Aortobronchial Fistula Repair Following Minimally Invasive Aortic Valve Replacement

Aortobronchial fistula is a rare complication of aortic surgery that has high mortality if left untreated. These fistulas are more common in the descending aorta; however, there are a few referrals in the literature following aortic valve replacement (AVR). In this case, the patient developed an aortobronchial fistula following minimally invasive AVR and reduction aortoplasty. The patient underwent an urgent redo repair. 

Operation 

Cardiopulmonary bypass was established by cannulating the right femoral artery with a 20 French cannula and vein with a long venous cannula under transesophageal echocardiography guidance. A redo sternotomy was performed, and the two halves of the sternum were separated. The edge of the right upper lobe was visualized, firmly attached to the aorta; therefore, it was decided to staple and divide it from the lung while leaving it attached to the aorta. 

Next, the distal ascending aorta was freed. The aorta was cross-clamped, and antegrade cold blood cardioplegia was delivered. After cardiac arrest, the remainder of the pericardium was opened, and the inferior surface of the heart was dissected. 

A transverse aortotomy was performed, and the aorta was inspected internally. The fistula arising from the noncoronary sinus next to the aortoplasty suture line was revealed, leading to a pseudoanerysm. The pseudoanerysm, along with the fistula and surrounding tissues, was dissected and removed en block with the ascending aorta and the attached edge of the right lung. There were no signs of active infection or collection. 

Fluid and tissue from the pseudoaneurysm were sent for cultures, which later returned negative. The aortic valve was inspected and was functioning well with no vegetations; therefore, the valve was preserved. The aorta was reconstructed using a Therumo-Vascutes prosthetic graft sized 28 mm. 

The graft was attached to the sinotubular junction using a continuous Prolene 5.0 running stitch. An additional dose of cardioplegia was delivered, and hemostasis was assessed, followed by the distal anastomosis reconstruction in a similar manner. The deairing maneuver was performed, and the cross-clamp was removed. Hemostasis was then performed, followed by straightforward weaning from the cardiopulmonary bypass (CPB). The cross-clamp time was 66 minutes, and the CPB time was 96 minutes. The patient required reexploration of the right femoral artery incision the following day due to leg ischaemia, which was completely resolved. 

The postoperative CT scan did not show any complications, and he was transferred to the local hospital for further recovery. 

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