Asian Cardiovasc Thorac Ann 1998;6:68-70
© 1998 Asia Publishing EXchange Pte Ltd
Post-Banding Pulmonary Artery Pseudoaneurysm
David LC Cheung, MChir,
Au Wing Kuk, FRCS,
Chiu Wing Hung, FRCS,
Chui Shui Wah, FRCS,
Lee Wai Tsun, FRCS
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Division of Cardiothoracic Surgery Department of Surgery Grantham Hospital Hong Kong, People's Republic of China
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For reprint information contact: David LC Cheung, MChir Division of Cardiothoracic Surgery Department of Surgery Grantham Hospital 125 Wong Chuk Hang Road Aberdeen 3205 Hong Kong, People's Republic of China Tel:852 2518 2111 Fax:852 2554 2011 Email: dlcheung{at}netvigator.com.
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ABSTRACT
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Following pulmonary artery banding and left subclavian aortoplasty, a neonate developed a staphylococcal wound infection and a pseudoaneurysm of the pulmonary artery. She died of uncontrolled sepsis.
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INTRODUCTION
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In recent years, early primary correction is preferred in the management of symptomatic infants with congenital cardiac anomalies. However, pulmonary artery banding remains a useful alternative for treating intractable heart failure and preventing the development of pulmonary vascular disease especially in those with more complex lesions. Although many complications of banding have been reported previously, to our knowledge a pseudoaneurysm of the pulmonary artery secondary to infection has never been described.1 We report here the clinical course of a neonate who developed this complication following banding.
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CASE REPORT
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A full-term baby girl delivered by forceps with a birth weight of 3.55 kg was referred to us because of heart failure at the age of 9 days. Cardiac investigations including cross-sectional echocardiography and cardiac catheterization disclosed a large perimembranous ventricular septal defect, a patent ductus arteriosus, a discrete juxta-ductal coarctation and a hypoplastic aortic isthmus. She underwent surgery soon after admission. Through a left thoracotomy, the main pulmonary artery was banded with a 4-mm Teflon felt strip so that the distal pulmonary artery systolic pressure was reduced to 30 mm Hg. The band was then fixed to the pulmonary artery with a few stitches and left subclavian aortoplasty was performed. She tolerated the procedure well. When the baby was returned to the intensive care unit, it was noted that her arterial oxygen tension (PaO2) was below 30 mm Hg. In view of the rather low oxygen saturation of her arterial blood, she was taken back to the operating room 10 hours later and the band on the pulmonary artery was readjusted to give a distal pulmonary artery systolic pressure of 40 mm Hg and a PaO2 of 45 mm Hg. A combination of penicillin 75,000 units 8 hourly and 10 mg gentamicin 12 hourly were given preoperatively and continued after surgery.
Following the second procedure, the baby's condition was stable and she was extubated on the 3rd postoperative day. Her PaO2 was 60 mm Hg when the inspired oxygen concentration was 45%. She became febrile after the surgery. Pus was noted to be discharging from the thoracotomy wound on the 5th postoperative day. Part of the thoracotomy wound was laid open and packed with Eusol dressing. Cloxacillin was added empirically to the antibiotic regimen. When the pus grew cloxacillin-resistant Staphylococcus aureus, cloxacillin was replaced with cephalothin. Two weeks after surgery, the wound was clean and granulating but she was noted to be tachypneic again. Although on ausculation her chest was clear, a chest radiograph showed some mottling in the left upper zone (Figure 1
). Her hemoglobin dropped from 125 g•L–1 to 54 g•L–1 and her white blood cell count was 23.2 x 109 L–1. Her peripheral blood smear revealed the presence of fragmented red blood cells. There was marked polychromasia and anisoleukocytosis. The white blood cells showed occasional degenerate cells with 20% wide-banded forms. A diagnosis of hemolytic anemia secondary to fulminating infection was made. She was given a blood transfusion but her condition deteriorated over the following 24 hours. She remained in respiratory distress and repeat chest radiographs showed a globular opacity over the pulmonary conus (Figure 1). Crosssectional echocardiogram revealed a mass with expansile pulsation anterior to the main pulmonary artery, extending to the left, and probably communicating with the main pulmonary artery. The position of the band appeared to be satisfactory. A diagnosis of aneurysm of the right ventricular outflow tract was made. In spite of changing her antibiotics to co-trimoxazole and fucidic acid to which the cultured Staphylococcus aureus was sensitive, repeat blood cultures still grew this organism. She died of uncontrolled sepsis 5 days later.
At autopsy examination, a cavitated hematoma of 3 cm in diameter was found anterior and to the left of the pulmonary artery (Figure 2). After clearing the blood clots and necrotic material, a 2-mm tear was found at the proximal edge of the band on the left lateral aspect of the main pulmonary artery. The intima of the pulmonary artery was smooth and there was no mural thrombosis or vegetation. Sections of the pulmonary artery showed that the arterial wall was totally necrotic at the site of the tear with masses of necrotic material on the outer aspect, infiltration by polymorphs, and the presence of other inflammatory mononuclear cells and macrophages. Many clumps of bacteria (mostly grampositive cocci) were seen among the necrotic tissues and degenerated blood clot. Since echocardiography had demonstrated that the hematoma was pulsatile, a sutopsy examination was carried out, which revealed a cavity communicating with the pulmonary artery. An infected pseudoaneurysm of the pulmonary artery was diagnosed.
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Figure 2. Gross specimen of the heart showing the pseudoaneurysm. The arrow indicates the site of rupture. RV = right ventricle.
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DISCUSSION
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Banding of the pulmonary artery invariably causes some injury to the vessel.2 However, rupture of the pulmonary artery seldom occurs. In a series of 104 patients, Idriss and colleagues2 reported one case of sudden death 8 days after banding, from rupture of the pulmonary artery beneath the knot of the band with a localized focus of staphylococcus infection. Hunt and colleagues3 reported that among 111 children who underwent pulmonary artery banding, one child died 26 months after banding. At necropsy a large false aneurysm and extensive destruction of the pulmonary artery proximal to the band were found. There was neither clinical nor pathological evidence of infection. In our patient it is likely that revision of the banding procedure predisposed to wound infection and subsequent infection around the pulmonary artery led to its rupture. The bleeding was contained by adhesions in the area resulting in pseudoaneurysm formation. Although in pulmonary artery banding the optimal degree of constriction varies according to the surgeons' experience and the anomaly, it would be reasonable to suggest that in determining the optimal degree of constriction not only the distal pulmonary artery pressure but also the post-banding PaO2 should be taken into consideration.4 In retrospect, reoperation of our patient could have been avoided if the post-banding PaO2 had been taken into consideration at the initial operation.
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REFERENCES
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Mahle S, Nicoloff DM, Knight L, Moller JH. Pulmonary artery banding: long-term results in 63 patients. Ann Thorac Surg
1979;27:216.[Abstract]
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Idriss FS, Riker WL, Paul MH. Banding of the pulmonary artery: a palliative surgical procedure. J Pediatr Surg
1968;3: 465.[Medline]
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Hunt CE, Formanek G, Levin MA, et al. Banding of the pulmonary artery. Results in 111 children. Circulation
1971; 43:395.[Abstract/Free Full Text]
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Stark J. Pulmonary artery banding. In: Stark J, deLeval M, editors. Surgery for congenital heart defects. London: Grune & Stratton, 1983:187–95.
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ABSTRACT
INTRODUCTION
