Brief communication

Aorta to right atrium fistula with congestive heart failure resulting from a patent Cabrol shunt affer repair of aortic dissection

Surgeons shy away from using the Cabrol fistula (perigraft space to right atrium [RA] shunt) due to unfamiliarity, concern for persistent left-to-right shunting, and fear of “painting-over” anastomotic defects that will result in later problems. We review nearly 2 decades of experience with application of the Cabrol fistula in a large thoracic aortic practice, with emphasis on precise surgical techniques, early and late outcomes, and detailed radiographic analysis.

Operative records of all procedures in which the Cabrol fistula was used were retrieved and analyzed, with precise review of the details of construction of each Cabrol fistula and clinical and radiologic (echocardiographic and computed tomographic) patient follow-up.

The Cabrol fistula successfully controlled the bleeding in all cases. There were no late false aneurysms at any anastomotic sites. There was no continued flow through any fistula. Good perioperative and long-term survival was achieved in these complex cases that found themselves at a very dangerous crux before application of the Cabrol fistula.

The Cabrol fistula is an important tool for the thoracic aortic surgeon to have in the toolbox. We found the Cabrol fistula to be extremely effective at controlling bleeding, with no late persistent fistula flow and no late false aneurysm formation. Without the fistula, outcome in these patients would likely have been lethal. We recommend the Cabrol fistula technique strongly for life-saving application in rare cases of bleeding uncontrollable by conventional methods.

Whether transesophageal echocardiography (TEE) should be routinely performed before hospital discharge after Bentall surgery remains unclear. The investigators took advantage of this practice at their institution to evaluate its benefit.

All patients who had undergone the Bentall procedure at Bichat Hospital from January 2010 to March 2014 were included. For each patient, transthoracic echocardiographic and transesophageal echocardiographic data and clinical events were retrospectively collected from the various reports.

One hundred ninety-eight patients underwent the Bentall procedure during the study period. Postoperative TEE was performed in 117 patients (59.1%), including nine with abnormalities observed on transthoracic echocardiography (a vibrating element on the new prosthetic valve, suspicion of peritubular complications in two patients, and aortic regurgitation in six patients). In 108 patients, routine TEE was performed (i.e., without clinical indication beyond baseline postoperative imaging). Patients with and those without routine TEE were identical, except for more frequent endocarditis as an indication for surgery in patients with routine TEE. Routine TEE did not reveal any new findings that prior transthoracic echocardiography had not shown. The most frequent finding on transthoracic echocardiography or TEE was periaortic hematoma, which sometimes led to the performance of computed tomography. This imaging did not change the care of the patients in this population.

This study does not support the performance of TEE after Bentall surgery during the in-hospital course in the absence of a specific indication. Baseline postoperative imaging using TEE or computed tomography should preferably be recommended beyond the early postoperative period after periaortic hematoma has resolved.

Cada día son más los pacientes que sobreviven tras cirugía de reconstrucción de aorta ascendente. Estos pacientes requieren seguimiento para detectar factores pronósticos postoperatorios, como persistencia de flujo en falsa luz, roturas intimales o complicaciones del injerto. Hemos realizado un estudio utilizando la ecocardiografía transtorácica y transesofágica con el objeto de detectar anomalías residuales y establecer la utilidad de esta técnica en un grupo de pacientes operados por patología de aorta ascendente con intervención de Bono-Bentall.

Se estudian con ecocardiografía transtorácica y transesofágica 12 pacientes, 4 de ellos intervenidos por anulectasia aórtica con insuficiencia aórtica severa y 8 por disección aórtica tipo A. La técnica quirúrgica fue la de Bono-Bentall en todos los pacientes y en tres de ellos se añadió la modificación de Cabrol.

De los enfermos intervenidos por disección aórtica, 7 de 8 (87%) presentaron anomalías residuales: 5 persistencia de disección distal, 1 seudoaneurisma y 1 hematoma peritubular. Sólo en 1 de los 4 enfermos (25%) intervenidos por anulectasia se encontró lesión residual (seudoaneurisma). La fracción de eyección era normal en los pacientes intervenidos por disección aórtica y deprimida en los intervenidos por anulectasia aórtica (60 ± 9 frente a 40 ± 10; p = 0,005).

En pacientes intervenidos con técnica de Bono-Bentall existe una alta incidencia de anomalías residuales aórticas, especialmente cuando la indicación quirúrgica es la disección aórtica. La ecocardiografía transesofágica es un método diagnóstico idóneo para la detección y seguimiento de anomalías residuales tras la cirugía de aorta ascendente. Creemos que esta técnica debe formar parte del seguimiento periódico de estos pacientes.

Increasingly patients are surviving after reconstructive surgery of the ascending aorta. These patients require follow-up to detect postoperative prognostic markers, such as persistence of the flow in a false lumen, intimal rupture, or graft complications. We conducted a study with transthoracic and transesophageal echocardiography in order to detect residual abnormalities and establish the usefulness of this technique in a group of patients after Bono-Bentall surgery for ascending aorta pathology.

Twelve patients were studied with transthoracic and transesophageal echocardiography, four after surgery for annulo-aortic ectasia with severe aortic insufficiency and eight for type A aortic dissection. The Bono-Bentall surgical procedure was used in all the patients with Cabrol’s modification being added in three.

Seven of the eight (87%) patients with aortic dissection had residual abnormalities: five persistence of the distal dissection, one pseudoaneurysm, and one peritubular haematoma. A residual lesion (pseudo-aneurysm) was found in just one of the four patients (25%) who underwent surgery for annulo-aortic ectasia. The ejection fraction was normal in those patients who had been operated on for aortic dissection and depressed in those who had annulo-aortic ectasia (60 ± 9 vs 40 ± 10; p = 0.005)

In patients undergoing surgery with the Bono-Bentall procedure there is a high incidence of residual aortic abnormalities, especially when the operation is for aortic dissection. Transesophageal echocardiography is an ideal diagnostic method for the detection and follow up of residual abnormalities after ascending aorta surgery. We believe this technique should be included in the periodic follow up of these patients.