Ann Thorac Surg 1999;68:1431-1432
© 1999 The Society of Thoracic Surgeons
How to Do It
Preparatory surgical stent placement facilitating extracardiac vascular connections
Gerhard Ziemer, MDa,
Markus K. Heinemann, MDa
a Division of Thoracic, Cardiac, and Vascular Surgery, Tübingen University Hospital, Tübingen, Germany
Address reprint requests to Dr Ziemer, Division of Thoracic, Cardiac, and Vascular Surgery, Tuebingen University Hospital, Hoppe-Seyler-St 3, D-72076 Tübingen, Germany
e-mail: gdziemer{at}med.uni-tuebingen.de
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Abstract
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Native pericardium can be valuable material for the construction of extracardiac vascular connections. To avoid its scarring by adhesions and to preform future vascular connections, ringed polytetrafluoroethylene prostheses were implanted into the pericardial sac during staged operations for univentricular heart disease. At reoperation, extracardiac connections were found to be greatly facilitated by this approach.
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Introduction
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The extracardiac construction of cavopulmonary connections may render significant benefits in the functional correction of univentricular heart disease [1–5]. To construct a wide and unobstructed tunnel, a sufficient amount of native pericardium is advantageous [5]. Staged preparation of a Fontan-type operation often necessitates several palliative operations. The resulting adhesions may leave the pericardium unsuitable for major reconstructive surgery. To avoid such scarring, and also to preform proper conduits, we have implanted polytetrafluoroethylene (PTFE) prostheses into the pericardial sac as temporary extracardiac stents.
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Technique
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Extracardiac PTFE prostheses (GoreTex ring-enforced PTFE prosthesis; W.L. Gore, Flagstaff, AZ) were implanted in 4 children with complex univentricular heart disease during establishment of a bipulmonary Glenn anastomosis in preparation for a Fontan-type operation. Their mean age was 2.5 years with a range of 1.5 to 4 years. The diameters of the ring-enforced grafts varied accordingly from 12 to 16 mm. The prostheses were fixed to the pericardium with a 4-0 polypropylene suture (Prolene, Ethicon, NJ) at their top and bottom ends in such a fashion as not to indent vascular structures or compromise the adjacent atrium. Upon chest closure, a thin PTFE membrane (Preclude pericardial membrane 0.1 mm, W.L. Gore, Flagstaff, AZ) was implanted as a pericardial substitute into the anterior rims of the pericardiotomy, as is our routine in all children undergoing staged procedures.
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Results
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Hemodynamic or anatomical problems with chest closure were not observed after implantation of the extracardiac prosthesis.
The Fontan-type completion operation was performed after an average of 12 months as a total cavopulmonary connection. In 3 children, the temporary PTFE prostheses served to provide an extracardiac pericardial tunnel from the inferior vena cava to the undersurface of the ipsilateral pulmonary artery. In 1 boy with bilateral superior venae cavae who had undergone multiple aortopulmonary shunting procedures with ensuing destruction of the right pulmonary artery, the cavity provided by the prosthesis was used to reconstruct the retroaortic segment of the pulmonary artery (Fig 1).
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Fig 1. CT scan after bilateral Glenn anastomosis. Retroaortic ringed PTFE prosthesis for planned reconstruction of destroyed pulmonary artery during Fontan completion.
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Upon reoperation, the intact pericardium could be peeled off the length of the prosthesis easily (Fig 2). There was ingrowth of richly vascularized connective tissue into the grafts (Fig 3). Histology showed a cylinder of scar tissue with central capillaries, surrounded by unspecific granulation tissue and fibrin.
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Fig 2. Ringed PTFE prosthesis placed in connection with a bipulmonary Glenn anastomosis in a child with heterotaxy and situs inversus. Dissection of graft during Fontan completion 10 months later.
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The preformed spaces created by the removed prostheses (Fig 4 ) enabled the creation of the planned extracardiac vascular connection in every case. After creating an inflow from the right atrium into the extracardiac cavity next to the inferior vena cava, the pericardial tunnel was appropriately formed around the atrial wall utilizing the tissue gained by the stent, and finally anastomosed directly to the undersurface of the pulmonary artery. Angiography showed patency and growth of the extracardiac tunnels in 3 children, 5 to 12 months postoperatively. In the boy with retroaortic creation of a neopulmonary artery without native endothelium, obstruction occurred after 1 year, presumably due to preferential blood flow to the left pulmonary artery from the left-sided second Glenn anastomosis.
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Fig 4. Status after removal of the PTFE prosthesis. The underlying pericardium is intact and serves as a preformed tunnel for extracardiac establishment of a total cavopulmonary connection.
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Comment
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Placement of a ringed PTFE prosthesis into the pericardial cavity reliably prohibits adhesion of the pericardium to the heart and preshapes the tissue after staged palliation of congenital heart disease. The subsequent creation of extracardiac vascular connections is greatly facilitated by this technique.
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References
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Petrossian E., Reddy V.M., McElhinney D.B., et al. Early results of the extracardiac conduit Fontan operation. J Thorac Cardiovasc Surg 1999;117:688-696.[Abstract/Free Full Text]
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Gundry S.R., Razzouk A.J., del Rio M.J., Shirali G., Bailey L.L. The optimal Fontan connection. J Thorac Cardiovasc Surg 1997;114:552-559.[Free Full Text]
Accepted for publication June 18, 1999.
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Abstract
Introduction
