents a technique avoiding direct alteration and potential narrowing of the coronary sinus while still providing adequate bleeding control.

A blow-out rupture mainly occurs in the middle portion of the coronary sinus either due to balloon overinflation or high infusion pressure. No such major rupture has been observed in our patient collective. In such a case it is important to stop coronary sinus cardioplegia immediately, carry out the repair, and alter the strategy for myocardial protection throughout the rest of the procedure [9]. Various repair techniques have been described for such ruptures. When using a pericardial patch it has been recommended to leave the catheter in place to present to edges of the rupture. Additional to the pericardial patch technique even a Gore-Tex conduit (W. L. Gore & Assoc, Flagstaff, AZ) has been suggested, creating an alternative route between the patch and the right atrium [10].

In case of a distal rupture and overt bleeding a pericardial patch can also be applied, whereas if no overt bleeding is present observation only is advocated by most publications [2, 5]. Transesophageal echocardiography has also been described as helpful in some cases to detect the exact location of injury [11].

All injuries observed in our patient collective were proximal, central injuries. As mentioned, direct suture frequently lead to stricture and distortion of the coronary sinus with increased risk for coronary sinus thrombosis with all adjacent problems similar to hemorrhagic infarction [12–14]. A patch sutured directly to the edges of the rupture to extend the lumen is in most cases technically not possible, thus a patch anchored in the surrounding pericardium is an excellent solution to avoid this problem. In our experience with a single running Prolene suture excellent bleeding control was achieved. We additionally used fibrin sealant to tighten the suture line. A second patch may be placed over the first one to provide additional coverage, even though bleeding is controlled after placement of the first patch. In our series the heart was arrested in all cases when the repair was performed; however, this method should potentially also be applicable on the beating heart.

We conclude that the pericardial patch technique is a safe and technically feasible technique for repair of central coronary sinus ruptures. Excellent bleeding control and, in our experience, no consecutive complications were observed.

	References

Top Abstract Introduction Material and Methods Patients and Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Clemens Aigner Ernst Wolner Werner Mohl Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Aigner, C. Articles by Mohl, W. Search for Related Content PubMed PubMed Citation Articles by Aigner, C. Articles by Mohl, W. Related Collections Cardiac - other