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Ann Thorac Surg 1997;64:37-42
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Modified Ultrafiltration Reduces Postoperative Morbidity After Cavopulmonary Connection

Division of Pediatric Cardiothoracic Surgery, Department of Anesthesiology, and Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

	Abstract

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
Background. Modified ultrafiltration reduces the deleterious effects of cardiopulmonary bypass in children. Patients undergoing repair of single-ventricle cardiac anomalies may be particularly sensitive to these adverse effects, and benefit from the use of modified ultrafiltration.

Methods. From January 1995 to June 1996, 120 consecutive cavopulmonary operations were performed at The Children's Hospital of Philadelphia. Procedures included lateral tunnel fenestrated Fontan (n = 50), extracardiac Fontan (n = 5), hemi-Fontan (n = 60), and bidirectional Glenn shunt (n = 5). Modified ultrafiltration was performed after cardiopulmonary bypass in 41 patients, and results were compared by t test with a control group of 79 patients in whom modified ultrafiltration was not used.

Results. There was one death for an operative (30-day) mortality of 0.8%. Age, weight, diagnosis, ischemic arrest time, and cardiopulmonary bypass time were similar between the modified ultrafiltration and control groups. Postoperative blood use, chest tube output, the incidence of pleural and pericardial effusions, and hospital stay were all significantly decreased when modified ultrafiltration was used.

Conclusions. By lowering the perioperative morbidity of staged cavopulmonary operations, modified ultrafiltration makes an important contribution to improving outcome after the correction of single-ventricle cardiac anomalies.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
See also page 43.

Since the introduction of right-heart bypass in the management of single-ventricle cardiac anomalies, a number of modifications have been introduced to reduce the morbidity and mortality of these operations. The lateral tunnel method of total cavopulmonary connection, a staged surgical approach using a superior cavopulmonary connection before the modified Fontan repair, and fenestration of the intraatrial baffle have led to improved operative outcomes [1–4]. As operative mortality rates for this approach decrease, attention now shifts to reducing the perioperative and long-term morbidity of these operations.

A number of adverse effects are associated with the use of cardiopulmonary bypass in children [5]. There is an increase in capillary permeability that leads to an overall increase in total body water and edema formation. Hemodilution occurs due to the large priming volumes of the cardiopulmonary bypass circuit. Pulmonary compliance and gas transfer are decreased, and myocardial edema may result in diastolic dysfunction. Efforts to reduce the deleterious effects of postbypass capillary leak syndrome include optimizing bypass and cooling techniques, reducing circuit volumes, perioperative antiinflammatory and diuretic therapies, and the use of postoperative peritoneal dialysis. In 1991, Naik and associates [6] introduced the technique of modified ultrafiltration (MUF) as an alternative method to reduce the adverse effects of cardiopulmonary bypass in pediatric patients.

The technique of MUF is performed after cardiopulmonary bypass is completed and allows ultrafiltration of both the patient and the remaining contents of the venous reservoir. In addition to plasma water, solutes less than 50 kilodaltons in size are removed, including a number of inflammatory mediators [7]. Early studies with modified ultrafiltration reported decreases in the accumulation of total body water that occurs after cardiopulmonary bypass, reduced perioperative blood loss, and decreased blood use [6]. Later studies demonstrated improvements in myocardial function and cerebral oxygenation after circulatory arrest [8, 9]. Postbypass pulmonary vascular resistance also appears to be reduced using MUF [8].

Children after the repair of single-ventricle anomalies are particularly sensitive to elevations in pulmonary vascular resistance and decreases in pulmonary and ventricular compliance. We addressed the use of MUF in these children, specifically after cavopulmonary operations. The hypothesis of this study is that the use of MUF after cardiopulmonary bypass improves early outcome after the staged repair of single-ventricle anomalies.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
Patient Population
From January 1995 to June 1996, 120 consecutive cavopulmonary operations were performed for the management of single-ventricle congenital heart defects. Median patient age was 1.3 years, and age ranged from 3 months to 17 years. Median patient weight at the time of the operation was 9.1 kg, and weight ranged from 3.8 to 52 kg. Procedures included the hemi-Fontan repair, the bidirectional Glenn shunt, and the modified Fontan repair:

Operations to revise previous Fontan repairs such as hepatic vein inclusion and baffle fenestration were not included in this series.

Hypoplastic left heart syndrome was the most common cardiac anomaly in this series, and 55 of the 120 procedures (46%) were for anatomic variations of this defect (Table 1). Other common diagnoses included complex forms of double-outlet right ventricle, tricuspid atresia, complex transposition of the great arteries, single ventricle, and heterotaxy syndromes.

	Operative Technique

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

The majority of these operations (91%) were performed with the use of circulatory arrest. All bidirectional Glenn shunts were performed using cardiopulmonary bypass alone. A few Fontan repairs were also performed on cardiopulmonary bypass, without the use of circulatory arrest. The median circulatory arrest time was 32 minutes, and arrest time ranged from 15 to 73 minutes. Cardiopulmonary bypass time, including the circulatory arrest period, had a median of 67 minutes and ranged from 22 to 147 minutes.

Modified ultrafiltration was performed after cardiopulmonary bypass in 41 of the 120 operations in this series (34%). We began using MUF routinely at The Children's Hospital of Philadelphia in October 1995, and its use was related to surgeon preference. Although two of the surgeons had patients in both the MUF and the control groups, one surgeon did not use MUF. The technique of MUF was described in detail previously by Elliott [8]. The MUF was generally performed over 15 to 20 minutes after the discontinuation of cardiopulmonary bypass. There were no significant complications associated with the ultrafiltration procedure.

Fresh whole blood was used for perioperative transfusion when necessary. Whole blood was also added to the cardiopulmonary bypass prime if needed to maintain a hematocrit between 18% and 20% while on bypass. Blood use was calculated for each patient by the sum of the blood given to the patient in the operating room (exclusive of the pump prime) and the amount given in the intensive care unit during the first 24 hours after the operation. Because of variations in patient size, this value was normalized for patient weight, and expressed as milliliters per kilogram per 24 hours. Clotting factors (fresh frozen plasma, cryoprecipitate, and platelets) were infrequently used, but were also calculated into the blood use. Perioperative blood loss was calculated from the chest tube drainage in the first 24 hours after the operation, and was also expressed as milliliters per kilogram per 24 hours.

	Assessment of Operative Outcome

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
Early extubation was encouraged for all patients with stable hemodynamics. Postoperative ventilator time had a median of 20 hours and ranged from 4 hours to 9 days. Only 4 patients (3%) had a total ventilator time greater than 48 hours. Postoperative intensive care unit stay had a median of 4 days and ranged from 1 day to 31 days, whereas the hospital stay after the operation had a median of 8 days and ranged from 4 days to 50 days.

Early pleural and pericardial effusions occurred frequently in this series, especially after modified Fontan repair. Early pleural or pericardial effusions were defined in this study as those requiring drainage within 30 days of the operation. Our standard management protocol for pleural and pericardial effusions was as follows:

1. Small effusion: observation.
   
2. Moderate-sized or enlarging effusion: medical management with diuretic therapy.
   
3. Large, rapidly enlarging, or symptomatic effusion: percutaneous catheter drainage.
   

Usually effusions were treated conservatively with diuretics unless hemodynamic or pulmonary compromise occurred, or if the effusions were large or enlarging rapidly. Overall, 24 of the 120 patients (20%) required percutaneous drainage of pleural or pericardial effusions.

	Statistical Analysis

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
Patient data were obtained retrospectively from medical records. Patient and outcome variables were expressed either as a median value or as the mean ± standard error of the mean. Student's t test was used for statistical analysis, using a computer software package (NCSS, Kaysville, UT). Statistical differences were considered significant if the p value was less than 0.05.

	Results

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
Patient Characteristics and Operative Data
A summary of the preoperative and operative variables is shown in Table 2. Variables were divided between patients who received MUF and the control group of patients who did not. No significant difference in patient age or size was seen between these two groups. No obvious differences in preoperative diagnosis for the MUF and control groups were noted (see Table 1). The ratio of patients undergoing MUF was similar for both the superior cavopulmonary connections and the modified Fontan repairs: 22 of 65 patients (33%) underwent MUF after superior cavopulmonary connection, and 19 of 55 patients (34%) after modified Fontan repair. With regard to intraoperative data, both the circulatory arrest and cardiopulmonary bypass times were equivalent.

	Operative Outcome

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

Mediastinal reexploration was required for bleeding in 6% of patients overall. The incidence of reexploration after MUF was 4.8%, whereas without MUF the incidence of reexploration was 6.4%. This difference was not statistically significant. An additional two reoperations were necessary in the control group to repair baffle leaks that occurred after hemi-Fontan procedures.

Perioperative blood use for each group is demonstrated in Figure 1. The average amount of blood transfused per patient using MUF was 29 ± 4 mL•kg^-1•24 hours^-1 (median, 25.6 mL•kg^-1•24 hours^-1); the control group averaged 63 ± 4 mL•kg^-1•24 hours^-1 (median, 56.8 mL•kg^-1•24 hours^-1). This difference was significant with a p value less than 0.001. When the transfusion volume was not normalized for weight the difference remained significant. Ten percent (4 of 41) of patients in the MUF group did not require a blood transfusion during their hospitalization. In contrast, only 2.5% (2 of 79) of patients in the control group did not receive a transfusion.

View larger version (17K): [in this window] [in a new window]   Fig 1. . Mean perioperative blood use for the modified ultrafiltration (MUF) and the control (nonmodified ultrafiltration; Non-MUF) groups.

View larger version (15K): [in this window] [in a new window]   Fig 2. . Mean postoperative blood loss (chest tubes) for the modified ultrafiltration (MUF) and the control (nonmodified ultrafiltration; Non-MUF) groups.

View larger version (12K): [in this window] [in a new window]   Fig 3. . Average hematocrit levels during the course of admission for the modified ultrafiltration (MUF) and the control (nonmodified ultrafiltration (Non-MUF) groups. (D/C = discharge; POD = postoperative day; Post-op = postoperative; Pre-op = preoperative.)

There was a significant difference in the incidence of early postoperative pleural and pericardial effusions between the MUF and control groups. When MUF was used, 4.9% of patients undergoing cavopulmonary operations had pleural or pericardial effusions during their postoperative course that required drainage (Fig 4). When MUF was used, 10.5% of patients required drainage of effusions after modified Fontan procedures, whereas no patients required drainage after superior cavopulmonary connection alone. Without the use of MUF in the control group the overall incidence of postoperative effusions requiring drainage was 28.2%. The incidence after superior cavopulmonary connection alone was 11.5%, whereas the incidence after modified Fontan repair was 48.5%. Each of these differences between the MUF and control groups was significant, with p values less than 0.01. Three patients, all of whom were in the control group, required reoperation for creation of a pericardial window due to persistent pericardial effusions.

View larger version (15K): [in this window] [in a new window]   Fig 4. . Incidence of postoperative pleural and pericardial effusions that required drainage. (MUF = modified ultrafiltration; Non-MUF = nonmodified ultrafiltration; SVC-PA = superior cavopulmonary connection.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
Fontan and Baudet [11] introduced the concept of right-heart bypass in 1971 as a method to physiologically correct tricuspid atresia. Although the Fontan method of physiologic correction was gradually adapted to other forms of univentricular anomalies, early results demonstrated a higher operative mortality rate for patients without tricuspid atresia, and in younger children (less than 3 to 4 years of age) [12]. There are a number of modifications to the original Fontan operation that now allow the repair of single-ventricle cardiac anomalies in younger and higher risk patients, with relatively low mortality rates when compared with several years ago. The lateral-tunnel modification of total cavopulmonary connection facilitated the use of the modified Fontan procedure in children with a systemic right ventricle [1, 10]. Staging cavopulmonary operations so that a superior cavopulmonary connection is performed before the completion modified Fontan repair has reduced the operative mortality in many otherwise high-risk patients [2, 10, 13]. Fenestration of the intraatrial baffle, whether adjustable or fixed, lowered operative mortality and morbidity even further, especially in "high-risk" Fontan patients.

Our current series represents a heterogeneous group of patients, the majority of whom were less than 3 years of age. Hypoplastic left heart syndrome and complex forms of double-outlet right ventricle (usually with mitral atresia) were the most common anomalies. Some consider these children to be high-risk Fontan candidates because of "unfavorable" atrioventricular valve anatomy [14]. Despite this, the overall operative mortality in this series was 0.8%. The operative mortality after modified Fontan repair was 1.8%, which is among the lowest reported for a series this size.

The hemi-Fontan repair was performed in half of the patients of this series. This type of superior cavopulmonary connection is advocated by some surgeons for the second stage of the surgical management of hypoplastic left heart syndrome, because the pulmonary arteries commonly may become distorted after the initial Norwood repair [10, 15, 16]. Nearly half of the children in this series had hypoplastic left heart syndrome, so this procedure was used frequently. In addition, a number of our patients underwent previous palliative operations that had distorted or narrowed the pulmonary arteries, such as pulmonary banding and systemic–pulmonary shunting. Elevated pulmonary artery pressures and pulmonary artery distortion were both shown to be risk factors for poor outcome after Fontan repair [14, 17]. The use of the hemi-Fontan repair limited pulmonary artery distortion in our experience. Also, because superior vena cava–right atrial continuity is maintained using the hemi-Fontan repair, the completion Fontan stage may be technically easier and faster.

The frequent use of circulatory arrest in this series is also an indication of the complexity of our patient population. The majority of these patients had at least one previous median sternotomy, and many had two or three. Bicaval cannulation may be difficult in this situation, especially in those patients with hypoplastic left heart syndrome. This method of cannulation also risks distortion and thrombosis of the venae cavae, a potentially lethal complication after Fontan repair. The use of circulatory arrest allowed for shorter cardiopulmonary bypass times, thus reducing the potential for postoperative pulmonary dysfunction, which may be a serious problem after cavopulmonary connection. Circulatory arrest times were kept fairly short, and despite the frequent use of circulatory arrest in this series, neurologic complications were uncommon. Two patients had perioperative strokes with evidence of cerebral infarction on computed tomography of the head, and 2 patients required treatment for postoperative seizures. The overall neurologic complication rate was 3.6%. Although our institution is currently involved in studying the long-term neurologic effects of circulatory arrest in infants and children, we performed no in-depth postoperative neurologic testing in this series.

The original randomized series using MUF after cardiopulmonary bypass in children demonstrated significant decreases in postoperative blood loss and perioperative blood use [6]. In our series the postoperative blood loss using MUF was half the amount compared with a control group in which MUF was not used. The same was true for the volume of blood transfused. Although this was not a randomized series, our perioperative management practices remained relatively standard during the study period. There was also no significant difference in perioperative hematocrit levels between the two groups of patients, suggesting no difference in management techniques. The use of MUF in our current practice has allowed the majority of children who do not require blood for the bypass pump prime to go without a blood transfusion during their perioperative course.

The adverse effects of the postbypass capillary leak syndrome were generally not seen in this study. Although modified ultrafiltration reduces the accumulation in total body water seen after cardiopulmonary bypass, the patients in the control group of this study did not require more diuretic therapy or have greater problems with edema. However, the bypass times and circulatory arrest times in this study were relatively short: for most modified Fontan repairs the circulatory arrest time was less than 20 minutes, and the bypass time was less than 60 minutes. Shorter duration of bypass may result in less capillary leak, thereby attenuating the beneficial effects of MUF.

The decrease in the incidence of early postoperative pleural and pericardial effusions using MUF was an unexpected benefit of the use of this technique. Although the incidence of pleural effusions after modified Fontan repair in the control group was higher than in other series [18], it compared with previous studies from our institution [10, 16]. The vast majority of the modified Fontan procedures in each group were fenestrated lateral-tunnel repairs. The only exception were the five extracardiac Fontan repairs, which were necessary due to the patients' cardiac anatomy. In each of these patients a fenestration was performed as well. Because the etiology of postoperative effusions after cavopulmonary connection is still unknown, it is difficult to postulate a precise mechanism for the lower incidence seen using MUF. One possibility is the removal of circulating inflammatory mediators by the ultrafiltration process. Another possibility is that subtle increases in postbypass total body water that occur when MUF is not used are manifested several days after the operation as pleural and pericardial effusions. Although we did not examine hemodynamics in this study, myocardial edema and diastolic dysfunction may be more pronounced without MUF, leading to higher central venous pressures. Reducing the incidence of postoperative effusions using MUF in this series resulted in a significant reduction in postoperative hospital stay.

The major limitation of this study is that the use of MUF was not randomized. Performing MUF after cardiopulmonary bypass was related to surgeon preference in this series, although it was used fairly routinely after October 1995. Although the argument may be made that our control group then represents little more than a historical control, in fact the only modification made in the perioperative routine of these patients during the study period was the introduction of MUF. All other variables such as operative techniques, indications for transfusion, and criteria for drainage of pleural effusions remained constant. Other aspects of the patient population (preoperative and operative characteristics, see Tables 1 and 2) were virtually identical between the two groups. It is difficult, however, to exclude the surgeon as a variable in the differences shown in this study, because one of our surgeons did not use MUF. Nevertheless, when the results for the two other surgeons in this series were compared using a t test, perioperative blood use, blood loss, and the incidence of postoperative effusions were still significantly less using MUF.

In summary, MUF is a safe adjunct to the staged repair of complex single-ventricle cardiac anomalies. Perioperative blood loss and blood use were significantly decreased when MUF was used. There was a lower incidence of early postoperative pleural and pericardial effusions in patients who received MUF after cardiopulmonary bypass, and this resulted in a significantly shorter hospital stay. The overall operative mortality rate in this series of 0.8% is among the lowest reported for cavopulmonary operations in a patient population of this size and complexity.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 
Presented at the Forty-third Annual Meeting of the Southern Thoracic Surgical Association, Cancun, Mexico, Nov 7-9, 1996.

Address reprint requests to Dr Spray, Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104.

	References

Top Footnotes Abstract Introduction Material and Methods Operative Technique Assessment of Operative Outcome Statistical Analysis Results Operative Outcome Comment Acknowledgments References

 

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3. Bridges ND, Lock JE, Castañeda AR. Baffle fenestration with subsequent transcatheter closure: modification of the Fontan operation for patients at increased risk. Circulation 1990;82:1681–9.[Abstract/Free Full Text]
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5. Maehara T, Novak I, Wyse RKH, et al. Perioperative monitoring of total body water by bioelectrical impedance in children undergoing open heart surgery. Eur J Cardiothorac Surg 1991;5:258–65.[Abstract/Free Full Text]
6. Naik SK, Knight A, Elliott MJ. A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery. Circulation 1991;84(Suppl 3):422–31.
7. Wang MJ, Chiu IS, Hsu CM, et al. Efficacy of ultrafiltration in removing inflammatory mediators during pediatric cardiac operations. Ann Thorac Surg 1996;61:651–6.[Abstract/Free Full Text]
8. Elliott MJ. Ultrafiltration and modified ultrafiltration in pediatric open heart operations. Ann Thorac Surg 1993;56:1518–22.[Medline]
9. Skaryak LA, Kirshbom PM, DiBernardo LR, et al. Modified ultrafiltration improves cerebral metabolic recovery after circulatory arrest. J Thorac Cardiovasc Surg 1995;109:744–52.[Abstract/Free Full Text]
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11. Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax 1971;26:240–8.[Abstract/Free Full Text]
12. Kirklin JK, Blackstone EH, Kirklin JW, et al. The Fontan operation: ventricular hypertrophy, age, and date of operation as risk factors. J Thorac Cardiovasc Surg 1986;92:1049–64.[Abstract]
13. Seliem MA, Baffa JM, Vetter JM, et al. Changes in right ventricular geometry and heart rate early after hemi-Fontan procedure. Ann Thorac Surg 1993;55:1508–12.[Abstract/Free Full Text]
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