Resection of Pulmonary Artery Trunk Mass

The patient was an 80-year-old former smoker who presented with shortness of breath and chest pain. Computed tomography showed a large filling defect in the main pulmonary artery presumed to be a pulmonary embolus. Further workup with transthoracic echocardiography revealed a 2.5 x 2.1 cm pedunculated mobile mass in the main pulmonary artery, just distal to the pulmonic valve. A cardiac MRI confirmed a mobile nonperfused 2.4 x 2.2 cm mass in the pulmonary artery above the pulmonary valve, attached to the lateral main PA by a stalk, in similar appearance to a myxoma. Given main pulmonary artery involvement and proximity to the pulmonic valve, the surgical plan included pulmonary root homograft valve conduit replacement versus pulmonary artery mass resection with patch reconstruction.

After midline sternotomy, cardiopulmonary bypass was instituted via ascending aorta and bicaval venous cannulation. Cardiac arrest was achieved with antegrade cold blood cardioplegia. Dissection of the pulmonary artery commenced medially in the aortopulmonary window travelling anteriorly to achieve a clear demarcation between the transition of the white pulmonary artery tissue and the red-purple hue of the right ventricle. Dissection next continued in a medial to posterior direction taking care to avoid the left main coronary artery in the vicinity of the aortic root.

Using an 11-blade scalpel, a longitudinal arteriotomy was performed on the anterior pulmonary artery. This was elongated to visualize the intraluminal mass and to assess for a 2 cm distal margin. The mass was noted to be a 3.5 cm x 2.5 cm pedunculated tumor, papillary in appearance. Its stalk appeared connected to the commissure of the anterior cusp left cusp. The pulmonary artery was then transected just proximal to the bifurcation of the left and right pulmonary arteries, providing approximately 2 cm of margin from the edge of the distal pulmonary artery to the origin of the tumor.

The attachments between the right ventricle and pulmonary artery were divided on the lateral and anterior aspect of the pulmonary root. In order to establish the proximal pulmonary root resection margin, a right-angled clamp was placed 2 cm below the commissure of the anterior and right cusp and was used to puncture through the anterior wall of the right ventricle. The proximal margin was elongated with a 15-blade scalpel in a curved transverse fashion across the pulmonary root and right ventricular muscle skirt anteriorly, then medially and laterally. The posterior wall was resected with a 15-blade at a steep upwards angle across the ventricle in order to avoid the first septal branch of the left anterior descending artery.

The pulmonary artery transection was completed and the pulmonary root was removed en bloc. Backtable inspection confirmed a 3.5 cm x 2.5 cm pedunculated mass with an anemone-like appearance and a stalk connected to the commissure of the anterior and left cusp.

To reconstruct the pulmonary root, a 32 mm cryopreserved pulmonary homograft that was thawed during en bloc resection was tailored to an appropriate size by removing excess muscle from the right ventricular muscle skirt. The distal homograft was then transected approximately 0.5 cm distal to the tip of commisures of the pulmonic valve to avoid kinking of anastomosis. The proximal anastomosis was completed with a 4-0 SH prolene in a running fashion starting at the posterolateral corner using shallow long bites to avoid involvement of the first perforator branch. The distal anastomosis was also performed in a continuous fashion using a 4-0 RB prolene suture.

The patient separated from cardiopulmonary bypass on minimal support and transesophageal echocardiography confirmed good coaptation of the valve leaflets with an absence of pulmonic insufficiency. The patient’s postoperative course was uneventful.

References

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