- Email: [email protected]
Extracardiac total cavopulmonary connection using a Y-shaped graft
Ann Thorac Surg 2002;74:2195–7
CASE REPORT OKANO ET AL TOTAL CAVOPULMONARY CONNECTION
2195
The authors appreciate the excellent illustrations by David Crawford.
References
Fig 2. Diagramatic representation of the repair with pledgeted stitches incorporating the tear and mitral leaflet.
ruptured on postoperative day 4 and was removed with difficulty. This patient had an unrecognized massive retroperitoneal hematoma leading to hemodynamic instability. She underwent surgical exploration and repair of the femoral artery. This patient subsequently developed sepsis, which led to multiorgan failure and death on the 11th postoperative day. One patient developed minor left hemiplegia, but had recovered fully within a month. Both the surviving patients are enjoying good quality of life at 1 year and 5 years post-left ventricle repair. There is no evidence of pseudoaneurysm in either of these patients on follow-up echocardiogram.
Comment Since its introduction in early 1960s [4], the IABP has become the most widely applied method in circulatory support. Bavaria and associates [5], in their animal studies, have proven a statistically significant reduction in left ventricle peak pressure and left ventricle end diastolic pressure with the use of IABP. Marks and colleagues [6] have similar observations with significant reduction in left ventricle peak pressure. Our experience and successful outcome of the left ventricle repairs support the importance of afterload reduction in this situation. Although 1 of our patients died with sepsis and multiorgan failure, the left ventricle repair remained intact without any hemorrhagic problem. IABP should be inserted electively before coming off bypass. This will decrease the afterload and help to prevent excessive build up of intraventricular pressure. This, in turn, will decrease the tension along the repaired suture line and avoid the stitches cutting through the edematous and friable myocardium. All of our patients survived the acute catastrophic situation as compared with the immediate high mortality reported in the literature [1, 8]. Cobbs and coworkers [7] emphasized the importance of preservation of the supporting structures of the posterior ventricular wall, ie, the attached chordae and the posterior leaflet of the mitral valve. In our experience, despite preservation of the posterior mitral leaflet with attached chordae, left ventricle ruptures still occurred. Although the number of cases are small to reach any definite conclusions, our experience suggests that the left ventricle rupture can occasionally occur despite taking all the precautions, and preserving the posterior mitral leaflet and its attachment. An IABP is an ideal adjuvant to left ventricle rupture repair, after mitral valve replacement, to avoid excessive tension on the suture line. © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Katske G, Golding LR, Tubbs DO, Loop FD. Posterior mid ventricular rupture after mitral valve replacement. Ann Thorac Surg 1979;27:130 –2. 2. Karlson KJ, Ashraf MM, Burger LR. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590 –97. 3. Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL Jr. Initial experience with intraaortic balloon pumping in cardiogenic shock. JAMA 1968;203:135–40. 4. Weber KT, Janicki JS. Intra-aortic balloon counterpulsation—a review of physiological principles, clinical results and device safety. Ann Thorac Surg 1974;17:249 –54. 5. Bavaria JE, Furukawa S, Kreiner G, et al. Effect of circulatory assist devices on stunned myocardium. Ann Thorac Surg 1990;49:123–8. 6. Marks JD, Pantalos GM, Long JW, et al. Myocardial mechanics, energetics and hemodynamics during intraaortic balloon and transvalvular axial flow hemopump support with a bovine model of ischaemic cardiac dysfunction. ASAIO J 1999;45:602–9. 7. Cobbs BW Jr, Hatcher CR Jr, Craver JM, et al. Transverse midventricular disruption after mitral valve replacement. Am Heart J 1980;99:33–50. 8. Dark JH, Bain WH. Rupture of posterior wall of left ventricle after mitral valve replacement. Thorax 1984;39:905–11.
Extracardiac Total Cavopulmonary Connection Using a Y-Shaped Graft Takahisa Okano, MD, Masaaki Yamagishi, MD, Keisuke Shuntoh, MD, Yoshiaki Yamada, MD, Kyoko Hayashida, MD, Takeshi Shinkawa, MD, and Nobuo Kitamura, MD Department of Pediatric Cardiovascular Surgery, Children’s Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
We report on 17-year-old Fontan candidate with a seerely distorted central pulmonary artery (PA) who underwent a successful extracardiac total cavopulmonary connection using a Y-shaped bifurcated graft. A nonanatomic pathway from the inferior vena cava to the left PA was constructed and positioned anterior to the ascending aorta. The other arm was used as a conduit between the inferior vena cava and the right PA. All procedures were performed under temporary venous bypass without cardiopulmonary bypass. (Ann Thorac Surg 2002;74:2195–7) © 2002 by The Society of Thoracic Surgeons Accepted for publication July 1, 2002. Address reprint requests to Dr Okano, Department of Pediatric Cardiovascular Surgery, Children’s Hospital, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamikyo-ku, Kyoto 602-8566, Japan; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(02)03978-4
2196
CASE REPORT OKANO ET AL TOTAL CAVOPULMONARY CONNECTION
Ann Thorac Surg 2002;74:2195–7
D
istortion of the pulmonary artery (PA) is a serious risk factor of the Fontan operation [1]. We successfully applied extracardiac total cavopulmonary connection (TCPC) using a Y-shaped prosthetic graft to a Fontan candidate with a severely distorted central PA. The patient was a 17-year-old boy with right isomerism, single atrium, single right ventricle, common atrioventricular valve, bilateral superior vena cava (SVC), and pulmonary atresia. He underwent bilateral BlalockTaussig shunts at the ages of 11 months and 5 years. Pulmonary arteriography at 16 years of age demonstrated a nonconfluent central PA at the site of ductal ligament. Pulmonary arterial index was 138 mm2/m2. He underwent bilateral bidirectional cavopulmonary shunt (BCPS), augmentation of central PA using expanded polytetrafluoroethylene (ePTFE) patch (W.L. Gore & Associates, Inc., Flagstaff, AZ), and amputation of the previous bilateral Blalock-Taussig shunts. Angiography 3 months after BCPS showed patent bilateral cavopulmonary anastomoses with adequate blood flow from the left and right SVC to respective PA. However, in spite of prior augmentation, severe diffuse narrowing of the central PA was noted. The central PA measured 2.7 mm in diameter (Fig 1). Fontan operation was performed 12 months after BCPS. During the operation, reconstruction of the central PA behind the ascending aorta was considered impossible, because the central PA was pressed by the thick ascending aorta anteriorly and tightly adhered to the surrounding scar tissue, resulting in narrowing of the space behind the ascending aorta. Both the SVC and sites of
Fig 1. Preoperative cardiac angiography showing severe distorted central pulmonary artery (PA) and patent anastomoses between bilateral superior vena cava and PAs after bidirectional cavopulmonary shunt. (LPA ⫽ left pulmonary artery; RPA ⫽ right pulmonary artery.)
Fig 2. (A) A Y-shaped bifurcated graft was used upside down as an extracardiac conduit. A nonanatomic pathway from the IVC to left pulmonary artery (PA) was positioned anterior to the ascending aorta. (IVC ⫽ inferior vena cava; LSVC ⫽ left superior vena cava; RSVC ⫽ right superior vena cava.) (B) Postoperative three-dimensional computed tomography anterior view showing no obstruction or kinking in the systemic venous pathway (ie, inverted Y-graft) from the IVC to PAs.
cavopulmonary anastomoses were dissected, and a temporary bypass between the right and left SVC was established. First, one side of the arm of the Y-shaped
Ann Thorac Surg 2002;74:2195–7
graft (Hemashield Gold, 22 ⫻ 11 mm; Meadox Medicals, Inc, Oakland, NJ) was anastomosed to the left PA just distal of the site of cavopulmonary anastomosis. After subtotal thymectomy, the left arm of the Y-shaped graft was detoured anterior to the cranial side of the ascending aorta to avoid pressure from the sternum. Second, the other arm of the graft was also anastomosed to the right PA. Under temporary bypass between the right atrium and inferior vena cava (IVC), the IVC was divided at the cavoatrial junction. Proximal stump was oversewn, while the distal end was anastomosed to the main trunk of the graft in end-to-end fashion (Fig 2A). All procedures were performed without cardiopulmonary bypass (CPB). Postoperative recovery was uneventful with stable hemodynamics. The patient is currently receiving antiplatelet therapy. Three-dimensional computed tomography at 14 months postoperatively showed sufficient patency of the systemic venous pathway without any stenosis (Fig 2B).
Comment After initial bilateral BCPS, distortion of the central PA often occurs due to decreased blood flow. Concomitant augmentation or replacement of the distorted or nonconfluent central PA is required in conventional extracardiac TCPC using a straight prosthetic graft. Controversy still exists regarding the best procedure to reroute the inferior vena caval blood to the pulmonary circulation [2–5]. We performed a unique extracardiac TCPC in a Fontan candidate with a severely distorted central PA as follows. (1) A Y-shaped bifurcated graft was used upside down as an extracardiac conduit. (2) A nonanatomic pathway from the IVC to the left PA was constructed and positioned anterior to the ascending aorta. (3) The other arm was used as a conduit between IVC and right PA. (4) A sufficient space for the left arm of the graft was provided by subtotal thymectomy. (5) All procedures were completed without CPB. The posterior anatomical route be-
CASE REPORT OKANO ET AL TOTAL CAVOPULMONARY CONNECTION
2197
hind the ascending aorta is preferable as a pathway for the graft to the left PA. However, because of tight adhesions after initial operation and pressure from the thick aorta anteriorly, sufficient space behind the ascending aorta for reconstructing the central PA was not available. Moreover, a graft passing behind the ascending aorta may induce left bronchial obstruction. Anterior routing in front of the ascending aorta needs minimum dissection. Subtotal thymectomy provided sufficient space for the graft to avoid pressure by the sternum. Although the left arm of the Y-shaped graft is rather long, excessive winding of the graft and consequent turbulent blood flow are avoided by use of the anterior route. The GoreTex grafts for the venous system are generally used to avoid late neointimal formation and peel formation. We were obliged to use a Dacron graft as a venous conduit because a Y-shaped GoreTex graft is not available commercially. Therefore, careful sureveillance for these late complications should be enforced by routine echocardiography and angiography. The Y-shaped graft with anterior route of the left arm is a useful alternative technique for extracardiac TCPC in Fontan candidates with severely distorted or nonconfluent central PA.
References 1. Mayer JE Jr, Bridges ND, Lock JE, Hanley FL, Jonas RA, Castaneda AR. Factors associated with marked reduction in mortality for Fontan operation in patients with single ventricle. J Thorac Cardiovasc Surg 1992;103:444 –52. 2. Burke RP, Jacobs JP, Ashraf MH, Aldousany A, Chang AC. Extracardiac Fontan operation without cardiopulmonary bypass. Ann Thorac Surg 1997;63:1175–7. 3. Giannico S, Corno AF, Marino B, et al. Total extracardiac right heart bypass. Circulation 1992;86(Suppl 2):110 –7. 4. Hashimoto K, Kurosawa H, Tanaka K, et al. Total cavopulmonary connection without the use of prosthetic material: technical considerations and consequences. J Thorac Cardiovasc Surg 1995;110:625–32. 5. Yamagishi M, Nakamura Y, Kanazawa T, Kawada N. Extracardiac direct total cavopulmonary connection. Ann Thorac Surg 1997;64:1817–20.
CASE REPORT OKANO ET AL TOTAL CAVOPULMONARY CONNECTION
2195
The authors appreciate the excellent illustrations by David Crawford.
References
Fig 2. Diagramatic representation of the repair with pledgeted stitches incorporating the tear and mitral leaflet.
ruptured on postoperative day 4 and was removed with difficulty. This patient had an unrecognized massive retroperitoneal hematoma leading to hemodynamic instability. She underwent surgical exploration and repair of the femoral artery. This patient subsequently developed sepsis, which led to multiorgan failure and death on the 11th postoperative day. One patient developed minor left hemiplegia, but had recovered fully within a month. Both the surviving patients are enjoying good quality of life at 1 year and 5 years post-left ventricle repair. There is no evidence of pseudoaneurysm in either of these patients on follow-up echocardiogram.
Comment Since its introduction in early 1960s [4], the IABP has become the most widely applied method in circulatory support. Bavaria and associates [5], in their animal studies, have proven a statistically significant reduction in left ventricle peak pressure and left ventricle end diastolic pressure with the use of IABP. Marks and colleagues [6] have similar observations with significant reduction in left ventricle peak pressure. Our experience and successful outcome of the left ventricle repairs support the importance of afterload reduction in this situation. Although 1 of our patients died with sepsis and multiorgan failure, the left ventricle repair remained intact without any hemorrhagic problem. IABP should be inserted electively before coming off bypass. This will decrease the afterload and help to prevent excessive build up of intraventricular pressure. This, in turn, will decrease the tension along the repaired suture line and avoid the stitches cutting through the edematous and friable myocardium. All of our patients survived the acute catastrophic situation as compared with the immediate high mortality reported in the literature [1, 8]. Cobbs and coworkers [7] emphasized the importance of preservation of the supporting structures of the posterior ventricular wall, ie, the attached chordae and the posterior leaflet of the mitral valve. In our experience, despite preservation of the posterior mitral leaflet with attached chordae, left ventricle ruptures still occurred. Although the number of cases are small to reach any definite conclusions, our experience suggests that the left ventricle rupture can occasionally occur despite taking all the precautions, and preserving the posterior mitral leaflet and its attachment. An IABP is an ideal adjuvant to left ventricle rupture repair, after mitral valve replacement, to avoid excessive tension on the suture line. © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
1. Katske G, Golding LR, Tubbs DO, Loop FD. Posterior mid ventricular rupture after mitral valve replacement. Ann Thorac Surg 1979;27:130 –2. 2. Karlson KJ, Ashraf MM, Burger LR. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590 –97. 3. Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL Jr. Initial experience with intraaortic balloon pumping in cardiogenic shock. JAMA 1968;203:135–40. 4. Weber KT, Janicki JS. Intra-aortic balloon counterpulsation—a review of physiological principles, clinical results and device safety. Ann Thorac Surg 1974;17:249 –54. 5. Bavaria JE, Furukawa S, Kreiner G, et al. Effect of circulatory assist devices on stunned myocardium. Ann Thorac Surg 1990;49:123–8. 6. Marks JD, Pantalos GM, Long JW, et al. Myocardial mechanics, energetics and hemodynamics during intraaortic balloon and transvalvular axial flow hemopump support with a bovine model of ischaemic cardiac dysfunction. ASAIO J 1999;45:602–9. 7. Cobbs BW Jr, Hatcher CR Jr, Craver JM, et al. Transverse midventricular disruption after mitral valve replacement. Am Heart J 1980;99:33–50. 8. Dark JH, Bain WH. Rupture of posterior wall of left ventricle after mitral valve replacement. Thorax 1984;39:905–11.
Extracardiac Total Cavopulmonary Connection Using a Y-Shaped Graft Takahisa Okano, MD, Masaaki Yamagishi, MD, Keisuke Shuntoh, MD, Yoshiaki Yamada, MD, Kyoko Hayashida, MD, Takeshi Shinkawa, MD, and Nobuo Kitamura, MD Department of Pediatric Cardiovascular Surgery, Children’s Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
We report on 17-year-old Fontan candidate with a seerely distorted central pulmonary artery (PA) who underwent a successful extracardiac total cavopulmonary connection using a Y-shaped bifurcated graft. A nonanatomic pathway from the inferior vena cava to the left PA was constructed and positioned anterior to the ascending aorta. The other arm was used as a conduit between the inferior vena cava and the right PA. All procedures were performed under temporary venous bypass without cardiopulmonary bypass. (Ann Thorac Surg 2002;74:2195–7) © 2002 by The Society of Thoracic Surgeons Accepted for publication July 1, 2002. Address reprint requests to Dr Okano, Department of Pediatric Cardiovascular Surgery, Children’s Hospital, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamikyo-ku, Kyoto 602-8566, Japan; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(02)03978-4
2196
CASE REPORT OKANO ET AL TOTAL CAVOPULMONARY CONNECTION
Ann Thorac Surg 2002;74:2195–7
D
istortion of the pulmonary artery (PA) is a serious risk factor of the Fontan operation [1]. We successfully applied extracardiac total cavopulmonary connection (TCPC) using a Y-shaped prosthetic graft to a Fontan candidate with a severely distorted central PA. The patient was a 17-year-old boy with right isomerism, single atrium, single right ventricle, common atrioventricular valve, bilateral superior vena cava (SVC), and pulmonary atresia. He underwent bilateral BlalockTaussig shunts at the ages of 11 months and 5 years. Pulmonary arteriography at 16 years of age demonstrated a nonconfluent central PA at the site of ductal ligament. Pulmonary arterial index was 138 mm2/m2. He underwent bilateral bidirectional cavopulmonary shunt (BCPS), augmentation of central PA using expanded polytetrafluoroethylene (ePTFE) patch (W.L. Gore & Associates, Inc., Flagstaff, AZ), and amputation of the previous bilateral Blalock-Taussig shunts. Angiography 3 months after BCPS showed patent bilateral cavopulmonary anastomoses with adequate blood flow from the left and right SVC to respective PA. However, in spite of prior augmentation, severe diffuse narrowing of the central PA was noted. The central PA measured 2.7 mm in diameter (Fig 1). Fontan operation was performed 12 months after BCPS. During the operation, reconstruction of the central PA behind the ascending aorta was considered impossible, because the central PA was pressed by the thick ascending aorta anteriorly and tightly adhered to the surrounding scar tissue, resulting in narrowing of the space behind the ascending aorta. Both the SVC and sites of
Fig 1. Preoperative cardiac angiography showing severe distorted central pulmonary artery (PA) and patent anastomoses between bilateral superior vena cava and PAs after bidirectional cavopulmonary shunt. (LPA ⫽ left pulmonary artery; RPA ⫽ right pulmonary artery.)
Fig 2. (A) A Y-shaped bifurcated graft was used upside down as an extracardiac conduit. A nonanatomic pathway from the IVC to left pulmonary artery (PA) was positioned anterior to the ascending aorta. (IVC ⫽ inferior vena cava; LSVC ⫽ left superior vena cava; RSVC ⫽ right superior vena cava.) (B) Postoperative three-dimensional computed tomography anterior view showing no obstruction or kinking in the systemic venous pathway (ie, inverted Y-graft) from the IVC to PAs.
cavopulmonary anastomoses were dissected, and a temporary bypass between the right and left SVC was established. First, one side of the arm of the Y-shaped
Ann Thorac Surg 2002;74:2195–7
graft (Hemashield Gold, 22 ⫻ 11 mm; Meadox Medicals, Inc, Oakland, NJ) was anastomosed to the left PA just distal of the site of cavopulmonary anastomosis. After subtotal thymectomy, the left arm of the Y-shaped graft was detoured anterior to the cranial side of the ascending aorta to avoid pressure from the sternum. Second, the other arm of the graft was also anastomosed to the right PA. Under temporary bypass between the right atrium and inferior vena cava (IVC), the IVC was divided at the cavoatrial junction. Proximal stump was oversewn, while the distal end was anastomosed to the main trunk of the graft in end-to-end fashion (Fig 2A). All procedures were performed without cardiopulmonary bypass (CPB). Postoperative recovery was uneventful with stable hemodynamics. The patient is currently receiving antiplatelet therapy. Three-dimensional computed tomography at 14 months postoperatively showed sufficient patency of the systemic venous pathway without any stenosis (Fig 2B).
Comment After initial bilateral BCPS, distortion of the central PA often occurs due to decreased blood flow. Concomitant augmentation or replacement of the distorted or nonconfluent central PA is required in conventional extracardiac TCPC using a straight prosthetic graft. Controversy still exists regarding the best procedure to reroute the inferior vena caval blood to the pulmonary circulation [2–5]. We performed a unique extracardiac TCPC in a Fontan candidate with a severely distorted central PA as follows. (1) A Y-shaped bifurcated graft was used upside down as an extracardiac conduit. (2) A nonanatomic pathway from the IVC to the left PA was constructed and positioned anterior to the ascending aorta. (3) The other arm was used as a conduit between IVC and right PA. (4) A sufficient space for the left arm of the graft was provided by subtotal thymectomy. (5) All procedures were completed without CPB. The posterior anatomical route be-
CASE REPORT OKANO ET AL TOTAL CAVOPULMONARY CONNECTION
2197
hind the ascending aorta is preferable as a pathway for the graft to the left PA. However, because of tight adhesions after initial operation and pressure from the thick aorta anteriorly, sufficient space behind the ascending aorta for reconstructing the central PA was not available. Moreover, a graft passing behind the ascending aorta may induce left bronchial obstruction. Anterior routing in front of the ascending aorta needs minimum dissection. Subtotal thymectomy provided sufficient space for the graft to avoid pressure by the sternum. Although the left arm of the Y-shaped graft is rather long, excessive winding of the graft and consequent turbulent blood flow are avoided by use of the anterior route. The GoreTex grafts for the venous system are generally used to avoid late neointimal formation and peel formation. We were obliged to use a Dacron graft as a venous conduit because a Y-shaped GoreTex graft is not available commercially. Therefore, careful sureveillance for these late complications should be enforced by routine echocardiography and angiography. The Y-shaped graft with anterior route of the left arm is a useful alternative technique for extracardiac TCPC in Fontan candidates with severely distorted or nonconfluent central PA.
References 1. Mayer JE Jr, Bridges ND, Lock JE, Hanley FL, Jonas RA, Castaneda AR. Factors associated with marked reduction in mortality for Fontan operation in patients with single ventricle. J Thorac Cardiovasc Surg 1992;103:444 –52. 2. Burke RP, Jacobs JP, Ashraf MH, Aldousany A, Chang AC. Extracardiac Fontan operation without cardiopulmonary bypass. Ann Thorac Surg 1997;63:1175–7. 3. Giannico S, Corno AF, Marino B, et al. Total extracardiac right heart bypass. Circulation 1992;86(Suppl 2):110 –7. 4. Hashimoto K, Kurosawa H, Tanaka K, et al. Total cavopulmonary connection without the use of prosthetic material: technical considerations and consequences. J Thorac Cardiovasc Surg 1995;110:625–32. 5. Yamagishi M, Nakamura Y, Kanazawa T, Kawada N. Extracardiac direct total cavopulmonary connection. Ann Thorac Surg 1997;64:1817–20.