Limits...
Surgical strategy to prevent cardiac injury during reoperation in infants.

Knott-Craig CJ, Goldberg SP, Kirklin JK - J Cardiothorac Surg (2008)

Bottom Line: Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations.We employed SAC in 4 infants undergoing reoperative cardiac surgery (prior Norwood, n = 2; prior arterial switch operation with suprasystemic pulmonary artery pressures after a Le Compte maneuver, n = 1; prior Ebstein's anomaly, n = 1).In all cases the innominate artery was exposed at the level of the supra-sternal notch, and a 3.5 mm expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the innominate artery (n = 3), and a 10 French cannula inserted into the graft for whole-body perfusion.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA. ckc@uab.edu

ABSTRACT

Introduction: Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations. Since few technical options are available for re-entry cardiac injuries in small infants, we postulate that this technique may be equally helpful in those situations.

Case presentation: We employed SAC in 4 infants undergoing reoperative cardiac surgery (prior Norwood, n = 2; prior arterial switch operation with suprasystemic pulmonary artery pressures after a Le Compte maneuver, n = 1; prior Ebstein's anomaly, n = 1). In all cases the innominate artery was exposed at the level of the supra-sternal notch, and a 3.5 mm expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the innominate artery (n = 3), and a 10 French cannula inserted into the graft for whole-body perfusion. Right atrial cannulation was obtained by dividing the anterior aspect of the diaphragm at the level of the xiphisternum, gaining easy access to the right atrial-inferior vena cava junction, without separating the sternal edges.

Discussion and evaluation: All four infants successfully underwent their operations using SAC. In one case (2nd stage palliation for hypoplastic left heart syndrome) a cardiac injury occurred upon sternal reentry, but utilizing SAC, this was repaired without consequence.

Conclusion: Simplified aortic cannulation and direct right atrial cannulation may be obtained without dividing the sternum in complex reoperative infant surgeries, without making additional incisions. This may be life-saving in reoperative cardiac injuries in small infants.

Show MeSH

Related in: MedlinePlus

Cannulation of the graft for arterial inflow.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC2270272&req=5

Figure 4: Cannulation of the graft for arterial inflow.

Mentions: The standard technique of SAC has previously been described by us in detail in the literature [1]. Specifically, in the setting of a reoperation, the initial skin incision over the previous scar is extended to the supra-sternal notch and slightly to the right. (Figure 1). This will allow easy exposure of the innominate artery in the superior mediastinum cephalad to its crossing behind the innominate vein (Figure 2). The artery is dissected out above the innominate vein, and encircled by a vessel loop. A side-biting CastaƱeda clamp is applied, and a longitudinal arteriotomy is made. The patient can be systemically heparinized at this point. A 3.5 mm thin-walled expanded polytetrafluoroethylene (ePTFE) graft is anastomosed in an end-to-side fashion using a running 7-0 polypropylene suture (Figure 3). The graft is left long, and a 10-French arterial extracorporeal membrane oxygenation (ECMO) cannula is inserted into the free end of the ePTFE graft and secured with a silk tie; this is used for the arterial side of the cardiopulmonary bypass circuit, allowing full-flow whole-body perfusion (Figure 4). Alternatively, the innominate artery can be cannulated directly in the standard fashion.


Surgical strategy to prevent cardiac injury during reoperation in infants.

Knott-Craig CJ, Goldberg SP, Kirklin JK - J Cardiothorac Surg (2008)

Cannulation of the graft for arterial inflow.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2270272&req=5

Figure 4: Cannulation of the graft for arterial inflow.
Mentions: The standard technique of SAC has previously been described by us in detail in the literature [1]. Specifically, in the setting of a reoperation, the initial skin incision over the previous scar is extended to the supra-sternal notch and slightly to the right. (Figure 1). This will allow easy exposure of the innominate artery in the superior mediastinum cephalad to its crossing behind the innominate vein (Figure 2). The artery is dissected out above the innominate vein, and encircled by a vessel loop. A side-biting CastaƱeda clamp is applied, and a longitudinal arteriotomy is made. The patient can be systemically heparinized at this point. A 3.5 mm thin-walled expanded polytetrafluoroethylene (ePTFE) graft is anastomosed in an end-to-side fashion using a running 7-0 polypropylene suture (Figure 3). The graft is left long, and a 10-French arterial extracorporeal membrane oxygenation (ECMO) cannula is inserted into the free end of the ePTFE graft and secured with a silk tie; this is used for the arterial side of the cardiopulmonary bypass circuit, allowing full-flow whole-body perfusion (Figure 4). Alternatively, the innominate artery can be cannulated directly in the standard fashion.

Bottom Line: Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations.We employed SAC in 4 infants undergoing reoperative cardiac surgery (prior Norwood, n = 2; prior arterial switch operation with suprasystemic pulmonary artery pressures after a Le Compte maneuver, n = 1; prior Ebstein's anomaly, n = 1).In all cases the innominate artery was exposed at the level of the supra-sternal notch, and a 3.5 mm expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the innominate artery (n = 3), and a 10 French cannula inserted into the graft for whole-body perfusion.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA. ckc@uab.edu

ABSTRACT

Introduction: Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations. Since few technical options are available for re-entry cardiac injuries in small infants, we postulate that this technique may be equally helpful in those situations.

Case presentation: We employed SAC in 4 infants undergoing reoperative cardiac surgery (prior Norwood, n = 2; prior arterial switch operation with suprasystemic pulmonary artery pressures after a Le Compte maneuver, n = 1; prior Ebstein's anomaly, n = 1). In all cases the innominate artery was exposed at the level of the supra-sternal notch, and a 3.5 mm expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the innominate artery (n = 3), and a 10 French cannula inserted into the graft for whole-body perfusion. Right atrial cannulation was obtained by dividing the anterior aspect of the diaphragm at the level of the xiphisternum, gaining easy access to the right atrial-inferior vena cava junction, without separating the sternal edges.

Discussion and evaluation: All four infants successfully underwent their operations using SAC. In one case (2nd stage palliation for hypoplastic left heart syndrome) a cardiac injury occurred upon sternal reentry, but utilizing SAC, this was repaired without consequence.

Conclusion: Simplified aortic cannulation and direct right atrial cannulation may be obtained without dividing the sternum in complex reoperative infant surgeries, without making additional incisions. This may be life-saving in reoperative cardiac injuries in small infants.

Show MeSH
Related in: MedlinePlus