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Ann Thorac Surg 1997;64:1489-1491
© 1997 The Society of Thoracic Surgeons

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How To Do It

Carbon Dioxide Field Flooding Minimizes Residual Intracardiac Air After Open Heart Operations

Divisions of Cardiothoracic Surgery and Cardiology, Louisiana State University School of Medicine, New Orleans, Louisiana

Accepted for publication May 13, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Transesophageal echocardiographic studies were used to monitor the presence of air bubbles in the heart after open heart operations. After cardiac valvular procedures all 22 patients managed with careful deairing procedures had persistence of air bubbles for at least 30 minutes and usually for 45 minutes. In 56 patients with CO₂ field flooding, all foam disappeared in less than 1 minute in 48 patients and the remaining 8 had complete disappearance in 1 to 24 minutes. These observations demonstrate the ineffectiveness of the usual deairing maneuvers and the effectiveness of CO₂ field flooding in displacing air.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Recent studies using refined techniques of neuropsychological testing have shown a high frequency of neurocognitive impairment in 32% to 83% of patients after all types of cardiopulmonary bypass procedures [1, 2], and many of these are progressive or persistent [3]. There are many causes for postoperative neurocognitive changes but van der Linden and associates [4], using transesophageal echocardiography, demonstrated a significant amount of air despite deairing maneuvers, and transcranial Doppler assessment demonstrated bursts of emboli on resumption of cardiac contractions. Other workers have similarly found increased emboli occurring with resumption of cardiac activity and that these correlated with increased neurophysiological defects [5, 6].

Displacement of the air in the open heart or aorta by carbon dioxide was proposed early in the development of cardiac surgery [7], as CO₂ is more than 20 times as soluble as nitrogen or oxygen and exhibits minimal detrimental effects with intravascular injection. This study was undertaken to determine the incidence of residual intracardiac air after careful deairing maneuvers in patients undergoing valvular heart procedures and whether CO₂ field flooding favorably modified these findings.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Fifty-six patients having cardiac valve operations had CO₂ instilled into the pericardial cavity through a multiperforated catheter or commercial drain (Jackson-Pratt). The catheter was sutured in the bottom of the pericardial well, starting inferiorly on the patient's right side and extending above the aortic cannulation site and down the left side Fig 1). This route provides the highest concentration of CO₂ at the atrial and aortic incisions. A flow of 10 L of CO₂ per minute was started before the cardiac or aortic incisions were made and continued until the cannulas had been removed. Care was taken to minimize the use of intrapericardial and intracardiac suctioning to avoid removal of the CO₂. Aortic needle vents were used in all patients, and left ventricular vents (through the right superior pulmonary vein) were used only in aortic valve procedures where venous drainage was through a single, double-stage cannula. Twenty-two other patients had valve replacement or repair without CO₂ field flooding. All patients had intensive deairing techniques at the completion of the repair, and all patients were monitored by transesophageal echocardiography to evaluate the persistence of air bubbles.

View larger version (61K): [in this window] [in a new window]   Fig 1. . Circumferential placement of multiperforated catheter in the base of the pericardial well.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Oxygen concentrations in the pericardial well were usually less than 1%, implying a CO₂ concentration of about 95%. Perfusion circuit CO₂ tension values were usually within normal limits, most often ranging from 36 to 50 mm Hg, and did not cause significant acid-base disturbances. Increased CO₂ tension levels correlated with intensive intrapericardial suctioning and quickly returned to normal when suctioning was discontinued.

All 22 patients having only deairing maneuvers exhibited residual foam inside the heart, aorta, or both for at least 30 minutes, and frequently for the full 45 minutes of transesophageal echocardiographic observation (Fig 2). Of the 56 patients with CO₂ field flooding, no foam was observed at the time of onset of cardiac contractions in 34 and in 14 additional cases all bubbles disappeared within the first minute (Fig 3). In 8 patients, bubbles persisted from 1 to 24 minutes after resumption of cardiac activity.

View larger version (68K): [in this window] [in a new window]   Fig 2. . Postoperative echocardiogram 35 minutes after resumption of heart beat. Note innumerable air bubbles in left atrium in spite of vigorous deairing maneuvers.

View larger version (91K): [in this window] [in a new window]   Fig 3. . Postoperative echocardiogram less than 1 minute after resumption of heart beat with CO2 field flooding. Note almost complete absence of bubbles.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Many previous workers have used echocardiographic methodology to detect air in the heart. Oka and associates [11] found intracardiac or intraaortic air after extensive deairing maneuvers in 79% of their patients having valve operations and in 11% of their patients having coronary bypass. Some patients had air persisting for as long as an hour. Several patients with positive echocardiograms exhibited cardiac or cerebral disturbances, whereas no disturbances occurred in the absence of retained air.

The lack of gross neurologic changes in most patients in spite of the presence of intracardiac air is surprising. The very high incidence of defects found by the careful neurocognitive studies of others, however, suggests that even these small bubbles may not be benign. We are continuing these observations with the addition of transcranial Doppler studies to determine the timing and frequency of intracerebral emboli with or without CO₂ field flooding.

In summary, the present studies demonstrate that after cardiac operations there is a plethora of residual small air bubbles in the heart and aorta in spite of extensive deairing maneuvers, but that air can be almost totally eliminated by using CO₂ field flooding and minimal intrapericardial suctioning.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Webb, Department of Surgery, Louisiana State University School of Medicine, 1542 Tulane Ave, New Orleans, LA 70112-2822.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Pugsley W, Klinger L, Pasachalis C. Micro emboli and cerebral impairment during cardiac surgery. Vasc Surg 1990;24:34–43.
2. Mahanna EP, Blumenthal JA, White WD, et al. Defining neuropsychological dysfunction after coronary artery bypass grafting. Ann Thorac Surg 1996;61:1342–7.[Abstract/Free Full Text]
3. McKhann GM, Goldsborough LM, Borowicz MS Jr, et al. Cognitive outcome after coronary artery bypass: a one-year prospective study. Ann Thorac Surg 1997;63:510–5.[Abstract/Free Full Text]
4. Van der Linden J, Casimir-Ahn H. When do cerebral emboli appear during open heart operations? A transcranial Doppler study. Ann Thorac Surg 1991;51:237–41.[Abstract/Free Full Text]
5. Hammon JW, Stump DA, Hines M, Rogers AT, Phipps JM. Prevention of embolic events during coronary artery bypass graft surgery. Perfusion 1994;9:412–3.
6. Brillman J, Clark RE, Donnalee AD, Lovell MR, Magovern GJ. The source of micro emboli during CABG and the neurological and cognitive sequelae. Perfusion 1994;9:1413–4.
7. Nichols HT, Morse DP, Hirose T. Coronary and other air embolization occurring during open heart surgery prevention by the use of gaseous carbon dioxide. Surgery 1958;43:236–44.[Medline]
8. Kolff WJ. Diluting residual air with CO₂ [Letter]. Tex Heart Inst J 1994;21:112.[Medline]
9. Selman MW, McAlpine WA, Albregt H, Ratan R. An effective method of replacing air in the chest with CO₂ during open-heart surgery. J Thorac Cardiovasc Surg 1967;53:618–22.[Medline]
10. Olinger GN. Carbon dioxide displacement of left heart chambers. J Thorac Cardiovasc Surg 1995;109:187–90.[Free Full Text]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Watts R. Webb Nabil A. Munfakh Herman A. Heck, Jr Peter V. Moulder Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Webb, W. R. Articles by Moulder, P. V. Search for Related Content PubMed PubMed Citation Articles by Webb, W. R. Articles by Moulder, P. V.