Ann Thorac Surg 2000;69:955-956
© 2000 The Society of Thoracic Surgeons
How To Do It
Veno-venous bypass to prevent myocardial ischemia during right heart bypass operation in PA, IVS, and RV dependent coronary circulation
Toshihide Asou, MDa,
Kouji Matsuzaki, MDa,
Kanzi Matsui, MDa,
Tom R. Karl, MDa,
Roger B.B. Mee, FRACSa
a Department of Cardiovascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
Address reprint requests to Dr Asou, Department of Cardiovascular Surgery, Matsuyama Red Cross Hospital, 1 Bunkyo-cho, Matsuyama, Ehime 790-8524, Japan
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Abstract
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There is a risk of myocardial ischemia in patients with pulmonary atresia and intact ventricular septum associated with right ventricle dependent coronary circulation, especially during open heart operation. Cardiopulmonary bypass unloads the right ventricle, and thereby reduces the coronary perfusion pressure in an area that is wholly or partly dependent on the right ventricle. We present a veno-venous bypass technique to keep the right ventricle beating and ejecting to supply the oxygenated blood into the right ventricle dependent myocardium and consequently to prevent myocardial ischemia during right heart bypass operation.
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Introduction
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Right ventricle (RV) dependent coronary circulation is known to be one of the major risk factors for poor outcome in patients with pulmonary atresia (PA) and intact ventricular septum (IVS) [1, 2]. Although decompression of the RV in PA and IVS is necessary for RV growth before biventricular repair, it is usually considered to be contraindicated in the presence of the severe RV dependency of the coronary perfusion [2–5]. Surgical decompression of the RV leads to a decrease in the intracavitary RV pressure, and thus compromises the blood supply to the RV dependent myocardium. As a result, the RV dependent myocardium may develop ischemia or even infarction if there are not sufficient collateral arteries to the region. Further, even less extensive coronary abnormalities may lead to regional left ventricular dysfunction [4].
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Patients and methods
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Cardiopulmonary bypass (CPB) may also cause myocardial ischemia and intractable arrhythmias because it unloads and decompresses the RV, and thereby reduces the coronary perfusion pressure. Special attention, therefore, must be paid to the coronary perfusion in an area where the hypertensive RV is responsible for its coronary blood supply when CPB is employed. We present herein a simple method to prevent myocardial ischemia during right heart bypass operations in patients with PA, IVS and RV dependent coronary circulation.
Patient 1 had PA and IVS with RV dependent coronary supply. He suffered from congestive heart failure caused by high pulmonary blood flow after a right and a left Blalock-Taussig (BT) shunt. Coil embolization of the left BT shunt graft was attempted at the age of 2 months, but the coil migrated into the left pulmonary artery. Frequent ventricular fibrillation occurred while the CPB was utilized to remove the coil, and also in the intensive care unit afterward. The RV angiogram showed that the left anterior descending (LAD) artery was interrupted at the middle of its course, and was perfused retrogradely through the RV during systole (Fig 1A). The patient had a bidirectional cavopulmonary shunt (BCPS) using the technique of veno-venous CPB (below).
Patient 2 had PA and IVS. The RV angiogram in the neonatal period revealed that the LAD was interrupted at the middle of its course, while the proximal LAD was retrogradely opacified through the RV during systole and drained into the RV during diastole forming an RV to coronary fistula. The distal part of the LAD was perfused through the RV (Fig 1B). The patient underwent a modified BT shunt and a bidirectional cavopulmonary shunt at the age of 3 years. Ventricular fibrillation occurred immediately after he was weaned from CPB, necessitating the short-term assistance of the heart with CPB. Postoperative scintigraphy showed the perfusion defect in the anteroseptal region of the left ventricle, indicating that myocardial infarction was produced in the area in which the RV dependent coronary artery was perfused. The patient subsequently had a total cavopulmonary connection (TCPC) using the technique of veno-venous CPB. An extracardiac conduit was used to perform TCPC to keep the heart beating and not to open the right atrium (RA) in which the oxygenated blood was perfused.
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Technique
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This technique was applied in the 2 patients described above, who underwent a BCPS and an extracardiac TCPC, respectively. Both had preoperative documentation of RV dependent coronary circulation. Through a median sternotomy, venous cannulae were inserted directly into the superior and the inferior vena cavae. An arterial perfusion cannula was inserted into the RA to conduct a veno-venous bypass. RA pressure was monitored by an indwelling RA pressure line, which enabled the perfusionist to judge adequate filling of the atrium during veno-venous bypass. Normothermic CPB was started with caval snares tightened, and thus providing oxygenated blood to the right atrium (Fig 2). Hence, the RV was kept loaded and maintained to supply oxygenated blood to the coronary artery, which was wholly or largely dependent on the RV. In addition, the left ventricle was also kept loaded, and ejected the oxygenated blood into the systemic circulation. After the right heart bypass operation was completed, the veno-venous bypass could be easily weaned in both patients, and both had uncomplicated postoperative courses.
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Fig 2. A veno-venous bypass circuit is conducted by draining systemic venous blood through cannulas inserted into the superior and the inferior vena cava (SVC, IVC), and perfusing the right atrium (RA) with oxygenated blood from the cardiopulmonary bypass machine while the right arterial pressure was monitored. The right ventricle can keep beating, ejecting oxygenated blood into the right ventricle dependent coronary artery.
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Comment
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We have successfully applied the present technique to 2 patients with PA, IVS, and RV dependent coronary circulation for right heart bypass operations. Previously, both patients had experienced life threatening ventricular arrhythmias during or after CPB, when the venoarterial CPB method was employed. RV and aortic angiography had demonstrated coronary fistulae to the RV as well as the coronary occlusion distal to it at the middle of the left anterior descending coronary artery in both patients (Fig 1). In one patient, the postoperative myocardial scintigraphy clearly showed perfusion defects at the area where the RV was responsible for its coronary perfusion.
Our technique prevents the RV from being decompressed and maintains a flow of oxygenated blood. Consequently the RV dependent myocardium does not develop ischemia. With the present technique, the postoperative course was uneventful, without any sign of either myocardial ischemia or arrhythmias.
Another surgical option to circumvent myocardial ischemia in performing right heart bypass operation in a patient with PA, IVS, and RV dependent coronary circulation could be an off-pump technique. However, indications for performing a nonbypass approach are not well established. Furthermore, there will always exist a question about the safety of the nonbypass approach [6]. Therefore, the present proposed method should be still useful in any case with PA, IVS, and RV dependent coronary circulation.
We suggest that perioperative myocardial ischemia and life threatening arrhythmias should be prevented by our present method during right heart operation in patients with PA, IVS, and the RV dependent coronary circulation.
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References
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Accepted for publication November 8, 1999.
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Top
Abstract
Introduction
), which is retrogradely opacified through the right ventricle, is interrupted at the middle of its course (