Ann Thorac Surg 1996;61:1555-1556
© 1996 The Society of Thoracic Surgeons
How to Do It
Simple Technique of Left Heart Bypass
Scott D. Lick, MD,
Vincent R. Conti, MD,
Joseph B. Zwischenberger, MD,
Mark Kurusz, CCP
Division of Cardiothoracic Surgery, The University of Texas Medical Branch, Galveston, Texas
Accepted for publication January 2, 1996.
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Abstract
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Left heart bypass is typically established by left atrial appendage cannulation. We report a technique using inferior pulmonary vein cannulation, which is technically simpler. We have used this technique in 20 cases with reliable venous inflow.
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Introduction
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Left heart bypass is typically established by cannulating the left atrial appendage [1, 2]. This cannulation can be awkward, because the left atrial appendage is long, narrow, and often friable. If torn, repair of the appendage may result in damage to the nearby circumflex coronary artery. If the cannula is not positioned in the body of the left atrium, flow may be limited by sumping of the appendage.
The superior pulmonary vein was used as an alternative cannulation site by Fullerton [3], who recently reported his experience with 4 patients using this technique. Although an easier structure to work with than the atrial appendage, it is higher in the chest and a bit more difficult to use than the inferior pulmonary vein, which we have been using for cannulation for the past 6 years. The angled venous cannula is easily inserted, provides reliable flow, and lies away from the operative field. Only a small opening in the pericardium at the junction of the inferior pulmonary vein is required.
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Technique
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An appropriate interspace or rib resection posterior lateral thoracotomy is used, depending on the level of aortic involvement. The inferior pulmonary ligament is divided, and the inferior pulmonary vein is dissected. A 4-0 polypropylene suture is used to create a generously long pursestring-twice as long as the cannula diameter. The pursestring is placed in an oval fashion along the longitudinal axis of the vein, so as not to narrow it when tied. The stitch starts on the pulmonary vein and extends just onto the junction of the left atrium. We use a right-angled Carmeda-coated (Medtronic Inc, Anaheim, CA) venous cannula of 16F to 34F (usually 24F). An incision is made within the pursestring, and the cannula is inserted and fixed with a tourniquet without occluding the venous drainage from the lung.
The distal thoracic aorta is cannulated in operations for localized disease, such as traumatic aortic transection and proximal localized aneurysms. The femoral artery is cannulated when the lower thoracic aorta is diseased.
Both arterial and venous thoracic cannulas are brought out of the lower end of the thoracotomy incision, away from the surgeon (Fig 1
). The cannulas are connected to a centrifugal pump, and bypass is managed according to conventional techniques.
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Fig 1. . The venous cannula is placed at the junction of the left inferior pulmonary vein and left atrium.
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Comment
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We have used this technique from August 1989 to July 1995 in 20 cases: 6 traumatic aortic tears, 8 thoracoabdominal aneurysms, 3 thoracic aneurysms, and 3 coarctations. Venous inflow has been excellent, with no chaffing or sumping. Total flow of 3.0 L/min has been reliably achieved using the 24F venous cannula. We have not found evidence of postoperative pulmonary venous obstruction clinically or by review of radiographs. We have had 1 case of cardiac tamponade due to bloody fluid after repair of a traumatic aortic tear. This was successfully treated with pericardiocentesis without re-exploration.
The most important technical point is that one must make a generously long venous pursestring for easy cannula insertion. The cannulas lie away from the operative field and are easily inserted. The angled cannula tends to lie in the low left atrium so that reliable flow can be obtained with little tendency for positional variation. We believe this technique to establish left heart bypass is superior to that using the left atrial appendage for venous access.
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Footnotes
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Address reprint requests to Dr Lick, Division of Cardiothoracic Surgery, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0528.
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References
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- Oliver HF, Maker TD, Liebler GA, Park SB, Burkholder JA, Magovern GJ. Use of the Biomedicus centrifugal pump in traumatic tears of the thoracic aorta. Ann Thorac Surg 1984;38:586–91.
- Grosso MA, Brown JM, Moore EE, Moore FA. Repair of the torn descending thoracic aorta using the centrifugal pump with partial left heart bypass: technical note. J Trauma 1991;31:395–400.[Medline]
- Fullerton DA. Simplified technique for left heart bypass to repair aortic transection. Ann Thorac Surg 1993;56:579–80.[Abstract/Free Full Text]
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Abstract
Introduction
