<div>Title page</div><div>Left atrial Appendage Rupture Following Intraoperative Hypertensive
Crisis</div><div>Mehrab Marzban, MD. Peyman Benharash,MD</div><div>Cardiovascular Outcomes Research Laboratories, Division of Cardiac
Surgery, David Geffen School of Medicine at UCLA, Los Angeles,
California</div><div>Corresponding author: Mehrab Marzban,MD</div><div>Email:MMarzban@mednet.ucla.edu</div><div>10833 Le Conte Ave.62-249 CHS</div><div>Los Angeles, CA 90095</div><div>Tel:(310)206-6717</div><div>Abstract:</div><div>The acute and severe rise in systemic blood pressure during or after
cardiac operations may be life- threatening and result in end-organ
injury. This case is the first report of spontaneous left atrial
appendage rupture following hypertensive crisis in cardiac surgery</div><div>Introduction: Hypertension is the leading cause of mortality and
morbidity worldwide. (1,2) It is estimated that nearly half of all
cardiovascular diseases are attributable to uncontrolled hypertension.
(3) Intraoperative hypertension in cardiovascular operations may result
in bleeding that may be diffuse or related to suture-lines, resulting in
retained hematoma and occasionally re-exploration. Moreover, high blood
pressure may result in acute aortic dissection, acute pulmonary edema,
kidney injury, or intracranial hemorrhage.</div><div>Case presentation: A waiver for the case report was obtained from the
Hospital Ethics committee. An 84-year- old woman with a long standing
history of hypertension and hyperlipidemia presented with stable angina
and was found to have three vessel coronary artery disease including the
left main. Preoperative echocardiography showed a left ventricular
ejection fraction of 45% with inferobasal hypokinesis and moderate
ischemic mitral regurgitation. She underwent on-pump coronary artery
bypass grafting (CABG) x4 through a conventional approach utilizing the
left internal mammary artery and saphenous vein grafts. She was easily
weaned from cardiopulmonary bypass and decannulated. Following routine
hemostasis and sternal closure, the patient became hypertensive with
blood pressures as high as 165/90 mmHg. In attempts to reduce the blood
pressure, the anesthesiologist inadvertently administered a bolus of
epinephrine, resulting in severe tachycardia and hypertension up with
systolic blood pressures of nearly 240 mmHg. Shortly thereafter, the
patient developed marked bright red bleeding from mediastinal drains.
Upon re-exploration, bleeding was noted from behind the heart. After
lifting the heart, a punctate site at the tip of the left atrial
appendage (LAA) was found to be the source which was repaired with a 4-0
prolene suture (fig 1A) Distal and proximal anastomosis suture lines
were hemostatic and free of bleeding. Intraoperative trans esophageal
echocardiography revealed near normal wall motion without evidence of
dissection in heart chambers or ascending aorta. (fig 2) Although the
patient’s postoperative course was complicated by delirium, she
recovered completely and was discharged home on the 6th postoperative
day.</div><div>Comment: To our knowledge, this is the first reported case of
spontaneous left atrial appendage rupture during cardiac surgery. Prior
work has described both early and late tamponade following percutaneous
device closure of the LAA (5,6,). From a surgical standpoint, the LAA
auricle may be caught in the jaws of the aortic cross clamp, causing
iatrogenic injury. (7) This complication is generally a point of concern
with the limited view in minimally invasive operations when the cross
clamp may injure the LAA through the transverse sinus. To avoid this
complication, it is crucial to visualize the tips of the cross-clamp
during its application. Acknowledging this complication, we always lift
the aorta under reduced bypass flow for cross clamping and routinely we
check the clamp location. Although the exact mechanism of injury was not
clear in the present case, it can be assumed that a micro perforation or
crushing of the LAA had occurred. Following the operation, the severe
rise in left ventricular pressure was likely transmitted to the left
atrium through a regurgitant mitral valve. Left atrial dissection is
another rare complication that can be the cause of unexplained hematoma
or hemorrhage usually during valve operations. Its presence was excluded
in our case by the general appearance of the appendage and via
transesophageal echocardiography (Figure 1B). Technical considerations
aside, this case illustrates the catastrophic consequences of medication
errors in the operating room. Such errors may occur at any stage and may
result from name confusion, prescription error and errors in dosage or
route of administration. (8)</div><div>Our patient and us were lucky that she did not suffer permanent damage.
Had this complication occurred in the postoperative period, the chances
of saving the patient without any neurological injury would have been
remote.</div><div>References:</div><div>1. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and
regional burden of disease and risk factors, 2001: systematic analysis
of population health data. Lancet. 2006;367:1747–1757 .</div><div>2.Donghao Zhou, Bo Xi, Min Zhao, Liang Wang, Sreenivas P. Veeranki</div><div>Uncontrolled hypertension increases risk of all-cause and cardiovascular
disease mortality in US adults: the NHANES III Linked Mortality Study.
Sci Rep. 2018; 8: 9418.</div><div>3. Lawes CM, Vander Hoorn S, Rodgers A. International Society of
Hypertension. Global burden of blood-pressure-related disease, 2001.
Lancet. 2008;371:1513–1518.</div><div>4.George A Mensah 1, Janet B Croft, Wayne H Giles</div><div>The heart, kidney, and brain as target organs in hypertension. Cardiol
Clin. 2002 May;20(2):225-47</div><div>5.Jian-Ming Wang, Qi-Guang Wang, and Xian-Yang Zhu. Delayed cardiac
tamponade after simultaneous transcatheter atrial septal defect closure
and left atrial appendage closure device implantation: a particular case
report. J Geriatr Cardiol. 2019 Dec; 16(12): 898–901.</div><div>6.Karen P. Phillips, Christopher Smith, Michelle Butler, Anders Taylor,
Terri Hall, Epicardial appendage ooze causing pericardial tamponade
after left atrial appendage device implantation</div><div>HeartRhythm Case Rep. 2018 Aug; 4(8): 350–352.</div><div>7.Markus Czesla, Julia Götte, Timo Weimar, Tamas Ruttkay, and Nicolas
Doll. Safeguards and pitfalls in minimally invasive mitral valve
surgery. Ann Cardiothorac Surg. 2013 Nov; 2(6): 849–852.</div><div>8. Medication Errors in Acute Cardiac Care. Circulation.
2002;106:2623–2629</div><div>Fig.1.Operative view; punctate rupture of LAA</div><div>Fig.2.Intraoperative TEE: No evidence of LAA dissection</div>