Asian Cardiovasc Thorac Ann 2002;10:376-377
© 2002 Asia Publishing EXchange Pte Ltd
Heartport Endoclamp for Complex Cardiac Repairs With Total Circulatory Arrest
Serban C Stoica, AFRCSEd,
Stewart R Craig, FRCS(CTh),
Colin J Sinclair, FRCA,
Ciro Campanella, FRCS
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Department of Cardiothoracic Surgery The Royal Infirmary of Edinburgh, Scotland UK
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For reprint information contact: Stewart R Craig, FRCS(CTh) Tel: 44 141 211 4000 Fax: 44 141 211 4845 email: srcraig{at}hotmail.com Department of Cardiothoracic Surgery, The Royal Infirmary, 16 Alexandra Parade, Glasgow, Scotland G31 2ER, UK.
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ABSTRACT
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A method of performing redo cardiac operations using port-access technology and total circulatory arrest is described. The technique was useful in 2 cases requiring re-intervention within 4 months of the primary procedure. The indications were repair of an infected ventricular aneurysm and recurrence of a postinfarction ventricular septal defect. Dense mediastinal adhesions were avoided by approaching the site of pathology directly via a left anterior thoracotomy.
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INTRODUCTION
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In cases of residual leakage after repair of postinfarction ventricular septal defect (VSD) or in patients with mediastinal infection following repair of a ventricular aneurysm (VA), reoperation may be the only option.1–3 Reoperation within months of the primary procedure is technically demanding. Difficulties arise from dissecting in a "frozen" mediastinum, especially when patent coronary grafts are present, and establishing cardiopulmonary bypass. A left anterior thoracotomy provides good exposure for VA repair when coronary grafting is not required.4 Repair of recurrent postinfarction VSD has been described via a right atrial approach or a left thoracotomy with circulatory arrest.5,6 Recently, minimally invasive cardiac surgery has provided tools that may circumvent some access problems and increase the safety margin.
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TECHNIQUE
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Femorofemoral cannulation is instituted with 28F venous cannulae and 21F/23F arterial cannulae (Heartport, Inc., Redwood City, CA, USA). Kinetic-assisted venous drainage augments venous return to the heart-lung machine and permits full circulatory support on a single femoral venous cannula. The aortic Endoclamp (10.5F, Heartport) is inserted into the contralateral femoral artery and advanced into the aortic root. When deployed, the Endoclamp allows controlled aortic occlusion, root venting, and antegrade delivery of cardioplegia. Transesophageal echocardiography is used for accurate placement of the Endoclamp (for example, above the level of aortocoronary grafts). Cardiopulmonary bypass is started and the circuit is run in a pressure-controlled mode. To prevent fibrillation, the patient is kept warm until the cardioplegia checks are completed. The temperature is lowered to below 30°C, the Endoclamp balloon is inflated, and blood cardioplegia is delivered antegradely into the aortic root. Systemic flow and pressure are reduced before inflating the balloon so as to avoid Endoclamp migration from any residual cardiac output. Further cooling to 20°C followed by total circulatory arrest allows safe dissection and completion of repair. After repair, bypass is initiated, the endoaortic balloon is deflated, and the patient is rewarmed. Cardiac decompression is carried out through the Endoclamp and the left ventriculotomy, which is also used for subsequent de-airing. The Endoclamp is withdrawn before the heart takes over the circulation. Bypass is discontinued in the usual fashion.
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DISCUSSION
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We combined port-access technology with hypothermic total circulatory arrest in 2 patients undergoing reoperation through a left anterior thoracotomy. A 55-year-old man had undergone double aortocoronary bypass grafting and linear repair of an anterior left VA using Teflon felt. After a good recovery, he returned 4 months later with lethargy, toxic symptoms, and an area of infection in the lower end of his sternotomy. Rapid clinical deterioration occurred despite wide-spectrum parenteral antibiotic therapy. Fluid collection was demonstrated in the immediate vicinity of the VA repair, and blood cultures grew methicillin-resistant Staphylococcus aureus. At surgery, the infected Teflon was removed and the defect was repaired by simple mattress closure. The patient was stable until the 4th postoperative day when he developed fulminant lethal staphylococcal septicemia. A 67-year-old woman had an anterior postinfarction VSD that was closed satisfactorily with a patch. She developed worsening dyspnea, and echocardiography revealed partial detachment of the patch. At 12 weeks, she underwent repeat closure of the VSD. She made an uncomplicated recovery and remained asymptomatic 22 months later.
Eradication of mediastinal infection following prosthetic repair of a VA aneurysm is not easy by conventional surgery.1 Similarly, recurrence of postinfarction VSD has an incidence of 10%–40% and is associated with an adverse outcome.2,3,5 Reoperation is necessary in 30%–70% of patients, and procedure-related mortality is between 31% and 43%.2,3 Reduction of the overall surgical trauma might be one way of improving results, and we feel that the technique described here has this potential. We ascribe the demise of our first patient primarily to the virulence and extent of the mediastinal infection. The interventricular septum was opened accidentally in the first patient and of necessity in the second. However, circulatory arrest prevented air entrapment in the circuit. The total circulatory arrest times were 19 and 22 minutes, respectively. Transesophageal echocardiography was helpful in de-airing maneuvers, checking for Endoclamp migration, assessing ventricular contractility on discontinuation of cardiopulmonary bypass, and confirming the adequacy of repair of the VSD in the second patient. The monitoring requirements and bypass parameters for the port-access method are becoming standardized and are described elsewhere.7,8 In our experience, transesophageal echocardiography was sufficient for placement of the intravascular devices and fluoroscopy was not required. Right atrial or bicaval cannulation was avoided altogether with this technique. However, air lock from opening the right heart remains a potential danger, particularly with the negative pressures created by kinetic-assisted venous drainage. Another possibility for avoiding air lock is to use a second venous pump, but we felt that circulatory arrest offered a wider safety margin.7 This technique combines the principles of minimal access via an anterior thoracotomy with the versatility of intravascular occlusion and cardioplegia. In both cases, the site of pathology was approached directly and surgical exposure was excellent.
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REFERENCES
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[Abstract]
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ABSTRACT
INTRODUCTION
