- Email: [email protected]
Multidose cardioplegia in a complex arterial switch procedure
280
CASE REPORT HARTZ ET AL MULTIDOSE CARDIOPLEGIA
aortic arch is corrected via sternotomy [8]. But this access might create major difficulties in adolescent patients especially in the setting of reoperation due to the limited access to proximal descending aorta. Derived from preoperative magnetic resonance imaging and computed tomographic imaging, we expected a narrow arch segment, a cranially distracted distal arch, and major adhesions around the previous coarctation repair through a left posterolateral thoracotomy. Thus, a repeat left posterolateral thoracotomy also was not preferred, as suboptimal access to the arch was anticipated with this approach. Instead, we decided to use an antero-axillary thoracotomy, a technique which is established as a standardized approach in lung surgery and has been introduced by Walterbusch and associates in 1994 for aortic surgery [9]. Different authors, like Sasaguri and colleagues, recommend this incision for aortic arch surgery combining the advantages of an isolated sternotomy and a posterolateral thoracotomy with optimal control of the aortic arch [10]. Another advantage of this incision is the minimum of muscle division, keeping the latissimus dorsi and trapezius muscles preserved compared with the standard lateral thoracotomy, and keeping the upper arm–shoulder belt unextended in contrast to a regular sternotomy. Our patient could be operated on safely, managed with superior exposure of the ascending aorta for clamping and evenly satisfying access to the posterior part of the aortic arch, so that reconstruction of the hypoplastic segment could be successfully performed with a bovine pericardial patch. Also, using this access, injury of the left recurrent laryngeal nerve and phrenic nerve could be avoided by the superior exposition, resulting in normal nerve function postoperatively. The patient recovered quickly from the surgical trauma and could be discharged home after an uneventful course of 8 postoperative days. Therefore, we recommend strongly the antero-axillary approach for the repair of a hypoplastic aortic arch in adolescents or adults, especially when surgical demands increase due to previous surgery performed through a midsternotomy or posterolateral thoracotomy.
References 1. Kopf GS, Hellenbrand W, Kleinmann C, Lister G, Talner N, Laks H. Repair of coarctation in the first three months of life: immediate and long-term results. Ann Thorac Surg 1986;41: 425–30. 2. Siewers RD, Ettedgui J, Pahl E, Tallman T, del Nido PJ. Coarctation and hypoplasia of the aortic arch: will the arch grow? Ann Thorac Surg 1991;52:608–14. 3. Moulaert AJ, Bruins CC, Oppenheimer-Dekker A. Anomalies of the aortic arch and ventricular septal defects. Circulation 1976;53:1011–5. 4. Daebritz S, Fausten B, Sachweh J, Muhler E, Franke A, Messmer BJ. Anatomically positioned aorta ascendingdescending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation. Eur J Cardiothorac Surg 1999;16:519–23. 5. Coselli JS, Bu¨ ket S, Djukanovic B. Aortic arch operation: current treatment and results. Ann Thorac Surg 1995;59: 19–27. 6. Biasi GM, Mingazzini P, Baronio L, Sampaolo A. Processed © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:280 –2
7. 8. 9.
10.
bovine pericardium as patch angioplasty for carotid endarterectomy: a preliminary report. Cardiovasc Surg 1996;4: 848–52. Araujo JD, Braile DM, Azenha Filho JO, Barros ET, Marconi A. The use of bovine pericardium as an arterial graft. A 5-year follow-up. J Cardiovasc Surg (Torino) 1987;28:434–9. Karl TR, Sano S, Brawn W, Mee RB. Repair of hypoplastic or interrupted aortic arch via sternotomy. J Thorac Cardiovasc Surg 1992;104:688–95. Walterbusch G, Marr U, Abramov V, Fro¨ mke J. The anteroaxillary thoracotomy for operations of the distal aortic arch and the proximal descending aorta. Eur J Cardiothorac Surg 1994;8:79– 81. Sasaguri S, Yamamoto S, Fukuda T, Hosoda Y. Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery. Eur J Cardiothorac Surg 1997;11: 657– 60.
Multidose Cardioplegia in a Complex Arterial Switch Procedure Renee S. Hartz, MD, Serafin Y. DeLeon, MD, Jaime G. Dorotan, MD, and Elaine M. Urbina, MD Department of Surgery and Division of Pediatric Cardiology, Tulane University Medical Center and Tulane University Medical School, New Orleans, Louisiana
Integrated cardioplegia techniques have gained wide acceptance by surgeons performing adult cardiac surgery, because patients being referred are likely to have poor ventricular function and energy-depleted hearts. In addition, the increasing complexity of available procedures has led to an increased threat of reperfusion injury and calcium contracture (“stone heart”) after prolonged ischemia. In this report, we describe the case of a newborn with transposition of the great arteries that survived almost 6 hours of ischemic time and has normal ventricular function postoperatively. We attribute this outcome to the myocardial protection employed throughout the procedure which allowed successful correction of a technical problem. (Ann Thorac Surg 2002;73:280 –2) © 2002 by The Society of Thoracic Surgeons
I
mprovements in cardioplegia composition and delivery have dramatically improved outcomes of complicated cardiac surgical procedures. Although less literature exists concerning various cardioplegia delivery systems in infants than in adults, we believe that the lessons learned in surgery for acquired heart disease can often be applied to congenital cardiac surgery. In this regard, we believe in an integrated approach, ie, one that allows various combinations of warm, cold, antegrade, retrograde, continuous and intermittent cardioplegia. Accepted for publication March 27, 2001. Address reprint requests to Dr Hartz, Tulane University Medical Center, Department of Surgery, 1430 Tulane Ave, SL22, New Orleans, LA 70112; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(01)02863-6
Ann Thorac Surg 2002;73:280 –2
CASE REPORT HARTZ ET AL MULTIDOSE CARDIOPLEGIA
281
The following case report illustrates successful application of these techniques in a newborn undergoing surgery for transposition of the great arteries. A 1-day-old 3100-gram infant presented to our newborn unit with cyanosis and was being maintained on a prostaglandin infusion (0.05 g/kg/min). Echocardiography revealed typical d-transposition of the great arteries (DTGA). However, both coronaries appeared to arise from the right posterior sinus with the left coronary traversing between the aorta and pulmonary artery. The surgical decision was made to proceed with the arterial switch procedure but to convert to an atrial switch operation if there proved to be a single coronary ostium. Operation was performed at 6 days of life. External observation revealed that the left coronary artery appeared to be coming off separately from the left posterior sinus, so we elected to proceed with the arterial switch procedure. Cardiopulmonary bypass was initiated through a single venous cannula in the right atrial appendage and the patent ductus arteriosus was divided. The aorta was clamped and antegrade cold blood cardioplegia (“Induction” in Table 1) was given. The right atrium was opened and bicaval cannulation was accomplished through the atriotomy. The left side was vented through the atrial septal defect with an intracardiac suction device, and retrograde cardioplegia was given through a hand-held cardioplegia catheter (9 Fr) (Edwards Lifesciences, Irvine, CA) which was repeated at 15 to 20 minute intervals. Topical cooling was also employed. Following transection of the aorta, a dimple in the left posterior coronary sinus (sinus 1) created the false impression that the left coronary artery arose at this location (Fig 1). In developing the coronary button for the right coronary artery, the left coronary remained with very little rim of aortic wall. The right coronary artery had a good aortic cuff. After a straightforward right coronary reimplantation to the right anterior sinus of the pulmonary artery, a tedious end-to-end anastomosis of the left coronary artery to the left anterior sinus was performed. Warm antegrade cardioplegia was given following an ischemic time of 246 minutes at moderate systemic hypothermia (28°C). The aortic cross-clamp was then re-
Table 1. Components of Induction (and Maintenance) Cardioplegia and of Warm Reperfusate (“Buckberg”) Cardioplegiaa Variable Volume Blood THAM CPD Aspartate/glutamate D50/W D5/.45NS D5/W KCl a
Induction (4°C)
Reperfusate (37°C)
830 cc 4:1 200 cc 50 cc 0 0 550 cc 0 60 meq
954 cc 4:1 225 cc 225 cc 250 cc 40 cc 0 200 cc 30 meq
Maintenance multidose contains 20 meq KCl.
CPD ⫽ citrate-phosphate-dextrose; nomethane.
THAM ⫽ trihydroxymethylami-
Fig 1. Coronary anatomy. Note “dimple” in left sinus which created the impression of a separate left ostium. (Ao ⫽ aorta; L ⫽ left; PA ⫽ pulmonary artery; R ⫽ right.)
moved and, at this time, the right ventricle was pink and well perfused but the left ventricle was blue-black and tense. There was no notable cardiac electrical activity. When it became clear that the anastomosis for the left coronary artery was stenotic, the cross-clamp was reapplied. One dose of antegrade cold cardioplegia was given, followed by cold retrograde every 15 to 20 minutes. The anastomosis was enlarged by incising the neoaorta, and extending the incision through the anastomosis into the proximal left coronary artery. A piece of a pericardium was excised and used as a patch to enlarge the coronary artery anastomosis. Following an additional ischemic time of 96 minutes, warm substrate-enhanced cardioplegia (“Reperfusate” in Table 1) was given antegrade and retrograde. Cardiopulmonary bypass support was continued for an additional 70 minutes, after which the patient was successfully weaned from cardiopulmonary bypass. Total cardiopulmonary bypass time was 489 minutes and ischemic time was 343 minutes. The left ventricle appeared well perfused and there was good contractility of both ventricles on transesophageal echocardiography. Inotropes consisted of isoproterenol (0.05) mcg/kg/min, dopamine (5 mg/kg/min) and milrinone (0.5 mg/kg/min). The sternum was left open and the skin was closed with a thin Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) patch. The postoperative course was uneventful and inotropes were weaned over 24 hours. Transesophageal echocardiogram, repeated on postoperative day 3 during the delayed sternal closure, showed good biventricular contractility and normal (E to A ratio 1.5). Cardiac catheterization performed at 9 months of age demonstrated normal left ventricular function (Fig 2) and patent left coronary artery anastomosis.
282
CASE REPORT GOEL ET AL ABSENT PULMONARY VALVE SYNDROME
Ann Thorac Surg 2002;73:282– 4
was not completely “integrated” (no warm induction was given), the combination of antegrade, retrograde, warm, and cold was undoubtedly important. A total of 2,740 mL of blood cardioplegia (4:1) was administered to this 3-kg neonate, of which 640 mL were warm reperfusate. The “hot shot” coupled with a long period of vented normothermic bypass resuscitated the myocardium sufficiently that extracorporeal membrane oxygenation and highdose inotropes were avoided. We report this case as an example of successful salvage of a patient who would probably have otherwise expired, and attribute the outcome to a myocardial protection strategy which allowed timely and aggressive correction of a technical problem. Congenital heart surgery teams, especially perfusion staff, must have thorough knowledge of all types of cardioplegia delivery systems, and must be prepared to deliver the various additives required to replete an energy-depleted heart.
References 1. DeLeon S, Idriss FS, Ilbawi MN, et al. Comparison of single versus multidose blood cardioplegia in arterial switch procedures. Ann Thorac Surg 1988;45:548–53. 2. Allen B, Murcia-Evans D, Hartz R. Integrated cardioplegia allows complex valve repairs in all patients. Ann Thorac Surg 1996;62:23–30. 3. Allen B, Winklemann J, Hanafy H, et al. Retrograde cardioplegia does not perfuse the right ventricle. J Thorac Cardiovasc Surg 1995;109:1116–26. 4. Hanafy H, Allen B, Winklemann J, et al. Warm blood cardioplegic induction: an underused modality. Ann Thorac Surg 1994;58:1589–94.
Fig 2. Contrast ventriculography in systole (A) and diastole (B) at 9 mo of age.
Comment Over 10 years ago, we reported the advantages of single versus multiple dose cardioplegia for the arterial switch operation [1]. At the time, there was a definite incidence of coronary artery injury using the stiff catheters available for direct coronary perfusion. However, improvements in retrograde catheters have allowed their safe use in neonates, therefore providing surgeons an unhurried repair of complex lesions. More recently, we reported that an “integrated” cardioplegia approach allows most patients to safely undergo complex cardiac surgical procedures [2], and have strongly encouraged surgeons not to rely on a single type of cardioplegia delivery for all cases. Specifically, we have demonstrated that retrograde cardioplegia does not protect the right ventricle when the catheter is advanced distally in the coronary sinus [3], and that energydepleted hearts require resuscitation before a period of ischemia [4]. Although the technique used in our patient © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Absent Pulmonary Valve Syndrome With Aortic Regurgitation in a 50-Year-Old Man Pankaj Goel, MCh, Sethurathinam Rajan, MCh, V. M. Kurian, MCh, Raibhan Yadav, MD, and Kotturathu Mammen Cherian, FRACS Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
A 50-year-old man was diagnosed as having absent pulmonary valve syndrome with aneurysmal dilatation of the pulmonary arteries. He also had a large subaortic ventricular septal defect and severe aortic regurgitation. He underwent successful intracardiac repair and aortic valve replacement. This case is presented in view of its rarity and controversies in the surgical management. (Ann Thorac Surg 2002;73:282– 4) © 2002 by The Society of Thoracic Surgeons Accepted for publication May 1, 2001. Address reprint requests to Dr Rajan, Institute of Cardiovascular Diseases, Madras Medical Mission, 4A, Dr J. J. Nagar, Mogappair, Chennai 600 050, India; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(01)02849-1
CASE REPORT HARTZ ET AL MULTIDOSE CARDIOPLEGIA
aortic arch is corrected via sternotomy [8]. But this access might create major difficulties in adolescent patients especially in the setting of reoperation due to the limited access to proximal descending aorta. Derived from preoperative magnetic resonance imaging and computed tomographic imaging, we expected a narrow arch segment, a cranially distracted distal arch, and major adhesions around the previous coarctation repair through a left posterolateral thoracotomy. Thus, a repeat left posterolateral thoracotomy also was not preferred, as suboptimal access to the arch was anticipated with this approach. Instead, we decided to use an antero-axillary thoracotomy, a technique which is established as a standardized approach in lung surgery and has been introduced by Walterbusch and associates in 1994 for aortic surgery [9]. Different authors, like Sasaguri and colleagues, recommend this incision for aortic arch surgery combining the advantages of an isolated sternotomy and a posterolateral thoracotomy with optimal control of the aortic arch [10]. Another advantage of this incision is the minimum of muscle division, keeping the latissimus dorsi and trapezius muscles preserved compared with the standard lateral thoracotomy, and keeping the upper arm–shoulder belt unextended in contrast to a regular sternotomy. Our patient could be operated on safely, managed with superior exposure of the ascending aorta for clamping and evenly satisfying access to the posterior part of the aortic arch, so that reconstruction of the hypoplastic segment could be successfully performed with a bovine pericardial patch. Also, using this access, injury of the left recurrent laryngeal nerve and phrenic nerve could be avoided by the superior exposition, resulting in normal nerve function postoperatively. The patient recovered quickly from the surgical trauma and could be discharged home after an uneventful course of 8 postoperative days. Therefore, we recommend strongly the antero-axillary approach for the repair of a hypoplastic aortic arch in adolescents or adults, especially when surgical demands increase due to previous surgery performed through a midsternotomy or posterolateral thoracotomy.
References 1. Kopf GS, Hellenbrand W, Kleinmann C, Lister G, Talner N, Laks H. Repair of coarctation in the first three months of life: immediate and long-term results. Ann Thorac Surg 1986;41: 425–30. 2. Siewers RD, Ettedgui J, Pahl E, Tallman T, del Nido PJ. Coarctation and hypoplasia of the aortic arch: will the arch grow? Ann Thorac Surg 1991;52:608–14. 3. Moulaert AJ, Bruins CC, Oppenheimer-Dekker A. Anomalies of the aortic arch and ventricular septal defects. Circulation 1976;53:1011–5. 4. Daebritz S, Fausten B, Sachweh J, Muhler E, Franke A, Messmer BJ. Anatomically positioned aorta ascendingdescending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation. Eur J Cardiothorac Surg 1999;16:519–23. 5. Coselli JS, Bu¨ ket S, Djukanovic B. Aortic arch operation: current treatment and results. Ann Thorac Surg 1995;59: 19–27. 6. Biasi GM, Mingazzini P, Baronio L, Sampaolo A. Processed © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;73:280 –2
7. 8. 9.
10.
bovine pericardium as patch angioplasty for carotid endarterectomy: a preliminary report. Cardiovasc Surg 1996;4: 848–52. Araujo JD, Braile DM, Azenha Filho JO, Barros ET, Marconi A. The use of bovine pericardium as an arterial graft. A 5-year follow-up. J Cardiovasc Surg (Torino) 1987;28:434–9. Karl TR, Sano S, Brawn W, Mee RB. Repair of hypoplastic or interrupted aortic arch via sternotomy. J Thorac Cardiovasc Surg 1992;104:688–95. Walterbusch G, Marr U, Abramov V, Fro¨ mke J. The anteroaxillary thoracotomy for operations of the distal aortic arch and the proximal descending aorta. Eur J Cardiothorac Surg 1994;8:79– 81. Sasaguri S, Yamamoto S, Fukuda T, Hosoda Y. Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery. Eur J Cardiothorac Surg 1997;11: 657– 60.
Multidose Cardioplegia in a Complex Arterial Switch Procedure Renee S. Hartz, MD, Serafin Y. DeLeon, MD, Jaime G. Dorotan, MD, and Elaine M. Urbina, MD Department of Surgery and Division of Pediatric Cardiology, Tulane University Medical Center and Tulane University Medical School, New Orleans, Louisiana
Integrated cardioplegia techniques have gained wide acceptance by surgeons performing adult cardiac surgery, because patients being referred are likely to have poor ventricular function and energy-depleted hearts. In addition, the increasing complexity of available procedures has led to an increased threat of reperfusion injury and calcium contracture (“stone heart”) after prolonged ischemia. In this report, we describe the case of a newborn with transposition of the great arteries that survived almost 6 hours of ischemic time and has normal ventricular function postoperatively. We attribute this outcome to the myocardial protection employed throughout the procedure which allowed successful correction of a technical problem. (Ann Thorac Surg 2002;73:280 –2) © 2002 by The Society of Thoracic Surgeons
I
mprovements in cardioplegia composition and delivery have dramatically improved outcomes of complicated cardiac surgical procedures. Although less literature exists concerning various cardioplegia delivery systems in infants than in adults, we believe that the lessons learned in surgery for acquired heart disease can often be applied to congenital cardiac surgery. In this regard, we believe in an integrated approach, ie, one that allows various combinations of warm, cold, antegrade, retrograde, continuous and intermittent cardioplegia. Accepted for publication March 27, 2001. Address reprint requests to Dr Hartz, Tulane University Medical Center, Department of Surgery, 1430 Tulane Ave, SL22, New Orleans, LA 70112; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(01)02863-6
Ann Thorac Surg 2002;73:280 –2
CASE REPORT HARTZ ET AL MULTIDOSE CARDIOPLEGIA
281
The following case report illustrates successful application of these techniques in a newborn undergoing surgery for transposition of the great arteries. A 1-day-old 3100-gram infant presented to our newborn unit with cyanosis and was being maintained on a prostaglandin infusion (0.05 g/kg/min). Echocardiography revealed typical d-transposition of the great arteries (DTGA). However, both coronaries appeared to arise from the right posterior sinus with the left coronary traversing between the aorta and pulmonary artery. The surgical decision was made to proceed with the arterial switch procedure but to convert to an atrial switch operation if there proved to be a single coronary ostium. Operation was performed at 6 days of life. External observation revealed that the left coronary artery appeared to be coming off separately from the left posterior sinus, so we elected to proceed with the arterial switch procedure. Cardiopulmonary bypass was initiated through a single venous cannula in the right atrial appendage and the patent ductus arteriosus was divided. The aorta was clamped and antegrade cold blood cardioplegia (“Induction” in Table 1) was given. The right atrium was opened and bicaval cannulation was accomplished through the atriotomy. The left side was vented through the atrial septal defect with an intracardiac suction device, and retrograde cardioplegia was given through a hand-held cardioplegia catheter (9 Fr) (Edwards Lifesciences, Irvine, CA) which was repeated at 15 to 20 minute intervals. Topical cooling was also employed. Following transection of the aorta, a dimple in the left posterior coronary sinus (sinus 1) created the false impression that the left coronary artery arose at this location (Fig 1). In developing the coronary button for the right coronary artery, the left coronary remained with very little rim of aortic wall. The right coronary artery had a good aortic cuff. After a straightforward right coronary reimplantation to the right anterior sinus of the pulmonary artery, a tedious end-to-end anastomosis of the left coronary artery to the left anterior sinus was performed. Warm antegrade cardioplegia was given following an ischemic time of 246 minutes at moderate systemic hypothermia (28°C). The aortic cross-clamp was then re-
Table 1. Components of Induction (and Maintenance) Cardioplegia and of Warm Reperfusate (“Buckberg”) Cardioplegiaa Variable Volume Blood THAM CPD Aspartate/glutamate D50/W D5/.45NS D5/W KCl a
Induction (4°C)
Reperfusate (37°C)
830 cc 4:1 200 cc 50 cc 0 0 550 cc 0 60 meq
954 cc 4:1 225 cc 225 cc 250 cc 40 cc 0 200 cc 30 meq
Maintenance multidose contains 20 meq KCl.
CPD ⫽ citrate-phosphate-dextrose; nomethane.
THAM ⫽ trihydroxymethylami-
Fig 1. Coronary anatomy. Note “dimple” in left sinus which created the impression of a separate left ostium. (Ao ⫽ aorta; L ⫽ left; PA ⫽ pulmonary artery; R ⫽ right.)
moved and, at this time, the right ventricle was pink and well perfused but the left ventricle was blue-black and tense. There was no notable cardiac electrical activity. When it became clear that the anastomosis for the left coronary artery was stenotic, the cross-clamp was reapplied. One dose of antegrade cold cardioplegia was given, followed by cold retrograde every 15 to 20 minutes. The anastomosis was enlarged by incising the neoaorta, and extending the incision through the anastomosis into the proximal left coronary artery. A piece of a pericardium was excised and used as a patch to enlarge the coronary artery anastomosis. Following an additional ischemic time of 96 minutes, warm substrate-enhanced cardioplegia (“Reperfusate” in Table 1) was given antegrade and retrograde. Cardiopulmonary bypass support was continued for an additional 70 minutes, after which the patient was successfully weaned from cardiopulmonary bypass. Total cardiopulmonary bypass time was 489 minutes and ischemic time was 343 minutes. The left ventricle appeared well perfused and there was good contractility of both ventricles on transesophageal echocardiography. Inotropes consisted of isoproterenol (0.05) mcg/kg/min, dopamine (5 mg/kg/min) and milrinone (0.5 mg/kg/min). The sternum was left open and the skin was closed with a thin Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) patch. The postoperative course was uneventful and inotropes were weaned over 24 hours. Transesophageal echocardiogram, repeated on postoperative day 3 during the delayed sternal closure, showed good biventricular contractility and normal (E to A ratio 1.5). Cardiac catheterization performed at 9 months of age demonstrated normal left ventricular function (Fig 2) and patent left coronary artery anastomosis.
282
CASE REPORT GOEL ET AL ABSENT PULMONARY VALVE SYNDROME
Ann Thorac Surg 2002;73:282– 4
was not completely “integrated” (no warm induction was given), the combination of antegrade, retrograde, warm, and cold was undoubtedly important. A total of 2,740 mL of blood cardioplegia (4:1) was administered to this 3-kg neonate, of which 640 mL were warm reperfusate. The “hot shot” coupled with a long period of vented normothermic bypass resuscitated the myocardium sufficiently that extracorporeal membrane oxygenation and highdose inotropes were avoided. We report this case as an example of successful salvage of a patient who would probably have otherwise expired, and attribute the outcome to a myocardial protection strategy which allowed timely and aggressive correction of a technical problem. Congenital heart surgery teams, especially perfusion staff, must have thorough knowledge of all types of cardioplegia delivery systems, and must be prepared to deliver the various additives required to replete an energy-depleted heart.
References 1. DeLeon S, Idriss FS, Ilbawi MN, et al. Comparison of single versus multidose blood cardioplegia in arterial switch procedures. Ann Thorac Surg 1988;45:548–53. 2. Allen B, Murcia-Evans D, Hartz R. Integrated cardioplegia allows complex valve repairs in all patients. Ann Thorac Surg 1996;62:23–30. 3. Allen B, Winklemann J, Hanafy H, et al. Retrograde cardioplegia does not perfuse the right ventricle. J Thorac Cardiovasc Surg 1995;109:1116–26. 4. Hanafy H, Allen B, Winklemann J, et al. Warm blood cardioplegic induction: an underused modality. Ann Thorac Surg 1994;58:1589–94.
Fig 2. Contrast ventriculography in systole (A) and diastole (B) at 9 mo of age.
Comment Over 10 years ago, we reported the advantages of single versus multiple dose cardioplegia for the arterial switch operation [1]. At the time, there was a definite incidence of coronary artery injury using the stiff catheters available for direct coronary perfusion. However, improvements in retrograde catheters have allowed their safe use in neonates, therefore providing surgeons an unhurried repair of complex lesions. More recently, we reported that an “integrated” cardioplegia approach allows most patients to safely undergo complex cardiac surgical procedures [2], and have strongly encouraged surgeons not to rely on a single type of cardioplegia delivery for all cases. Specifically, we have demonstrated that retrograde cardioplegia does not protect the right ventricle when the catheter is advanced distally in the coronary sinus [3], and that energydepleted hearts require resuscitation before a period of ischemia [4]. Although the technique used in our patient © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Absent Pulmonary Valve Syndrome With Aortic Regurgitation in a 50-Year-Old Man Pankaj Goel, MCh, Sethurathinam Rajan, MCh, V. M. Kurian, MCh, Raibhan Yadav, MD, and Kotturathu Mammen Cherian, FRACS Institute of Cardiovascular Diseases, Madras Medical Mission, Chennai, India
A 50-year-old man was diagnosed as having absent pulmonary valve syndrome with aneurysmal dilatation of the pulmonary arteries. He also had a large subaortic ventricular septal defect and severe aortic regurgitation. He underwent successful intracardiac repair and aortic valve replacement. This case is presented in view of its rarity and controversies in the surgical management. (Ann Thorac Surg 2002;73:282– 4) © 2002 by The Society of Thoracic Surgeons Accepted for publication May 1, 2001. Address reprint requests to Dr Rajan, Institute of Cardiovascular Diseases, Madras Medical Mission, 4A, Dr J. J. Nagar, Mogappair, Chennai 600 050, India; e-mail: [email protected].
0003-4975/02/$22.00 PII S0003-4975(01)02849-1