Ann Thorac Surg 1996;62:565-566
© 1996 The Society of Thoracic Surgeons
Case Report
Blalock-Taussig Operation With an Assist of Venovenous Extracorporeal Membrane Oxygenation
Haruo Miyamura, MD,
Masa-aki Sugawara, MD,
Hiroshi Watanabe, MD,
Shoji Eguchi, MD
Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Niigata, Japan
Accepted for publication January 31, 1996.
 |
Abstract
|
|---|
Three infants with congenital cyanotic heart disease encountered severe hypoxemia during a Blalock-Taussig shunt procedure using a right thoracotomy approach. Pericardiotomy was performed and venovenous extracorporeal membrane oxygenation was instituted using right atrial canulation. The shunt procedure was completed with good oxygenation and hemodynamic stability in all cases. Venovenous extracorporeal membrane oxygenation can be easily established in the right thorax, and is an effective support technique for unexpected hypoxemia encountered during systemic-to-pulmonary artery shunt operations.
|
Introduction
|
|---|
Since the systemic artery-to-pulmonary artery shunt operation was first introduced by Blalock and Taussig in 1945 [1], the procedure has been widely applied to various cyanotic congenital heart diseases associated with pulmonary ischemia. Although the recent trend is to treat the patient by primary intracardiac repair, the systemic-to-pulmonary artery shunt operation remains an important palliative surgical choice in some complex heart diseases and in situations in which a hypoplastic pulmonary artery tree exists. In our institution, the first-choice shunt procedure is a modified Blalock-Taussig anastomosis using a polytetrafluoroethylene graft on the contralateral side of the aortic arch. The anastomosis can usually be performed by simply clamping either the right or left main pulmonary artery. However, clamping of the pulmonary artery sometimes results in exacerbation of hypoxemia. When hypotension follows the hypoxemia, the clamp must be removed, making anastomosis impossible by the usual manner. We experienced 3 such cases, and we used venovenous (V-V) extracorporeal membrane oxygenation (ECMO) to successfully accomplish the shunt procedure.
Between 1992 and 1995, 3 children with congenital heart disease were treated at our institution by systemic-to-pulmonary artery shunt using a V-V ECMO assist. The children ranged in age from 2 to 4 months, and in body weight from 3.0 to 6.0 kg. The diagnosis was tetralogy of Fallot with tight infundibular stenosis in 2 patients, and a single ventricle with pulmonary atresia in 1 patient. All 3 patients had severe progressive pulmonary ischemia preoperatively, and palliative shunt operations were scheduled because the hypoplasia of the pulmonary artery tree indicated that primary intracardiac repair would be unsuitable. The aortic arch was on the left side in all 3 patients, and a modified Blalock-Taussig anastomosis was planned on the right side.
Under general anesthesia with the patient in a left lateral decubitus position, right thoracotomy was performed and the right pulmonary artery was dissected. However, the clamping of the right main pulmonary artery induced an exacerbation of hypoxemia. Arterial oxygen saturation, which was greater than 70% before clamping, decreased to less than 50% in all 3 patients, and bradycardia and hypotension followed. The clamp had to be removed, and then the hemodynamic stability was restored. The clamping procedure was repeated several times and the hypoxic event occurred each time. Therefore we decided to employ ECMO as an oxygenation support. The pericardium was incised longitudinally anterior to the phrenic nerve to expose the right atrium. Two pursestring sutures were made in the right atrial wall, and two wire-reinforced Stockert-Shiley venous catheters (Shiley Inc, Irvine, CA) were inserted after systemic heparinization. The tip of one catheter was placed in a shallow position to serve as a drainage line, and the other one was secured close to the tricuspid valve orifice to serve as an injection line (Fig 1
). Using a heparin-bonded circuit that included a Medtronic Minimax oxygenator and Medtronic CBAS tubing set (Medtronic, Inc, Anaheim, CA), V-V (specifically, right atrium to right atrium) ECMO was instituted. The flow of the extracorporeal circulation was kept between 75 and 100 mL•kg-1•min-1 to maintain the patient's arterial oxygen saturation at 90% to 100%. A modified Blalock-Taussig shunt was constructed using a 5-mm polytetrafluoroethylene graft, but in 1 patient, because of insufficient shunt flow, it was converted to an ascending aorto-pulmonary artery shunt. Total ECMO time for each patient was 51, 121, and 179 minutes, during which hemodynamic stability was obtained. After the completion of shunt construction, patients were weaned from ECMO, and their arterial oxygen saturation became 91%, 95%, and 76%, respectively.
View larger version (30K):
[in this window]
[in a new window]
|
Fig 1. . Operative procedure: Two catheters are inserted through the right atrial wall. A drainage catheter is placed in a shallow position, and the infusion catheter tip is positioned close to the tricuspid valve.
|
|
After several days of intensive care, all 3 patients were discharged from the hospital. One patient underwent successful intracardiac repair 2 years later, and the other 2 patients are now waiting for the next operation.
|
Comment
|
|---|
In 1976, Bartlett and associates [2] reported the first successful use of ECMO in neonatal respiratory failure. Thereafter, ECMO has been widely applied to children and adults suffering severe respiratory failure. Given the expectation of ventricular assist and improved oxygenation, the indication of ECMO has been expanded, and patients with postoperative arterial desaturation or acute cardiogenic shock can now benefit from this methodology [3, 4]. Extracorporeal membrane oxygenation is also used as a support technique during angioplasty in patients who sustain a catastrophic event in the cardiac catheterization laboratory [5, 6]. For pediatric patients with congenital heart disease, intraoperative or postoperative use of ECMO with a venoarterial circuit has been reported [7–9]. However, for the support of palliative systemic-to-pulmonary artery shunt, oxygenation during the anastomotic procedure is all that is needed, and ventricular assist is not mandatory. Therefore, during right thoracotomy access, we used V-V ECMO due to the ease with which the circuit could be established simply by opening the pericardium and exposing the right atrium. In our first case of V-V ECMO, we were concerned that recirculation might occur between the two catheters. However, by placing the drainage catheter in a shallow position in the right atrium and by securing the infusion catheter tip close to the tricuspid valve orifice, we minimized the recirculation effect and maintained good systemic oxygenation. The efficacy of V-V ECMO in neonatal respiratory failure has already been reported by Delius and colleagues [10], and we propose that V-V ECMO be used in the event of an unexpected hypoxemic event during the systemic-to-pulmonary artery shunt operation.
|
Footnotes
|
|---|
Address reprint requests to Dr Miyamura, Division of Cardiothoracic Surgery, Nagaoka Red Cross Hospital, Nisseki-cho 2-6-1, Nagaoka, 940, Japan.
|
References
|
|---|
- Blalock A, Taussig HB. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA 1945;128:189–202.[Abstract/Free Full Text]
- Bartlett RH, Gazzaniga AB, Jefferies MR, Huxtable RF, Haiduc NJ, Fond SW. Extracorporeal membrane oxygenation (ECMO) cardiopulmonary support in infancy. Trans Am Soc Artif Intern Organs 1976;22:80–93.[Medline]
- Kanter KR, Pennington DG, Weber TR, Zambie MA, Braun P, Martychenko V. Extracorporeal membrane oxygenation for postoperative cardiac support in children. J Thorac Cardiovasc Surg 1987;93:27–35.
- Del Nido PJ, Dalton HJ, Thompson AE, Siewers RD. Extracorporeal membrane oxygenator rescue in children during cardiac arrest after cardiac surgery. Circulation 1992;86 (Suppl 2):300–4.
- Mooney MR, Arom KV, Joyce LD, et al. Emergency cardiopulmonary bypass support in patients with cardiac arrest. J Thorac Cardiovasc Surg 1991;101:450–4.[Abstract]
- Phillips SJ, Zeff RH, Kongtahworn C, et al. Percutaneous cardiopulmonary bypass: application and indication for use. Ann Thorac Surg 1989;47:121–3.[Abstract/Free Full Text]
- Ziomek S, Harrell JE, Fasules JW, et al. Extracorporeal membrane oxygenation for cardiac failure after congenital heart operation. Ann Thorac Surg 1992;54:861–8.[Abstract/Free Full Text]
- Raithel SC, Pennington DG, Boegner E, Fiore A, Weber TR. Extracorporeal membrane oxygenation in children after cardiac surgery. Circulation 1992;86 (Suppl 2):305–10.
- Atkinson JB, Kitagawa H, Humphries B. Major surgical intervention during extracorporeal membrane oxygenation. J Pediatr Surg 1992;27:1197–8.[Medline]
- Delius R, Anderson H, Schumacher R, et al. Venovenous compares favorably with venoarterial access for extracorporeal membrane oxygenation in neonatal respiratory failure. J Thorac Cardiovasc Surg 1993;106:329–38.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
J. B Zwischenberger and S. K Alpard
Artificial lungs: a new inspiration
Perfusion,
July 1, 2002;
17(4):
253 - 268.
[Abstract]
[PDF]
|
|
|
Top
Abstract
Introduction
