Cabrol Patch with Cooley Fistula: A Useful Tool for Difficult-to-Control Bleeding

This video demonstrates the construction and implementation of a Cabrol patch and Cooley fistula, which can be an effective technique to combat persistent aortic bleeding. In this case, the Cabrol patch was used on a fifty-eight-year-old women, a former smoker with uncontrolled diabetes and BMI of 34.

The patient had undergone aortic valve replacement with a bioprosthetic valve and a two-vessel coronary artery bypass surgery one year prior. She presented with fever, and Staph bacteremia was detected.

An echocardiogram showed prosthetic aortic valve endocarditis with aortic root abscess. With this finding, the patient was taken to the operating room for homograft aortic root replacement.

The Surgery

Intraoperative findings included a large aortic root abscess extending from the right noncoronary commissure, along the aortomitral curtain, and over the noncoronary sinus and noncoronary annulus. It continued through the left noncoronary commissure and along the left coronary annulus, just below the coronary ostium, and ended at the left-right commissure. The prosthetic valve leaflets were thickened and infected with vegetations. The root abscess was immediately noted at the left-right commissure, before the valve was even removed.

During removal of the valve, many annular sutures and pledgets came out intact with the valve using gentle pulling and blunt dissection. At this time, a second large pocket of purulence was noted at the right-noncoronary commissure. With prosthesis removal, the surgeons could clearly see the intact annular sutures remaining on the sewing cuff of the valve.

Next, the aortic root was exposed via cutting down on the noncoronary sinus to debride the remaining infected tissues. This is when the full root abscess and surrounding phlegmon were seen, extending from the right noncoronary commissure toward the left noncoronary commissure, then directly below the left coronary ostium, and ended at the left-right coronary commissure. The aortic root was heavily dissected, and surgeons noted the remaining left coronary button tissue and its fragility.

Next, a mitral valve repair with aortomitral curtain reconstruction was performed, along with homograft aortic root replacement, tricuspid valve repair, and closure of a patent foramen ovale. Concerns remained about the strength of the left coronary button because of its friable surrounding tissue secondary to the root abscess.

After cross-clamp removal, mild persistent bleeding continued at this coronary button despite placing multiple repair sutures, all of which were perilously close to the ostium of the left coronary artery. Therefore, the decision was made to initiate placement of a Cabrol patch with Cooley fistula.

Prior to patch placement, the Cooley fistula was prepared via a large right atriotomy, which was snared down using a purse-string suture. Then, a 10 cm by 16 cm patch of bovine pericardium was opened and partially tailored.

Using a double loaded 4-0 SH Prolene suture, the patch was sutured to the heart, starting at the right ventricle and right ventricular outflow tract, going over the pulmonary artery and the nearby pericardium, onto the aortic arch and innominate vein, then down onto the superior vena cava and its surrounding pericardium.

The patch was further tailored and the second arm of the 4-0 Prolene suture was used to continue the Cabrol patch anastomosis onto the anterior wall of the right ventricle, then finally over the right atrium. Just prior to completion of the Cabrol patch, the snare was removed from the right atrium, the atriotomy was confirmed to be easily opened, and the Cabrol patch was completed.

The patient’s postoperative course was uneventful, with discharge home on postoperative day seven and a transthoracic echocardiogram showing no evidence of any significant aorta to right atrial fistula.

Conclusion

This case demonstrates how Cabrol patch can be considered as an ideal usage for cases with mild persistent aortic bleeding. If used in severe aortic root bleeding, a significant aorta to right atrial fistula would remain and could result in high output heart failure.

Additionally, the Cabrol patch is best used in redo cardiac surgeries because of the mediastinal adhesions. If used in a virgin chest, the transverse sinus would allow an alternative route for the blood to flow. In addition, although it may be possible to close the transverse sinus, it is technically challenging and can be dangerous.

Some technical considerations include creating a sizable right atriotomy, larger than 4 or 5 cm, since smaller ones tend to easily close. The ideal location would be in thinner areas of the right atrium and avoiding the heavily trabeculated tissues. The use of a very large patch of bovine pericardium will allow for redundancy and an easier pathway for the aortic blood to flow in the right atrium.

One possible pitfall is noticing a taut and pressurized patch at the end. This will result in bleeding through the patch suture lines since it is very likely the right atriotomy has closed. With a closed right atriotomy, the high-pressure aortic bleeding cannot flow into the low pressure right atrial system. Therefore, the Cabrol patch will fail, and bleeding will continue through the patch suture lines. To correct this, create an opening in the bovine pericardial patch just near the right atrium, enlarge the right atriotomy, and then quickly close the pericardial patch opening.

Another pitfall occurs when there is continued bleeding noted in the pericardial well. This is due to another escape pathway for the aortic blood. Often, the location is the superior vena cava, in which it is either located anteriorly because of gaps in the patch-to-SVC suture lines, or it is located posterior to the SVC, which can occur if the SVC was mobilized, such as during bicaval cannulation with SVC snaring. Either way, it is usually an easy fix.

References

1. Cabrol, C., et al. "Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach." The Journal of thoracic and cardiovascular surgery 81.2 (1981): 309-315.

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