Ann Thorac Surg 1998;66:1413-1414
© 1998 The Society of Thoracic Surgeons
Case Reports
Funnel graft to innominate vein to control epicardial bleeding
Inder D. Mehta, MDa,
John A. Elefteriades, MDa
a Cardiothoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
Accepted for publication April 25, 1998.
Address reprint requests to Dr Elefteriades, Yale University School of Medicine, 121 FMB, 333 Cedar St, New Haven, CT 06437
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Abstract
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A simple technique to control severe epicardial bleeding is described. This technique constructs a "funnel graft" to deliver shed blood into the venous system. This technique was lifesaving during pericardiectomy in a critically ill patient with acute presentation of constrictive pericarditis.
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Introduction
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Epicardial bleeding encountered during cardiac operations usually is self-limiting or can be easily controlled with the use of conventional suturing or local hemostatic agents. Occasionally, however, uncontrollable bleeding from the epicardial surface of the heart may be seen. This may be a result of a degloving injury, where part of the epicardium is stripped from the heart, exposing the myocardium proper. This is more likely to occur in situations where, because of either a previous cardiac operation or chronic inflammation of the pericardium, the epicardium becomes adherent to the pericardium, the lungs, or other adjacent structures. Separation of the adherent structures during dissection may strip off part of the epicardium and cause persistent or severe bleeding.
A case of such severe, life-threatening bleeding that required shunting to the venous system via a "funnel graft" is presented.
A 43-year-old morbidly obese man presented with intractable edema, weight gain, fatigue, shortness of breath, and azotemia during multiple hospitalizations over a period of 5 years. A diagnosis of constrictive pericarditis was made. The morbid obesity (175.5 kg) discouraged referral for catheterization or surgical evaluation. Chronic renal insufficiency developed as a result of low cardiac output under an increased diuretic regimen. Because of rapidly worsening hemodynamic deterioration, the patient was taken urgently to the operating room in anuric renal failure.
In the operating room, a thick, inflamed, calcified pericardium chronically adherent to the surface of the heart and producing frank constriction was found. The pericardium was freed from the surface of the heart, initially without cardiopulmonary bypass and later with cardiopulmonary bypass to allow completion of dissection on the inferior and posterior surface of the heart. During dissection, bleeding was encountered from the denuded surface of the heart at a localized area on the diaphragmatic aspect beyond the acute margin of the heart where the calcification in the pericardium extended through the epicardium into the myocardium. A large, distended plexus of veins at this location was difficult to control by sutures or by application of conventional hemostatic agents, including Surgicel (Johnson and Johnson, Arlington, TX), Gelfoam (Upjohn, Kalamazoo, MI), and fibrin glue. The patient was also given fresh frozen plasma, platelets, and desmopressin to optimize hemostatic function and correct the platelet dysfunction of azotemia. Continued bleeding precluded safe chest closure and led to cardiac tamponade after attempted closure.
A pericardial patch was sewn to the epicardium and adjacent adherent diaphragm around the area of bleeding. The patch was sutured with continuous 4-0 polypropylene without resumption of cardiopulmonary bypass. Interrupted pledgeted sutures were added around the perimeter of the patch as needed for additional hemostasis. There were no major coronary arteries discernible in the region to which the patch was sutured. A 10-mm Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) graft was sutured to an opening in the dome of the patch, and the other end of the graft was anastomosed in an end-to-side fashion to the left innominate vein (Fig 1). This maneuver immediately and effectively drained the epicardial bleeding into the low-pressure venous system, producing a dry field. To facilitate drainage into the venous system, the head of the bed was kept elevated to decrease the pressure in the innominate vein.
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Fig 1. Schematic representation of the funnel graft. A pericardial sheet is sewn in onlay fashion over the area of bleeding on the surface of the heart. A Gore-Tex tube graft is anastomosed to the center of the onlay pericardial patch. The other end of the pericardial graft is anastomosed end-to-side to the left innominate vein. The funnel graft produces a dry field by diverting shed blood immediately to the venous system. (IVC = inferior vena cava; RA = right atrium; SVC = superior vena cava.)
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The patient did well postoperatively with return of good hemodynamic function and normal renal function and was discharged without any consequences on postoperative day 4. Postoperative echocardiography before discharge showed no remaining flow in the funnel graft.
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Comment
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The funnel graft technique applied in this case provided a lifesaving alternative in a setting where other alternatives had been exhausted.
This technique is similar to the technique described in the literature to divert aortic bleeding into the right atrium with a Cabrol shunt [1, 2]. The shunting technique was modified in this case to manage persistent bleeding from the diaphragmatic surface of the heart, which would otherwise have been lethal. The onlay pericardial patch and the attached tube graft functioned as a funnel to collect and deliver shed blood to the venous system. Such a funnel shunt would not be expected to remain patent, but rather would likely thrombose after a few hours or days, having served the purpose of controlling the severe bleeding in the immediate perioperative period. The innominate vein provided a convenient, noninflamed portal of entry into the venous system. The right atrium would have been problematic because of denudation and friability from pericardial resection. The innominate vein proved quite suitable for funnel connection, and the venous pressure could be modulated by manipulating the position of the head of the bed. Such a funnel shunt may be useful in other unusual cases of uncontrollable cardiac bleeding.
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References
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- Cabrol C., Gandjbakhch I., Pavie A. Surgical treatment of aneurysms of ascending pathology. J Card Surg 1988;81:309-315.
- Hoover E.L., Hsu H.K., Ergin A., et al. Left-to-right shunts in control of bleeding following surgery for aneurysms of the ascending aorta. Chest 1987;91:844-849.[Abstract/Free Full Text]
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