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Persistent Right Atrial distension during minimally invasive valve surgery
Toshinori Totsugawa, Taichi Sakaguchi, Arudo Hiraoka, Yusuke Irisawa, Kazuki Maeda, Hidenori Yoshitaka.
The Sakakibara Heart Institute of Okayama, Okayama, Japan.

OBJECTIVE: Hypertrophic unusual aortic branches are rare condition. Here we present two clinical cases with a difficulty to obtain good intraoperative exposure due to hypertrophic unusual aortic branches in minimally invasive cardiac surgery (MICS).
METHODS: (Case 1) A 65-year-old man who had a past history of chronic pulmonary thromboembolism underwent mitral valve repair (MVP), tricuspid annuloplasty (TAP), and Maze procedure through right mini-thoracotomy. (Case 2) A 65-year-old man without a particular past history underwent MVP and concomitant aortic valve replacement (AVR) via right mini-thoracotomy.
RESULTS: On preoperative computed tomography (CT) scan, we had not realized the hypertrophic bronchial artery (arrows) in Case 1 and the dilated intercostal artery (arrows) making a fistula (arrowhead) to the branch of right pulmonary artery in Case 2. In both cases, the right atrium was fully expanded after aortic cross-clamping. In Case 1, good exposure of the mitral valve could not be obtained because of the overflowing blood from the pulmonary veins in the left atrium; too much blood came from the pulmonary artery during TAP subsequent to MVP. After aortic declamping, myocardial infarction related to the right coronary artery occurred; cardiopulmonary bypass was not terminated without any supports of veno-arterial extracorporeal membrane oxygenation (ECMO). He was weaned from ECMO on 5th postoperative day and from mechanical ventilation 15 days after surgery. In Case 2, we first opened the right atrium and added one more suction tube to the right ventricle for sufficient venting. Furthermore, we lowered patient’s core temperature and shortened the interval of administration of cardioplegia to prevent malprotection. Postoperative course was uneventful and he recovered normal activity of daily life within a week.
CONCLUSIONS: Hypertrophic unusual aortic branches can potentially cause critical problems in MICS by overflow of the increased pulmonary blood to the small surgical field. Preoperative evaluation of contrast-enhanced CT scans is important especially for the patients with pulmonary diseases developing collateral arteries.

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