Surgical repair of the pulmonary trunk aneurysm

Ex Vivo Comparison of the Elastic Properties of Vascular Substitutes Used for Pulmonary Artery Replacement

INTRODUCTION

Study aims were to evaluate the elastic properties of vascular substitutes frequently used for pulmonary artery (PA) replacement, and then to compare their compliance and stiffness indexes to those of human PA.

METHODS

A bench-test pulsatile flow experiment was developed to perfuse human cadaveric vascular substitutes (PA, thoracic aorta, human pericardial conduit), bovine pericardial conduit, and prosthetic vascular substitutes (polytetrafluorethylene and Dacron grafts) at a flow and low pulsed pressure mimicking pulmonary circulation. Intraluminal pressure was measured. An ultrasound system with an echo-tracking function was used to monitor vessel wall movements. The diameter, compliance, and stiffness index were calculated for each vascular substitute and compared to the human PA at mean pressures ranging from 10 to 50 mmHg.

RESULTS

The compliance of the PA and the thoracic aorta were similar at mean physiological pressures of 10 mmHg and 20 mmHg. The PA was significantly less compliant than the aorta at mean pressures above 30 mmHg (P = 0.017). However, there was no difference in stiffness index between the two substitutes over the entire pressure range. Compared to the PA, human pericardial conduit was less compliant at 10 mmHg (P = 0.033) and stiffer at 10 mmHg (P = 0.00038) and 20 mmHg (P = 0.026). Bovine pericardial conduit and synthetic prostheses were significantly less compliant and stiffer than the PA for mean pressures of 10, 20, and 30 mmHg. There were no differences at 40 and 50 mmHg.

CONCLUSIONS

Allogenic arterial grafts appear to be the most suitable vascular substitutes in terms of compliance and stiffness for PA replacement.

A Novel Approach for the Treatment of Pulmonary Artery Aneurysm Repair Using Inclusion Technique: A Case Report

Pulmonary artery aneurysm (PAA) is a rare disease with life-threatening complications, especially when accompanied by pulmonary artery hypertension. Due to its rarity, there are currently no specific guidelines for the treatment of PAA. Several surgical techniques have been described to be beneficial in the treatment of PAA originating at the pulmonary trunk. However, several adverse complications have been described for traditional techniques. In this case, we present the first successful repair of PAA with idiopathic pulmonary artery hypertension using a graft inclusion technique.

Idiopathic Pulmonary Artery Aneurysm: A Case Report

BACKGROUND

Idiopathic pulmonary artery aneurysm is a rare disorder that has been reported in less than 50 cases. This complication is often asymptomatic, while the first manifestation can be severe hemoptysis or death.

CASE PRESENTATION

A 36-year-old man presented to our institute with hemoptysis and fever. Dilated pulmonary artery trunk (5.5 cm) and the left pulmonary artery branch (6.90 cm) were discovered during a computed tomography angiogram scan in the patient's chest region. Therefore, the patient was diagnosed with a pulmonary artery aneurysm. According to the results of the tests requested for the patient, the cause of the patient's pulmonary artery aneurysm was not determined. Therefore, an idiopathic pulmonary artery aneurysm was proposed for the patient.

CONCLUSION

Idiopathic pulmonary artery aneurysm poses a double diagnostic and therapeutic problem. The rarity of the disease, and the absence of specific clinical signs make diagnosis difficult.

Bilateral lung transplantation for pulmonary artery aneurysm with severe pulmonary hypertension: An evolution or a revolution?

The surgical treatment of pulmonary hypertension (PH), with or without pulmonary artery aneurysm, has evolved during the last 40 years from heart-lung transplants to bilateral lung transplants as the treatment of choice for PH patients with preserved right and left ventricular function and without complex cardiac abnomalies.

Pulmonary Artery Aneurysm Associated With Severe Pulmonary Hypertension in a Patient Presenting for Double Lung Transplant: Review of a Rare Disorder and Role of Transesophageal Echocardiography

Pulmonary artery aneurysm (PAA) is a rare disorder that may be classified as congenital, acquired, or idiopathic, in the case of unclear etiology. When associated with severe idiopathic pulmonary arterial hypertension, such a case of PAA may present to the operating room as an indication for lung transplantation. In this article, we present such a case of a patient with a giant main and right PAA that underwent a double lung transplant. We describe the pathophysiology and natural course of this PAA and discuss the role of intraoperative transesophageal echocardiography in the management of patients with this rare diagnosis.

Pulmonary artery aneurysm as a result of group 2 pulmonary artery hypertension in a patient with significant mitral and aortic valve disease - review and case report

Aneurysms are uncommon, but potentially life-threatening abnormalities of the pulmonary arteries. Aneurysm of the main pulmonary artery (MPA) defined as MPA diameter over 40 mm was reported in 1 : 14 000 autopsies. The most frequent location is the main pulmonary artery (89% of cases), whereas the maximum described diameter is 106–170 mm. Clinical manifestations are usually nonspecific or asymptomatic. Right heart failure symptoms, pulmonary regurgitation, trachea or bronchi compression or pulmonary emboli caused by enlarged MPA are the most commonly described clinical manifestations. Pulmonary artery aneurysm dissection is an uncommon complication but associated with a high mortality rate. Unfortunately, guidelines regulating the optimal time for the surgical intervention still have not been developed. We present the history of 76-year-old patient suffering from an aneurysm of the pulmonary artery (74 × 61 mm), as well as mitral and aortic valve disease, who was successfully operated on in our hospital.

Case report and management approach in idiopathic pulmonary arteries aneurysm

Background

Idiopathic pulmonary artery aneurysm is a rare anomaly with only a handful reports in the literature. It is often asymptomatic, while the first presentation could be severe hemoptysis or death.

Surgical intervention needs to be planned carefully with a multidisciplinary team approach to secure optimal outcome. We hope to spread our experience with such cases and to encourage other surgeons worldwide to deal surgically with these cases when its indicated.

Case presentation

A 47 years old man presented to our institution after three episodes of hemoptysis, echo demonstrated good left ventricle (LV) systolic function, normal right ventricle (RV) size and function, Chest computed tomography (CT) revealed aneurysmal dilatation with pending rupture of the pulmonary artery trunk (4.5 cm), the left pulmonary artery (6 cm) and the right pulmonary artery (2.3 cm). The patient successfully underwent replacement of Pulmonary artery trunk, left pulmonary artery and right pulmonary artery by Wovex Prosthetic graft (28 mm). The patient discharged home on the eight postoperative day in good clinical condition .

Conclusion

With this case report we wish to emphasize the need for a careful multidisciplinary approach given the complex and rare nature of the reported pathology.

Electronic supplementary material

The online version of this article (10.1186/s13019-018-0791-9) contains supplementary material, which is available to authorized users.

Rasmussen's pseudoaneurysm- case report

Background

Pulmonary aneurysms and pseudoaneurysms have various etiologies; however, the term Rasmussen's pseudoaneurysm refers specifically to a focal dilatation of a branch of the pulmonary artery into adjacent tuberculous cavity. The incidence of such tuberculosis related pulmonary vascular complication is extremely rare, hence, under recognized by many physicians. Management of pulmonary pseudoaneurysms is challenging as they present by life-threatening hemoptysis. Furthermore, contrary to the most causes of massive hemoptysis their bleeding is of pulmonary rather than bronchial artery origin. Prompt diagnosis and early interventions are needed as a very high mortality rate is associated with this illness.

Case description

We are reporting on a case of a young male who was presented to our hospital with recurrent episodes of massive hemoptysis and was diagnosed to have pulmonary tuberculosis. Despite being actively treated, his hemoptysis persisted. We describe in this case the role of different diagnostic modalities and the available therapeutic options.

Conclusion

Rasmussen's psudoaneurysm is rare and potentially lethal pulmonary vascular complication of tuberculosis. It should be considered in the differential diagnosis of hemoptysis in patients known or suspected to have pulmonary tuberculosis. In such cases, multidetector computed tomography (MDCT) scanning is the investigation of choice to confirm the diagnosis and to localize the source of bleeding prior to the therapeutic interventions. Head to head comparison between interventional radiology procedures and surgery in treatment of pulmonary psudoaneurysms is lacking, thus, choice depend on the availability and local expertise.

Bilateral multiple pulmonary artery aneurysms associated with cavitary pulmonary tuberculosis: a case report

BACKGROUND

Pulmonary artery aneurysms constitute <1% of aneurysms occurring in the thoracic cavity. Congenital cardiac defects are responsible for the majority (>50%) of cases, however, pulmonary artery aneurysm is a rare sequelae of pulmonary tuberculosis reported in about 5% of patients with chronic cavitary tuberculosis on autopsy. The natural history of this potentially fatal condition remains poorly understood and guidelines for optimal management are controversial.

CASE PRESENTATION

A 24-year-old man, a nursing student of African descent, was referred to us from an up-country regional hospital with a 4-week history of recurrent episodes of breathlessness, awareness of heartbeats and coughing blood 3 weeks after completing a 6-month course of anti-tuberculosis drugs. A physical examination revealed conjuctival and palmar pallor but there were no stigmata of connective tissue disorders, systemic vasculitides or congenital heart disease. An examination of the cardiovascular system revealed accentuated second heart sound (S2) with early diastolic (grade 1/6) and holosystolic (grade 2/6) murmurs at the pulmonic and tricuspid areas respectively. Blood tests showed iron deficiency anemia, prolonged bleeding time, and mild hyponatremia. A chest radiograph revealed bilateral ovoid-shaped perihilar opacities while a computed tomography scan showed bilateral multiple pulmonary artery pseudoaneurysms with surrounding hematoma together with adjacent cystic changes, consolidations, and tree-in-bud appearance. Our patient refused to undergo surgery and died of aneurismal rupture after 9 days of hospitalization.

CONCLUSIONS

The presence of intractable hemoptysis among patients with tuberculosis even after completion of anti-tuberculosis course should raise an index of suspicion for pulmonary artery aneurysm. Furthermore, despite of its rarity, early recognition and timely surgical intervention of pulmonary artery aneurysm is crucial to reducing morbidity and preventing the attributed mortality.

Anesthesia for pulmonary trunk aneurysmorrhaphy

BACKGROUND AND OBJECTIVES

The aneurysm in the pulmonary trunk is a rare disease. Because of its location, a rupture can lead to right ventricular failure and sudden death. Aneurysmorraphy is the most widely used surgical treatment in these cases. The aim of this study is to report a successful balanced general anesthesia for aneurysmorraphy of pulmonary trunk.

CASE REPORT

Male patient, 28 years, asymptomatic, diagnosed with an aneurysm in the pulmonary trunk. According to the location of the aneurysm and the consequent failure of the pulmonary valve, an aneurysmorraphy was indicated, with implantation of vascular-valvular prosthesis (valved tube). We opted for a balanced general anesthesia, seeking to prevent an increase in systemic and pulmonary vascular resistances, thus avoiding to cause stress on the wall of the aneurysmal vessel.

CONCLUSIONS

A balanced general anesthesia, in combination with adequate ventilation to prevent elevation in pulmonary vascular pressure, was appropriate for surgical repair of an aneurysm in the pulmonary trunk.

[Anesthesia for pulmonary trunk aneurysmorrhaphy]

BACKGROUND AND OBJECTIVES

The aneurysm in the pulmonary trunk is a rare disease. Because of its location, a rupture can lead to right ventricular failure and sudden death. Aneurysmorraphy is the most widely used surgical treatment in these cases. The aim of this study is to report a successful balanced general anesthesia for aneurysmorraphy of pulmonary trunk.

CASE REPORT

Male patient, 28 years, asymptomatic, diagnosed with an aneurysm in the pulmonary trunk. According to the location of the aneurysm and the consequent failure of the pulmonary valve, an aneurysmorraphy was indicated, with implantation of vascular-valvular prosthesis (valved tube). We opted for a balanced general anesthesia, seeking to prevent an increase in systemic and pulmonary vascular resistances, thus avoiding to cause stress on the wall of the aneurysmal vessel.

CONCLUSIONS

A balanced general anesthesia, in combination with adequate ventilation to prevent elevation in pulmonary vascular pressure, was appropriate for surgical repair of an aneurysm in the pulmonary trunk.

Giant high-pressure pulmonary artery aneurysm in an elderly patient with chronic obstructive pulmonary disease

The authors report the case of a 74-year-old man, with a history of chronic obstructive pulmonary disease (COPD), GOLD grade 3, stable for the past two decades, who was admitted to our center with severe right heart failure. The chest radiograph showed moderate heart enlargement mainly of the right atrium and pulmonary artery, similar to previous chest radiographs in the previous 20 years. The transthoracic echocardiogram showed a pulmonary artery aneurysm (PAA), dilatation of the right chambers with pulmonary artery systolic pressure of 52 mmHg, and preserved right ventricular systolic function. A thoracic computed tomography scan confirmed the presence of a giant PAA 72 mm in diameter. The patient was started on high-dose diuretics, with significant clinical improvement. After optimization of medical therapy right heart catheterization was carried out with the patient in optimal clinical condition, which revealed mild precapillary pulmonary hypertension with a mean pulmonary artery pressure of 26 mmHg. On the basis of the clinical and imaging findings a stable, giant, high-pressure, PAA was diagnosed secondary to pulmonary hypertension induced by COPD, with a 20-year follow-up without need for surgical repair, which helped in our decision to maintain medical surveillance. The recent onset of heart failure is explained by the unfavorable evolution of COPD. This case may change the attitude expressed in previous studies favoring the choice of an invasive approach to treat giant high-pressure PAAs, instead supporting the maintenance of medical treatment.

Pulmonary artery aneurysm in an adult patient with idiopathic dilatation of the pulmonary artery

Idiopathic dilatation of the pulmonary artery (IDPA) is a rare congenital heart disease. It has been described for almost one hundred years, and numerous definitions have been proposed. The IDPA diagnostic criteria have not been updated for years. Secondary to primary disease, pulmonary artery aneurism was recognised as a lethal defect; however, long-term follow-up of patients with IDPA has not been well researched. Thus, indications to medical or surgical treatment are not evidence based. Here, we present a rare case of a 54-year-old patient with IDPA, who remained under observation for 36 years without surgical intervention.

Novel Pulmonary Artery Reduction Plasty for Pulmonary Artery Aneurysm With Pulmonary Arterial Hypertension

We present the case of a 60-year-old female with pulmonary artery aneurysm (PAA) associated with an atrial septal defect and pulmonary arterial hypertension. There is no standard therapeutic approach for PAA at the present time. We performed a novel surgical repair of a 67-mm PAA consisting of internal plication of the pulmonary artery to reduce the diameter and approximation of remnant unfolding pulmonary artery to reinforce the stability of the pulmonary artery and prevent bleeding.

Mucormycosis causing pulmonary artery aneurysm

Pulmonary artery aneurysm (PAA) is an uncommon entity and is usually congenital in origin or secondary to pulmonary arterial hypertension. Infections causing PAA are few, tuberculosis and bacterial infections being the common causative organisms. There have been few cases reported previously, in which the organism causing PAA was found to be a rare fungus called mucor. Pulmonary mucormycosis causing PAA is an infrequent and almost fatal complication as most of the diagnosis was made post mortem. This report brings out a case of pulmonary mucormycosis causing ruptured PAA in a patient with diabetes. This patient was cured by a timely treatment of a combination of surgery and medical therapy.

Giant pulmonary artery aneurysm secondary to patent ductus arteriosus: a case report

Aneurysms involving the main pulmonary artery and its branches are rare. Clinical experience is limited, and their management is not well established. We present the case of a 35-year-old male patient with dyspnea and hemoptysis in whom subsequent imaging studies revealed a giant pulmonary artery aneurysm associated with an uncorrected patent ductus arteriosus and Eisenmenger’s syndrome. We chose to treat the patient conservatively with medical management due to the development of Eisenmenger’s physiology while waiting for heart-lung transplantation.

Giant idiopathic pulmonary artery aneurysm: an interesting incidental finding

Idiopathic pulmonary artery aneurysm is a rare condition. This type of aneurysm can be presented with noncardiac symptoms or even asymptomatic. We report a 73-year-old man with a gigantic idiopathic pulmonary artery aneurysm which was referred to our unit for his kidney problems. During his workup we incidentally found the aneurysm by an abnormal chest-X ray and auscultation. Our further evaluations revealed a 9.8 cm aneurysm in transthoracic echocardiography.

Pulmonary artery aneurysm with patent arterial duct: resection of aneurysm and ductal division

Congenital or acquired aneurysm of the pulmonary artery (PA) is rare. Although aneurysms are described following surgical treatment of patent ductus arteriosus (PDA), occurrence of this lesion in association with PDA without previous surgery is extremely uncommon. An eight-year-old patient with PDA and aneurysm of the main PA is described in this report. Clinical diagnosis of PDA was made upon presentation. Diagnosis of PA aneurysm was suspected on chest x-ray and was confirmed on transthoracic echocardiography. Successful surgical resection of the aneurysm and division of the duct were performed under cardiopulmonary bypass. The patient did well on follow-up both from clinical and echocardiographic point of view.

Successful surgical repair of pulmonary artery aneurysm and regurgitation

Pulmonary artery aneurysm (PAA) is generally a rare lesion, and there is no definitive approach for it. We report the case of a 45-year-old man who was admitted for the evaluation of dyspnea. In childhood, he had been diagnosed with PAA with congenital pulmonary valve stenosis and regurgitation, and he had a percutaneous transvenous pulmonary valve commissurotomy. Transthoracic echocardiogram showed dilatation of the right atrium and right ventricle, with right ventricular hypertrophy. There was severe pulmonary valve regurgitation, and the main pulmonary artery was dilated to 68 mm in diameter. From the surgical findings, the left leaflet of pulmonary valve was torn from commissure with failure to coapt with the other leaflet. After direct sutures of edges of the left leaflet, a nearly normal valvular competence was restored. The PAA was repaired with a Y-shaped 24 × 12 mm Dacron graft replacement. The postoperative course was uneventful, and the patient was discharged.

Suppurative pericarditis complicated by mycotic aneurysm of the pulmonary artery

Aneurysms of the pulmonary artery are very rare. Here, the authors report the clinical scenario of a middle aged diabetic who presented with suppurative cardiac tamponade that was complicated by mycotic aneurysm of the pulmonary artery. In addition to the clinical presentation, aetiology, diagnostic modalities and therapeutic options are discussed.

Main pulmonary artery aneurysm

Pulmonary artery aneurysm is a rare lesion of the thoracic cavity. Different etiologies have been reviewed, but idiopathic lesions without other symptoms are seldom reported. Usually, surgical interventions are suggested, but the long-term outcomes are not well established. Here, we report a 24-year-old man with main pulmonary artery aneurysm who successfully underwent aneurysmectomy and polytetrafluoroethylene vascular graft replacement. The postoperative course was uneventful, and the following image study revealed normal size of the great vessels.

Surgical Therapy of Pulmonary Artery Aneurysms: A Report of 2 Cases

Pulmonary artery aneurysm is a rare condition that may be acquired rather than congenital. The natural history of pulmonary artery aneurysms is not defined yet, and management is still controversial. We present 2 cases of adult patients with pulmonary artery aneurysms who were treated surgically. We suggest replacement as the surgical strategy.

Pulmonary Artery Aneurysm With Ascending Aortic Aneurysm Concomitant With Bilateral Bicuspid Semilunar Valves

Aneurysm of both the pulmonary trunk and the ascending aorta concomitant with bilateral bicuspid valves is very rare. The reason for the formation of aneurysm with bicuspid semilunar valve is still inconclusive. Surgical repair was performed successfully (ie, aortic valve replacement, graft replacement for the ascending aorta, and plication of the pulmonary artery). Pathology of the pulmonary artery wall did not demonstrate cystic medial necrosis. The hemodynamic turbulence by the bilateral bicuspid valve may cause the formation of aneurysms even at low pressure. This case demonstrates an explanation for aneurysm with the bicuspid valve.

Low pressure giant pulmonary artery aneurysms in the adult: natural history and management strategies

OBJECTIVE

To describe aspects of the natural history and pathophysiology of giant low pressure pulmonary artery aneurysms and to propose potential surgical strategies.

DESIGN

Cross sectional retrospective review.

SETTING

Supraregional tertiary referral centre.

PATIENTS

All adult patients referred for assessment of giant pulmonary artery aneurysm retrospectively identified from the Mayo Adult Congenital Heart Disease Clinic database.

METHODS

Patient data were reviewed from hospital records, including echocardiograms, magnetic resonance images, radiographs, and histology slides.

RESULTS

Four patients were identified with a median age of 52 years (range 37-64 years). Presenting symptoms were effort related dyspnoea, chest discomfort, and hoarseness in one patient. All patients had pulmonary regurgitation and clinical evidence of right ventricular enlargement in association with a pulsatile mass at the upper left sternal edge. Transthoracic echocardiography showed the giant pulmonary artery aneurysm involving the main pulmonary artery and proximal branches, and confirmed severe pulmonary regurgitation in all patients. None of the patients had intimal tearing, medial dissection, or pulmonary arterial rupture. The pulmonary valve was replaced to relieve symptoms and preserve right ventricular function. Pulmonary arterial histology showed medial degeneration of elastic fibres with accumulation of basophilic ground substance.

CONCLUSIONS

Rupture or dissection of these low pressure aneurysms is rare. The timing of surgical intervention should be determined by changes in right ventricular size and function resulting from pulmonary regurgitation or pulmonary stenosis, and not the size of the aneurysm.

Magnetic resonance imaging of the main pulmonary artery: reliable assessment of dimensions in Marfan patients on a simple axial spin echo image

OBJECTIVE

To investigate if a simple axial spin echo (SE) image can be used for reliable assessment of pulmonary artery dimensions in patients with Marfan syndrome.

METHODS

Fifty Marfan patients (mean age 33 +/- 10 years; 34 men, 16 women) and 15 normal subjects (mean age 28 +/- 4 years; nine men, six women) underwent cardiac magnetic resonance imaging (MRI). Pulmonary artery dimensions were obtained on axial SE images at two different levels: (1) the level of the pulmonary artery root, and (2) the level of the pulmonary artery bifurcation. To evaluate the accuracy of axial plane measurements 10 Marfan patients also underwent contrast-enhanced MR angiography (CE-MRA).

RESULTS

In the 10 Marfan patients who also underwent CE-MRA, the mean diameter at the pulmonary bifurcation assessed with CE-MRA (31.5 +/- 3.6 mm) was almost equal to mean diameter assessed with axial SE (30.7 +/- 3.6 mm). Agreement of methodology according to Bland and Altman analysis showed a 95% confidence interval ranging from -2.6 to + 4.4 mm for all distances of the pulmonary artery root. In Marfan patients the mean right-left diameter measured on both axial SE images and CE-MRA was approximately 2.5 mm larger than the anterior-right and anterior-left diameters (p < 0.001).

CONCLUSIONS

Axial SE MRI is a reliable and easy acquisition to measure pulmonary artery dimensions in patients with Marfan syndrome, and could be used for follow-up, especially in patients with severe involvement of the cardiovascular system. Not only the pulmonary artery trunk but also the asymmetric pulmonary root should be measured, although the clinical relevance of the asymmetric root is not yet known.

Isolated idiopathic pulmonary artery aneurysm

Aneurysm formation of the main pulmonary artery is rare. Its natural history is not well understood and there are no clear guidelines on optimal treatment. A 20-year-old woman with a huge saccular aneurysm of the main pulmonary artery, underwent repair with a pericardial patch and concomitant reconstruction of the pulmonary valve. The patient was doing well on follow-up at 6 months; echocardiography revealed a good repair with mild to moderate pulmonary regurgitation.