- Email: [email protected]
A novel minimally invasive technique of temporary caval occlusion for right heart surgery
Journal Pre-proof A novel minimally invasive technique of temporary caval occlusion for right heart surgery Faizus Sazzad, MBBS MS FCPS FACS, Michał Kuzemczak, MD PhD MSc, Theodoros Kofidis, MD PD (Ger) FRCS FAHA FAMS PII:
S0003-4975(19)31821-1
DOI:
https://doi.org/10.1016/j.athoracsur.2019.10.033
Reference:
ATS 33273
To appear in:
The Annals of Thoracic Surgery
Received Date: 27 July 2019 Revised Date:
30 September 2019
Accepted Date: 11 October 2019
Please cite this article as: Sazzad F, Kuzemczak M, Kofidis T, A novel minimally invasive technique of temporary caval occlusion for right heart surgery, The Annals of Thoracic Surgery (2019), doi: https:// doi.org/10.1016/j.athoracsur.2019.10.033. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
A novel minimally invasive technique of temporary caval occlusion for right heart surgery Running Head: Caval occlusion for right heart surgery.
Faizus Sazzad MBBS MS FCPS FACS1, Michał Kuzemczak MD PhD MSc1,2, Theodoros Kofidis MD PD (Ger) FRCS FAHA FAMS1,3
[1] National University of Singapore, Yong Loo Lin School of Medicine; Department of Cardiac, Thoracic and Vascular Surgery; CTVS/Myocardial Restoration Laboratory, Singapore; Address: 14 Medical Drive, MD6 Building, Level 8 South, Singapore 117599 [2] Poznan University of Medical Sciences, Poznań, Poland; Chair of Emergency Medicine, Department of Medical Rescue Address: ul. Rokietnicka 7, 60-806 Poznań, Poland [3] Department of Cardiac, Thoracic and Vascular Surgery; National University Heart Centre, Singapore; Address: 1E Kent Ridge Road, Towerblock Level 9, Singapore 119228
Classifications: minimally invasive surgery, atrium Word Count: 1481
Corresponding author: Assoc. Prof. Theodoros Kofidis MD PD (Ger) FRCS FAHA FAMS Head, Department of Cardiac, Thoracic and Vascular Surgery National University Heart Centre, Singapore 1E Kent Ridge Road, Towerblock Level 9, Singapore 117599 Email: [email protected]
1
Abstract Right heart surgery is challenging in the minimally invasive cardiac surgery setting, particularly in terms of caval isolation procedures in patients with enlarged and pressurized atria. We describe a novel minimally invasive caval occlusion technique with the use of a balloon catheter designed for temporary large vessel occlusion. A patient with a large ostium secundum atrial septal defect and significant shunt flow underwent a successful minimally invasive closure of the pathological connection between atria with a bovine pericardial patch. The employed occlusion technique provided excellent visibility of the surgical site and may facilitate minimally invasive procedures in various clinical scenarios.
2
Although minimally invasive cardiac surgery (MICS) has expanded over the last several years and become a safe alternative to classical heart surgery in various clinical scenarios, it is still not widely practiced[1]. In many instances, complexity of these procedures is exceptionally demanding and act as a deterrent to performing them more extensively in the clinical arena. Right heart surgery performed via a right thoracotomy approach is considered a challenge in terms of caval isolation and can be particularly demanding in patients with enlarged and pressurized atria. In the present paper, we give an account of a novel minimally invasive caval occlusion technique that facilitates MICS procedures and therefore may contribute to their more widespread application.
Technique A 45-year old female patient was admitted due to a large ostium secundum atrial septal defect (ASD) and significant shunt flow (the pulmonary to systemic blood flow ratio (Qp/Qs) 2:1). Because of the absence of a posterior rim, the patient could not be treated percutaneously and was referred for a minimally invasive ASD closure via right thoracotomy. Due to a difficult approach to the inferior vena cava (IVC) and a potential risk of the vessel injury, an alternative strategy for the IVC isolation and occlusion under control of transesophageal echocardiography (TEE) was employed. Access to the patient’s IVC was obtained via a left femoral vein (LFV)(Figure 1). The route was used to introduce a Coda balloon catheter (Cook Incorporated, Bloomington, IN, USA) which was then advanced to the IVC and placed at the junction of the vessel with the right atrium (RA) under TEE guidance(Figure 2B). For the catheter to be propagated in the right position, the IVC cannula had to be retracted into the IVC. A superior vena cava (SVC) was cannulated via a right internal jugular vein (RIJV) ultrasonography-guided access and occluded by external snaring. Right femoral artery (RFA) was used for aortic cannulation. The surgical procedure was performed using a vacuumassisted cardiopulmonary bypass (CPB) and selective one-lung ventilation. The aorta was crossclamped via a right transaxillary approach and the heart was arrested with del Nido cardioplegia administered via the aortic root. Following vacuum-assisted evacuation of the heart and the right atriotomy, the ASD was closed with a bovine pericardial patch (approximately 5.0x2.5 cm). The Coda balloon (Cook
3
Incorporated, Bloomington, IN, USA) was found in situ occluding the IVC entry without any dislocation. More surgical instruments intended for MICS procedures that are used in our centre on a routine basis did not need to be utilized. The patient was discharged from the hospital on 4th postoperative day in good clinical condition.
Comment In recent years, there has been a remarkable increase in MICS techniques that provide excellent clinical outcomes with a reduced surgical trauma, lower rate of complications, better cosmetic results and shorter hospital stay as compared to classical surgeries[1]. Nowadays, with a better equipped surgical armamentrium, a modern minimally invasive cardiac surgeon is able to deal with more complex cases than ever before[2,3,4]. Many of these surgeries are performed via a right thoracotomy with caval isolation as an inherent part of the procedure. The conventional way to isolate these vessels is to make a blunt dissection and external snaring. This can be challenging and hazardous when MICS is employed and may result in bleeding from fragile tissues, necesssitating a conversion to a median sternotomy[5]. An alternative thoracoscopic approach has been described by Hui et al.[6]. However, the technique cannot be utilized in procedures performed via a right thoracotomy as thoracoscopy ports would interfere and impair access to the already limited surgical exposure. The presented TEE-guided IVC occlusion technique provides a complete cessation of caval inflow and excellent visibility of the surgical site without compromising patients‘ safety. The method is applicable for right heart surgery only while the SVC is snared or occluded similarly separately. In the available literature scarce data were found on „internal snaring“ techniques. Capestro et al. employed a similar technique with the use of Fogarty catheters for redo mitral and tricuspid surgeries[7]. Sansone et al. exploited Foley catheters for combined mitro-tricuspid redo surgeries[8]. However, these techniques require positioning of the balloons in IVC after RA opening and, therefore, with a gush of venous blood. Furthemore, these balloons do not have a pressure control system which pose a danger of iatrogenic caval injury. Last but not least, the use of thoracotomy to place them in a desired area reduces a surgeon’s working space.
4
The technique has its limitations that need to be acknowledged. In patients with challenging anatomy, particularly flat-chested individuals with a vertical position of the heart, it can be hard to implement. Similarly, patients with extremely enlarged atria and dilated IVC orifices may also warrant traditional, albeit risky and cumbersome technique. The MICS performed in proper clinical settings and by a skilled cardiac surgeon may succeed in taking up a double challenge, namely to achieve excellent clinical outcomes and patients‘ quality of life. Being a field of innovation and, as presented in this patient, not rarely improvisation it has the potential to offer all of these benefits. As a commited minimally invasive and hybrid cardiac surgery team, we strongly believe that the presented technique, although to a small extent, may contribute to a more widespread application of MICS procedures without compromising their safety and clinical efficacy.
5
References [1]Kofidis T, Chang GH, Lee CN. Establishment of minimally invasive cardiac surgery programme in Singapore. Singapore Med J 2017; 58 (10): 567-579 [2]Glauber M, Karimov JH, Farneti PA, et al. Minimally invasive mitral valve surgery via right minithoracotomy. Multimed Man Cardiothoracic Surg 2009 (122): mmcts.2008.003350 [3]Santana O, Pineda AM, Cortes-Bergoderi M, Mihos CG, Beohar N, Lamas GA, Lamelas J. Hybrid approach of percutaneous coronary intervention followed by minimally invasive valve operations. Ann Thorac Surg 2014; 97 (6): 2049-55 [4]Smit PJ, Shariff MA, Nabagiez JP, Khan MA, Sadel SM, Mginn JT Jr. Experience with a minimally invasive approach to combined valve surgery and coronary artery bypass grafting through bilateral thoracotomies. Heart Surg Forum 2013;16 (3): E125-31 [5]Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience. Ann Thorac Surg 2009; 88: 1845-1850 [6]Hui DS, Gill IS, Cunningham MJ. Minimallly invasive approach to the supradiaphragmatic inferior vena cava: total thoracoscopic caval isolation. Innovations (Phila) 20114; 9 (2): 145-7 [7]Capestro F, Matteucci S, Rescigno G, Torracca L. A simplified technique for caval occlusion in reoperative small thoracotomies. J Thorac Cardiovasc Surg 2011; 142 (2): 460-2 [8]Sansone F, del Ponte S, Zingarelli E, Casabona R. Internal snaring of the caval veins by Foley catheters in case of reoperations via right thoracotomy. Interact Cardiovasc Thorac Surg 2011; 13 (4): 370-2
6
Figure legends Figure 1. The novel caval isolation technique with the use of the Coda balloon (IVC–inferior vena cava, SVC–superior vena cava). Figure 2. Selected steps of the surgical procedure. A–Exploration of right femoral vessels. B– Positioning of the baloon under control of transesophageal echocardiography. C–Inferior vena cava cannula in situ. D–Right thoracotomy via forth intercostal space (lack of visibility of inferior vena cava, even following a right lung deflation).
7
S0003-4975(19)31821-1
DOI:
https://doi.org/10.1016/j.athoracsur.2019.10.033
Reference:
ATS 33273
To appear in:
The Annals of Thoracic Surgery
Received Date: 27 July 2019 Revised Date:
30 September 2019
Accepted Date: 11 October 2019
Please cite this article as: Sazzad F, Kuzemczak M, Kofidis T, A novel minimally invasive technique of temporary caval occlusion for right heart surgery, The Annals of Thoracic Surgery (2019), doi: https:// doi.org/10.1016/j.athoracsur.2019.10.033. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
A novel minimally invasive technique of temporary caval occlusion for right heart surgery Running Head: Caval occlusion for right heart surgery.
Faizus Sazzad MBBS MS FCPS FACS1, Michał Kuzemczak MD PhD MSc1,2, Theodoros Kofidis MD PD (Ger) FRCS FAHA FAMS1,3
[1] National University of Singapore, Yong Loo Lin School of Medicine; Department of Cardiac, Thoracic and Vascular Surgery; CTVS/Myocardial Restoration Laboratory, Singapore; Address: 14 Medical Drive, MD6 Building, Level 8 South, Singapore 117599 [2] Poznan University of Medical Sciences, Poznań, Poland; Chair of Emergency Medicine, Department of Medical Rescue Address: ul. Rokietnicka 7, 60-806 Poznań, Poland [3] Department of Cardiac, Thoracic and Vascular Surgery; National University Heart Centre, Singapore; Address: 1E Kent Ridge Road, Towerblock Level 9, Singapore 119228
Classifications: minimally invasive surgery, atrium Word Count: 1481
Corresponding author: Assoc. Prof. Theodoros Kofidis MD PD (Ger) FRCS FAHA FAMS Head, Department of Cardiac, Thoracic and Vascular Surgery National University Heart Centre, Singapore 1E Kent Ridge Road, Towerblock Level 9, Singapore 117599 Email: [email protected]
1
Abstract Right heart surgery is challenging in the minimally invasive cardiac surgery setting, particularly in terms of caval isolation procedures in patients with enlarged and pressurized atria. We describe a novel minimally invasive caval occlusion technique with the use of a balloon catheter designed for temporary large vessel occlusion. A patient with a large ostium secundum atrial septal defect and significant shunt flow underwent a successful minimally invasive closure of the pathological connection between atria with a bovine pericardial patch. The employed occlusion technique provided excellent visibility of the surgical site and may facilitate minimally invasive procedures in various clinical scenarios.
2
Although minimally invasive cardiac surgery (MICS) has expanded over the last several years and become a safe alternative to classical heart surgery in various clinical scenarios, it is still not widely practiced[1]. In many instances, complexity of these procedures is exceptionally demanding and act as a deterrent to performing them more extensively in the clinical arena. Right heart surgery performed via a right thoracotomy approach is considered a challenge in terms of caval isolation and can be particularly demanding in patients with enlarged and pressurized atria. In the present paper, we give an account of a novel minimally invasive caval occlusion technique that facilitates MICS procedures and therefore may contribute to their more widespread application.
Technique A 45-year old female patient was admitted due to a large ostium secundum atrial septal defect (ASD) and significant shunt flow (the pulmonary to systemic blood flow ratio (Qp/Qs) 2:1). Because of the absence of a posterior rim, the patient could not be treated percutaneously and was referred for a minimally invasive ASD closure via right thoracotomy. Due to a difficult approach to the inferior vena cava (IVC) and a potential risk of the vessel injury, an alternative strategy for the IVC isolation and occlusion under control of transesophageal echocardiography (TEE) was employed. Access to the patient’s IVC was obtained via a left femoral vein (LFV)(Figure 1). The route was used to introduce a Coda balloon catheter (Cook Incorporated, Bloomington, IN, USA) which was then advanced to the IVC and placed at the junction of the vessel with the right atrium (RA) under TEE guidance(Figure 2B). For the catheter to be propagated in the right position, the IVC cannula had to be retracted into the IVC. A superior vena cava (SVC) was cannulated via a right internal jugular vein (RIJV) ultrasonography-guided access and occluded by external snaring. Right femoral artery (RFA) was used for aortic cannulation. The surgical procedure was performed using a vacuumassisted cardiopulmonary bypass (CPB) and selective one-lung ventilation. The aorta was crossclamped via a right transaxillary approach and the heart was arrested with del Nido cardioplegia administered via the aortic root. Following vacuum-assisted evacuation of the heart and the right atriotomy, the ASD was closed with a bovine pericardial patch (approximately 5.0x2.5 cm). The Coda balloon (Cook
3
Incorporated, Bloomington, IN, USA) was found in situ occluding the IVC entry without any dislocation. More surgical instruments intended for MICS procedures that are used in our centre on a routine basis did not need to be utilized. The patient was discharged from the hospital on 4th postoperative day in good clinical condition.
Comment In recent years, there has been a remarkable increase in MICS techniques that provide excellent clinical outcomes with a reduced surgical trauma, lower rate of complications, better cosmetic results and shorter hospital stay as compared to classical surgeries[1]. Nowadays, with a better equipped surgical armamentrium, a modern minimally invasive cardiac surgeon is able to deal with more complex cases than ever before[2,3,4]. Many of these surgeries are performed via a right thoracotomy with caval isolation as an inherent part of the procedure. The conventional way to isolate these vessels is to make a blunt dissection and external snaring. This can be challenging and hazardous when MICS is employed and may result in bleeding from fragile tissues, necesssitating a conversion to a median sternotomy[5]. An alternative thoracoscopic approach has been described by Hui et al.[6]. However, the technique cannot be utilized in procedures performed via a right thoracotomy as thoracoscopy ports would interfere and impair access to the already limited surgical exposure. The presented TEE-guided IVC occlusion technique provides a complete cessation of caval inflow and excellent visibility of the surgical site without compromising patients‘ safety. The method is applicable for right heart surgery only while the SVC is snared or occluded similarly separately. In the available literature scarce data were found on „internal snaring“ techniques. Capestro et al. employed a similar technique with the use of Fogarty catheters for redo mitral and tricuspid surgeries[7]. Sansone et al. exploited Foley catheters for combined mitro-tricuspid redo surgeries[8]. However, these techniques require positioning of the balloons in IVC after RA opening and, therefore, with a gush of venous blood. Furthemore, these balloons do not have a pressure control system which pose a danger of iatrogenic caval injury. Last but not least, the use of thoracotomy to place them in a desired area reduces a surgeon’s working space.
4
The technique has its limitations that need to be acknowledged. In patients with challenging anatomy, particularly flat-chested individuals with a vertical position of the heart, it can be hard to implement. Similarly, patients with extremely enlarged atria and dilated IVC orifices may also warrant traditional, albeit risky and cumbersome technique. The MICS performed in proper clinical settings and by a skilled cardiac surgeon may succeed in taking up a double challenge, namely to achieve excellent clinical outcomes and patients‘ quality of life. Being a field of innovation and, as presented in this patient, not rarely improvisation it has the potential to offer all of these benefits. As a commited minimally invasive and hybrid cardiac surgery team, we strongly believe that the presented technique, although to a small extent, may contribute to a more widespread application of MICS procedures without compromising their safety and clinical efficacy.
5
References [1]Kofidis T, Chang GH, Lee CN. Establishment of minimally invasive cardiac surgery programme in Singapore. Singapore Med J 2017; 58 (10): 567-579 [2]Glauber M, Karimov JH, Farneti PA, et al. Minimally invasive mitral valve surgery via right minithoracotomy. Multimed Man Cardiothoracic Surg 2009 (122): mmcts.2008.003350 [3]Santana O, Pineda AM, Cortes-Bergoderi M, Mihos CG, Beohar N, Lamas GA, Lamelas J. Hybrid approach of percutaneous coronary intervention followed by minimally invasive valve operations. Ann Thorac Surg 2014; 97 (6): 2049-55 [4]Smit PJ, Shariff MA, Nabagiez JP, Khan MA, Sadel SM, Mginn JT Jr. Experience with a minimally invasive approach to combined valve surgery and coronary artery bypass grafting through bilateral thoracotomies. Heart Surg Forum 2013;16 (3): E125-31 [5]Lee TC, Desai B, Glower DD. Results of 141 consecutive minimally invasive tricuspid valve operations: an 11-year experience. Ann Thorac Surg 2009; 88: 1845-1850 [6]Hui DS, Gill IS, Cunningham MJ. Minimallly invasive approach to the supradiaphragmatic inferior vena cava: total thoracoscopic caval isolation. Innovations (Phila) 20114; 9 (2): 145-7 [7]Capestro F, Matteucci S, Rescigno G, Torracca L. A simplified technique for caval occlusion in reoperative small thoracotomies. J Thorac Cardiovasc Surg 2011; 142 (2): 460-2 [8]Sansone F, del Ponte S, Zingarelli E, Casabona R. Internal snaring of the caval veins by Foley catheters in case of reoperations via right thoracotomy. Interact Cardiovasc Thorac Surg 2011; 13 (4): 370-2
6
Figure legends Figure 1. The novel caval isolation technique with the use of the Coda balloon (IVC–inferior vena cava, SVC–superior vena cava). Figure 2. Selected steps of the surgical procedure. A–Exploration of right femoral vessels. B– Positioning of the baloon under control of transesophageal echocardiography. C–Inferior vena cava cannula in situ. D–Right thoracotomy via forth intercostal space (lack of visibility of inferior vena cava, even following a right lung deflation).
7