Bleeding sites and treatment strategies for cardiac tamponade by catheter ablation requiring thoracotomy: risks of catheter ablation in patients with left atrial diverticulum.

BACKGROUND: There is insufficient information regarding the bleeding sites and surgical strategies of cardiac tamponade during catheter ablation for atrial fibrillation (AF). CASE PRESENTATION: Of the five patients with cardiac tamponade, three required surgical intervention and two required pericardiocentesis. In the first case of three cardiac tamponades requiring surgical intervention, considering that the peripheral route was used, the catecholamines did not reach the heart, and due to unstable vital signs, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was inserted. No bleeding point was identified, but a thrombus had spread around the left atrium (LA) with diverticulum. Hemostasis was achieved with adhesives placed around the LA under on-pump beating. In the second case, pericardiocentesis was performed, but the patient showed heavy bleeding and unstable vital signs. Thus, VA-ECMO was inserted. Heavy bleeding was expected, and safety was enhanced by attaching a reservoir to the VA-ECMO. The bleeding point was found between the left upper pulmonary artery and LA under cardiac arrest to obtain a good surgical view for suturing repair. In the third case, the LA diverticulum was damaged. Pericardiocentesis resulted in stable vitals, but sustained bleeding was present. A bleeding point was found at the LA diverticulum, and suture repair under on-pump beating was performed. CONCLUSIONS: When cardiac tamponade occured in any patient with LA diverticulum, treatment could not be completed with pericardiocentesis alone, and thoracotomy was likely to be necessary. If the bleeding point could be confirmed, suturing technique is a more reliable surgical strategy than adhesive alone that leads to pseudoaneurysm. If the bleeding point is unclear, it is important to confirm the occurrence of LA diverticulum using a preoperative CT, and if confirmed, cover it with adhesive due to a high possibility of diverticulum bleeding. The necessity of CPB should be determined based on whether these operations can be completed while maintaining vital stability.

Aortobronchial fistula after Bentall procedure treated with elective arch replacement: A case report.

Aortobronchial fistula often requires emergency surgery as it causes rapidly progressing respiratory failure. Some patients present with recurrent hemoptysis episodes. We report the case of a patient who was saved by elective surgery after aortobronchial fistula following aortic pseudoaneurysm rupture into the lung. An 84-year-old man, who had undergone mechanical Bentall replacement of the ascending aorta 20 years ago, complained of persistent fever. Computed tomography indicated a pseudoaneurysm at the distal anastomosis of the ascending aorta, and an urgent surgery was planned. During hospitalization, his aneurysm ruptured, suddenly penetrating the right lung and triggering acute respiratory failure and unconsciousness before the planned urgent operation. Mechanical ventilation was immediately provided; his respiratory status remarkably improved through intensive care and medical therapy. After nutritional status recovery, partial arch replacement was performed as an elective operation without any intervention for the injured lung. He did not exhibit any respiratory or neurological complications postoperatively.