Ann Thorac Surg 1997;63:248-249
© 1997 The Society of Thoracic Surgeons
Case Report
Cardiac Tamponade After a Systemic-Pulmonary Shunt Complicated by Serous Leakage
Luis García-Guereta, MD, PhD,
Margarita Burgueros, MD,
Daniel Borches, MD,
Virginia Gonzalez, MD,
José Jiménez, MD
Divisions of Cardiology, Cardiac Surgery, and Neonatology, Hospital Infantil La Paz, Madrid, Spain
Accepted for publication July 5, 1996.
 |
Abstract
|
|---|
A newborn baby with complex congenital heart disease had severe persistent pericardial effusion after a systemic-pulmonary shunt. Pericardiocentesis and pericardiotomy could not stop pericardial leakage. At reoperation, topical application of a fibrin glue resulted in resolution of the leak and avoided replacement of the graft.
|
Introduction
|
|---|
See also page 250.
Systemic-pulmonary shunts are the standard palliative procedure used to increase pulmonary flow in newborns and infants with cyanotic congenital heart disease with severe pulmonary valve stenosis or atresia. The purpose of this article is to report an extremely unusual complication of a polytetrafluoroethylene shunt (Impra vascular graft; Impra, Inc, Tempe, AZ) in a neonate who suffered repeated episodes of severe pericardial effusion and who was successfully managed with topical application of Tissucol Immuno (Immuno AG, Wien, Austria; 1 mL = 75 mg of coagulant protein, 300 KIU of bovine aprotinin, 4 IU of bovine thrombin, 500 IU of bovine thrombin, and 40 mmol/L of calcium chloride) on the surface of the graft.
A newborn baby was admitted to the neonatal intensive care unit after an uneventful delivery. A prenatal echocardiogram revealed mitral atresia, hypoplastic left ventricle, ventricular septal defect, double-outlet right ventricle, and severe pulmonary valve stenosis. Prenatal diagnosis was confirmed at birth by echocardiography and angiography. On the third day of life a systemic-pulmonary shunt was performed through a right thoracotomy. Surgical examination revealed a very hypoplastic right pulmonary artery (less than 3 mm in diameter). We decided to open the pericardium and placed a 4-mm polytetrafluoroethylene shunt between the brachycephalic trunk and the main pulmonary artery. Systemic heparinization was used during the first 48 hours.
The initial postoperative period was uneventful, and the chest tube was withdrawn the day after the operation. Clinical deterioration occurred during the third postoperative day. Oxygen saturation remained in the mid 80s, but the patient became dyspneic and suffered a cardiac arrest that responded to resuscitation measures. Roentgenograms revealed severe pleural effusion (Fig 1
), which was tapped and drained. An echocardiogram was performed and showed severe pericardial effusion (Fig 2). Pleurocentesis and pericardiocentesis significantly improved the clinical situation, but a persistent fluid leak through the pericardial drainage required further opening of the pericardium. There was still a persistent pericardial drainage averaging 80 mL/day for 18 days.
View larger version (85K):
[in this window]
[in a new window]
|
Fig 2. . Echocardiogram (subcostal short-axis view) shows pleural effusion (#) and pericardial effusion (A and EFF). (RA = right atrium.)
|
|
Analysis of the recovered leak showed a plasma-like composition without lymphocytes or fatty acids. The patient was taken back to the operating room, where local examination showed a patent graft with continuous leakage of large drops of clear, colorless fluid. The graft was intensively sprayed with Tissucol Immuno, and serous leakage appeared to stop. There was a progressive decrease of draining fluid, and the pericardial tube was withdrawn 3 days after the operation. The patient was successfully discharged from the hospital in good condition and was well and thriving 6 weeks after the procedure; there was a continuous murmur over the chest, and the oxygen saturation was 85%.
|
Comment
|
|---|
Perigraft seromas after systemic pulmonary shunt procedures have been very infrequent or absent in most series [1], being reported most commonly as case reports [2–4]. However, this condition has also been underlined as a not uncommon complication by some authors [5, 6]. Serous leakage through the walls of the graft may reach the pleural space and cause prolonged drainage from the chest tubes or pleural effusion after tube withdrawal. It may also accumulate around the graft, producing a widening of the mediastinum on the chest roentgenogram [2, 6]. Severe cases may need reoperation and replacement of the graft [2].
The exact mechanism by which the seroma is formed has not been determined. Polytetrafluoroethylene grafts are made from an expanded polymer of Teflon that is hydrophobic and impermeable to whole blood. Graft sweating has been related to damage of the grafts by organic solvents, povidone iodine, tissue fluids, or blood, which may increase the permeability of the graft wall. It has been emphasized [6] that polytetrafluoroethylene becomes hydrophilic 48 to 96 hours after implantation, which explains the initial normal course and the delayed complication. Several theories have tried to explain this phenomenon, and there has been limited experimental research aimed to identify molecules within the perigraft fluid or in the patient's serum that may alter the permeability of the graft [7].
The occurrence of pericardial effusion after systemic-pulmonary shunts is extremely infrequent. Most shunt procedures connect the subclavian artery to the right or left pulmonary artery. These procedures are usually done through a lateral thoracotomy, and the pericardium is not opened. In our case the pericardium was opened and the graft was connected to the pulmonary trunk to provide symmetric growth of both pulmonary arteries and to prevent arterial tree distortion, which could complicate future atriopulmonary or cavopulmonary anastomosis [8]. The opening of the pericardium during the operation may explain why the perigraft seroma reached the pericardial space. We have only found 2 cases in which severe pericardial effusion complicated Blalock-Taussig procedures. They were both described by LeBlanc and associates in their extensive review [6]. One of them was managed with prolonged pericardial drainage, but the other required repeated operation after two episodes of cardiac arrest; surgical inspection showed a tiny perforation of the pericardium, which explained the access of a perigraft leakage to the pericardial space.
LeBlanc and associates noted that excessive fluid leakage was evident in 26 of 138 patients after shunting procedures and reported that it was more frequently observed when a silicone wrapping was used to cover the graft [6]. Treatment included delayed tube withdrawal or pleurocentesis, and only 5 of the patients required reoperation (3.6%). Later, the same group reported a 2.3% incidence of reoperation for the same cause [4], similar to the 3% found by Feil and colleagues [5]. The true incidence of excessive perigraft leakage is difficult to determine because mild cases may go undetected.
Surgical inspection of the graft in our patient showed clear fluid around the graft and clear drops on its wall, which rapidly reappeared after its surface was dried, as others had also reported [2, 4]. We chose to apply a fibrin glue to the surface of the graft instead of replacing it and to maintain the pericardial draining tube. The amount of fluid recovered progressively decreased, and the tube was withdrawn 3 days later.
LeBlanc and associates [6] treated 1 of their patients by topical application of thrombin and Surgicel (Johnson & Johnson, Norderstedt, Germany) and noted that drainage slowed and stopped in the following days. Maitland and colleagues [4] made the graft impermeable by instilling a solution containing aprotinin, thrombin, and calcium chloride inside the graft, which was temporarily clamped during the procedure. The type of congenital heart defect was not stated in their report; however, it would not appear advisable to totally clamp the graft if all pulmonary flow is provided by the shunt.
Perigraft seroma is a rare cause of persistent pericardial effusion after a systemic-pulmonary shunt. Topical application of Tissucol Immuno or other similar substances may be useful to control serous leakage and to avoid graft replacement.
|
Footnotes
|
|---|
Address reprint requests to Dr García-Guereta, Hospital Infantil La Paz, P de la Castellana 261, Madrid 28046, Spain.
|
References
|
|---|
- Gold JP, Violaris K, Engle MA, et al. A five-year clinical experience with 112 Blalock-Taussig shunts. J Card Surg 1993;8:9–17.[Medline]
- Damus PS. Seroma formation after implantation of Gore-Tex vascular grafts in cyanotic children. J Thorac Cardiovasc Surg 1984;88:310–1.[Medline]
- Ozkutlu S, Ozbarlas N Demircin M. Perigraft seroma diagnosed by echocardiography: a complication following Blalock-Taussig shunt. Int J Cardiol 1992;36:244–6.[Medline]
- Maitland A, Williams WG, Coles JG, et al. A method of treating serous fluid leak from a polytetrafluoroethylene Blalock-Taussig shunt. J Thorac Cardiovasc Surg 1985;90:791–3.[Abstract]
- Feil E, Arnold G, Borowski A, et al. Perigraft Reaktion. Eine Komplikation nach Aulage eines Prothesenshunts bei Kindern mit angeborenen zyanotischen Herzfehlern. Z Kardiol 1992;81:283–9.[Medline]
- LeBlanc J, Albus R, Williams WG, et al. Serous fluid leakage: a complication following the modified Blalock-Taussig shunt. J Thorac Cardiovasc Surg 1984;88:259–62.[Abstract]
- Alh SS, Williams DE, Thye DA, et al. The isolation of a fibroblast growth factor inhibitor associated with perigraft seroma. J Vasc Surg 1994;20:202–8.[Medline]
- Mietus-Snyder M, Lang P, Mayer JE. Childhood systemic-pulmonary shunts: subsequent suitability for Fontan operation. Circulation 1976;76(Suppl 3):39–43.
Related Article
-
Invited Commentary
- Jeffrey P. Gold
Ann. Thorac. Surg. 1997 63: 250.
[Extract]
[Full Text]
Top
Abstract
Introduction
