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Ann Thorac Surg 1997;63:250
© 1997 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, 3316 Rochambeau Ave, Bronx, NY 10467
García-Guereta and associates nicely describe an experience with a neonate palliated with a systemic-pulmonary artery polytetrafluoroethylene shunt for cyanotic congenital heart disease who sustained the complication of a persistent, large-volume serous fluid drainage from the shunt into the pericardium and right pleural space, necessitating reoperation. Pleural and pericardial effusions after the creation of polytetrafluoroethylene shunts in general have been quite rare, even with the transition to thin-walled polytetrafluoroethylene conduit material. The "breathing" of the graft material predisposes it to an ultrafiltration-like process, which allows for the accumulation of periprosthetic serous effusions.
Fortunately, the overwhelming majority of these are self limited. Adequate pericardial or pleural drainage with a due amount of patience usually allows these effusions to be self sealing and stop. On the rare occasion that time and drainage are inadequate, various techniques have been proposed, which include replacing the graft and wrapping the graft with either pericardium, pleura, or another type of graft material. Coating the graft with either a fibrin glue or other topical hemostatic agents has been used as well. Tissue glue materials can be either commercially available or manufactured by combinations of cryoprecipitate and topical thrombin based on either autologous or volunteer donor cryoprecipitate products.
Other local complications associated with the use of polytetrafluoroethylene shunts include the development of a localized seroma surrounding the graft with marked periprosthetic inflammatory changes and local compression syndromes. Distortion of either the architecture of the donor vessel or the recipient pulmonary vessel may occur as well. Careful attention to suture technique and graft length, torque, and lie are critical to alleviating these latter potential complications. Infection, another rare complication, may have devastating consequences and therefore requires aggressive diagnosis and treatment.
The hydrophilic nature of the expanded polytetrafloethylene graft material predisposes it to "sweating" and therefore underlies, to at least some extent, the basis of this patient's drainage problem. Careful attention to postsurgical follow-up and demonstration of high-volume early fluid production followed by early reoperation for either wrapping or surface treatment are certainly indicated and frequently lifesaving in this very small subset of patients. Future developments in graft conduit materials, perhaps with nonhydrophilic coatings, may completely prevent this problem. Clearly, classic Blalock-Taussig shunts also avoid many of these "graft"-related complications, but are associated with other potential technical and developmental drawbacks. All attempts to avoid palliative procedures and employ definitive anatomic or physiologic repair are therefore warranted.
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