Use of the endoclamp device in a patient with a native mitral valve endocarditis and a previous arch replacement with a modified Griepp technique

Abstract

times directly into the LA or inferior vena cava. They usually are embedded to lung parenchyma. In addition to causing shunt resulting in dyspnea, volume overload, and cyanosis, PAVMs also cause the loss of filter function of lungs and thus may allow development of stroke and cerebral abscess. The classic triad of dyspnea, cyanosis, and clubbing is present in only 10% of cases. In our case, the lesion was producing high-output right-to-left shunt and causing severe cyanosis. The aneurysm had a single large feeding artery (afferent vessel) and no efferent vessel. Interestingly, it was in continuity with the LA with an orifice as big as the aneurysm itself. In our knowledge no similar case has been reported in literature. Traditional options for the definitive management of PAVM include embolization and surgery. Ligation, local excision, segmentectomy, lobectomy, or pneumonectomy have been performed, although most of the time parenchyme-saving operations are preferred. It was obvious that embolization would be inappropriate for this case not only because leaving a residual aneurysm would result in a high risk of rupture but also because of the unsuitable anatomy of the feeding artery. During preoperative evaluation we considered 2 possible approaches for surgical treatment of this PAVM. Instead of median sternotomy and repair through the LA with cardiopulmonary bypass and cardiac arrest, we used simple ligation and resection through thoracotomy, which allowed better exposure, a shorter operation, and faster recovery. We believe the origin of this sac would be one of the following: an aneurysmal PAVM with draining vessel was absorbed in time and united widely to the LA, or a distal PA aneurysm ruptured and united to the LA. Unusual features like extraparenchymal location of the lesion, absence of an efferent vessel, unity of aneurysmal sac with the LA, and the absence of associated etiologic factors make this lesion interesting. Nonetheless, prompt surgical treatment with a simple approach relieved the severe symptoms and prevented a potential fatal rupture. In conclusion, although PAVMs are rare, they should be included in any differential diagnosis of worsening dyspnea, cyanosis, stroke, or hemoptysis. Their presence should be considered especially in patients with cyanosis whom no evidence of intracardiac shunts in echocardiography. Prompt workup and intervention can prevent fatal complications like rupture and lead to dramatic improvement in symptoms.