Ann Thorac Surg 1996;62:590-591
© 1996 The Society of Thoracic Surgeons
Case Report
Successful Conduit Repair Using Aortic Homograft in a Jehovah's Witness Child
Kagami Miyaji, MD,
Akira Furuse, MD,
Makoto Takeda, MD,
Masahide Chikada, MD,
Minoru Ono, MD,
Motohiro Kawauchi, MD
Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan
Accepted for publication March 1, 1996.
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Abstract
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A 10-year-old female child of the Jehovah's Witness faith presented with congenitally corrected transposition of the great arteries {S,L,L}, pulmonary atresia, and a ventricular septal defect. A successful surgical correction was performed using an aortic homograft as a valved extracardiac conduit without the use of homologous blood or blood products. We used permanent splinting of the sternum with a methyl methacrylate resin plate to prevent compression of the conduit.
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Introduction
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B lood conservation techniques, such as blood scavenging with a cell-saving device or autotransfusion in a closed loop system or the preoperative use of recombinant human erythropoietin, now allow cardiac operations in patients of the Jehovah's Witness faith, who are unwilling to undergo conventional blood transfusions [1–3]. However, there is little clinical experience of the children of Jehovah's Witnesses with complex congenital cardiac anomalies. We report a successful surgical operation for congenitally corrected transposition of the great arteries {S,L,L}, pulmonary atresia, and ventricular septal defect (VSD).
A 10-year-old girl, 138 cm tall and weighing 30 kg, of the Jehovah's Witness faith, was referred to us with diagnoses of congenitally corrected transposition of the great arteries {S,L,L}, pulmonary atresia, VSD, and atrial septal defect. At 7 months old she underwent a right Blalock-Taussig shunt. At 9 years she was recommended for total correction. She and her parents were adamant that she should not be given blood or blood products. Laboratory investigation revealed polycythemia (hemoglobin level, 19.6 g/dL) on admission. Electrocardiography revealed normal sinus rhythm without heart block. Cardiac catheterization and echocardiography confirmed the diagnosis. The pulmonary-to-systemic flow ratio was 0.68 and the arterial oxygen saturation was 79.5%.
In the operating room 600 mL of undiluted whole blood was reserved in a closed circuit connecting the radial artery to the femoral vein. After cardiopulmonary bypass, this 600 mL of blood was reinfused. One million units of aprotinin was administered before the bypass. The patient underwent the operation using cardiopulmonary bypass with moderate hypothermia at 25°C. After cross-clamp of the aorta, the atrial septal defect was closed. The VSD was then closed with a Dacron patch through a left ventriculotomy. The stitches on the anterior and superior rim of the VSD were placed through the VSD and anchored on the left side of the septum to avoid the injury to the penetrating bundle of His [4]. The distance between the pulmonary artery and the predicted left ventriculotomy, which was the length of the extracardiac conduit, was measured before the operation using the magnetic resonance imaging of the chest. We decided to use a whole cryopreserved aortic homograft, 8 cm in length and with a valve of 20 mm in diameter as a valved extracardiac conduit (Fig 1
). After anastomosis of the pulmonary artery and distal conduit, the aorta was unclamped. At the proximal anastomosis of the conduit, the autologous pericardium was used as an augmentation patch to prevent compression and distortion of the valve. The final position of the conduit was on the lateral side of the right atrium (Fig 1). The patient was weaned from cardiopulmonary bypass with inotropic agent support. During dilutional cardiopulmonary bypass the hemoglobin level ranged from 7.6 to 8.7 g/dL. The approximation of the sternum caused a severe deterioration in hemodynamics due to compression of the conduit. The large aortic homograft conduit extended and lengthened because of increased pulmonary blood flow after the bypass. A 15 by 2.0 by 1.5-cm methyl methacrylate plate made from a cranioplastic resinous material was used as a permanent splint for the sternum to relieve compression of the conduit [5].
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Fig 1. . The operation was performed using an aortic homograft, 8 cm long and with a 20-mm valve diameter, as a valved extracardiac conduit. The orifices of branch vessels of the homograft were closed with autologous pericardial patches.
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The patient's postoperative course was uneventful except for temporary heart block. No homologous blood transfusion was required and her hemoglobin level was 11.9 g/dL at discharge. Catheterization showed mild conduit stenosis (30 mm Hg gradient), but the homograft valve was competent. At 4 months postoperatively, the patient was doing well without rhythm disturbance.
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Comment
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Henling and colleagues [6] reviewed 110 cardiac operations for congenital heart disease in children of Jehovah's Witnesses. However, there have been few clinical reports of open heart operation for complex cardiac anomalies, especially conduit repairs for congenitally corrected transposition of the great arteries, pulmonary atresia, and VSD. In our patient, the preoperative hemoglobin level was very high (19.6 g/dL) because of severe cyanosis. Then, after the reservation of 600 mL of undiluted whole blood in a closed circuit, it was quite easy to manage cardiopulmonary bypass without using homologous blood or blood products. After cardiopulmonary bypass, this 600 mL of blood was reinfused. This autotransfusion technique as well as the administration of aprotinin was very useful in the surgical procedure for the children of Jehovah's Witnesses with cyanotic complex congenital cardiac anomalies. To reduce the number of anastomoses and the chance of bleeding from the conduit anastomosis, a whole aortic homograft was used to maintain continuity between the left ventricle and the pulmonary artery. Using the long aortic homograft caused a compression of the conduit because of its stretch and extension after bypass. To deal with this problem, the methyl methacrylate plate was very useful as permanent splinting of the sternum. Recently, Salim and colleagues [7] reported that the functional lumen of aortic homograft conduits decreased with time. Therefore, careful observation and long-term follow-up are important in this patient.
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Footnotes
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Address reprint requests to Dr Miyaji, Hongo 7-3-1, Bunkyo-ku, Tokyo 113, Japan.
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References
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- Ott DA, Cooley DA. Cardiovascular surgery in Jehovah's Witnesses: report of 542 operations without blood transfusion. JAMA 1977;238:1256–8.[Abstract/Free Full Text]
- Lewis CTP, Murphy MC, Cooley DA. Risk factors for cardiac operations in adult Jehovah's Witnesses. Ann Thorac Surg 1991;51:448–50.
- Chikada M, Furuse A, Kotsuka Y, Yagyu K. Open heart surgery in Jehovah's Witness patients. Cardiovasc Surg (in press)
- De Leval M, Bastos P, Stark J, Taylor JF, Macartney FJ, Anderson RH. Surgical technique to reduce the risks of heart block following closure of ventricular septal defect in atrioventricular discordance. J Thorac Cardiovasc Surg 1979;78:515–26.[Abstract]
- Kawauchi M, Furuse A, Kotsuka Y, Ono M. Resinous plate for permanent sternal splinting in patients with extracardiac conduits. Ann Thorac Surg 1996;61:1245–6.[Abstract/Free Full Text]
- Henling CE, Carmichael MJ, Keats AS, Cooley DA. Cardiac operation for congenital heart disease in children of Jehovah's Witnesses. J Thorac Cardiovasc Surg 1985;89:914–20.[Abstract]
- Salim MA, DiSessa TG, Alpert BS, Arheart KL, Novick WM, Watson DC Jr. The fate of homograft conduits in children with congenital heart disease: an angiographic study. Ann Thorac Surg 1995;59:67–73.[Abstract/Free Full Text]
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