Ann Thorac Surg 2001;71:362-364
© 2001 The Society of Thoracic Surgeons
Case report
Simplified retrograde systemic perfusion for removal of air from the aorta in an infant
Si Chan Sung, MDa,
Hee Jae Jun, MDa,
Jong Soo Woo, MDa
a Department of Thoracic and Cardiovascular Surgery, Dong-A University Hospital, Pusan, South Korea
Accepted for publication March 22, 2000.
Address reprint requests to Dr Sung, Department of Thoracic and Cardiovascular Surgery, Dong-A University Hospital, 3-1, Dongdaeshin-Dong, Seo-Gu, Pusan 602-715, Korea
e-mail: scsung{at}mail.donga.ac.kr
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Abstract
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Total circulatory arrest with full venous drainage can result in air entering the arterial system through several possible sites such as the aortic cannulation site or collateral vessels. Air present in the arterial system during total circulatory arrest imposes a special problem. We describe a simple technique of short-term retrograde systemic perfusion to remove air from the arterial system before restarting systemic arterial perfusion after total circulatory arrest.
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Introduction
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Accidental introduction of air into the arterial system during cardiopulmonary bypass or after total circulatory arrest is a challenging problem. Many cases of iatrogenic air embolism during cardiopulmonary bypass were managed successfully by retrograde cerebral or systemic perfusion [1–3]. However, case reports in which retrograde systemic perfusion was used in small infants after total circulatory arrest for the removal of air from the arterial system are uncommon. We report such a case using a simple technique.
A 3.5-month-old male infant (weight 4.9 kg) was admitted for elective repair of total anomalous pulmonary venous connection with supracardiac drainage. After ligation of the patent ductus arteriosus through median sternotomy, routine aortic cannulation was performed at the distal ascending aorta and a right-angled venous cannula was inserted through the right atrial appendage. When rectal temperature reached 18°C after initiation of hypothermic cardiopulmonary bypass, the ascending aorta was clamped and cardioplegia was induced. Systemic perfusion was then ceased and the arterial line was clamped. Blood from the venous system was fully drained to the reservoir to obtain a bloodless field and the venous cannula was then removed. A large anastomosis between the common pulmonary vein and the left atrium was created. The atrial septal defect was closed by direct suturing technique. At the end of the procedure, a considerable amount of air appeared in the arterial circuit. We observed air bubbles originating from the ascending aorta. After completion of the intracardiac repair, we performed retrograde systemic perfusion to drive air out of the arterial system.
The patient was placed in the Trendelenburg position. The arterial circuit was divided between clamps and a Y-connector was connected to the arterial circuit. We did not remove the aortic cannula at this time because more air could enter the aorta due to persistent negative pressure. The venous cannula disconnected from the venous line was connected to an arm of the Y-connector. The main pulmonary artery was clamped. Subsequently, the venous cannula was reinserted into the right atrium through the previous cannulation site. Retrograde systemic perfusion was commenced as the central venous pressure was monitored closely and kept below 25 mm Hg. Then we removed the aortic cannula from the ascending aorta and gently enlarged the aortic cannulation site with a pair of small hemostatic forceps to ascertain free drainage of blood. We observed a large amount of dark blood draining from the ascending aorta (Fig 1). After 5 minutes of retrograde systemic perfusion, the arterial cannula was reinserted into the ascending aorta through the original aortic cannulation site while blood was still spilling due to the retrograde systemic perfusion. Shortly after aortic recannulation, the venous cannula was disconnected from the arterial circuit and reconnected to the venous line for drainage. The patient was rewarmed with resumption of full antegrade systemic perfusion.
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Fig 1. Removal of air from the ascending aorta with a simple technique of retrograde systemic perfusion.
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After procedures for the removal of air were performed, the aortic cross-clamp was removed and the patient was subsequently weaned from cardiopulmonary bypass uneventfully. He was extubated on the 2nd postoperative day and discharged home on the 9th postoperative day without neurologic or other complications. He is now 8 months old and has normal physical growth without any neurologic abnormality.
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Comment
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It is well known that air can enter the arterial system through many possible sites during total circulatory arrest. In our case, air most likely entered the aorta through the aortic cannulation site around the cannula due to the negative intraluminal pressure created by full venous drainage. Presence of air in the aorta is a challenging problem because it is not easy to remove air and air embolism can occur. The most effective method to remove air from the aorta during or after total circulatory arrest has not been established. However, there are many reports of successful management of iatrogenic massive arterial air embolism during cardiopulmonary bypass by retrograde systemic or cerebral perfusion [1–3]. It has been suggested recently that retrograde cerebral perfusion during aortic operation can reduce arterial embolisms in the central nervous system [4–6].
We think that air emboli might not reach small peripheral arteries in situations in which air enters the aorta during total circulatory arrest, which is somewhat different from that caused by the iatrogenic massive air embolism during cardiopulmonary bypass. Short-term retrograde systemic perfusion with Trendelenburg position seems to be enough to remove air in the aorta in this situation by making intraluminal pressure positive before recommencing antegrade systemic perfusion. Our technique is simple. We did not need to insert the cannula into the superior vena cava, but we employed the same venous cannula after clamping the main pulmonary artery. We also did not reverse the direction of the roller pump and did not use any modification of the bypass system except the use of a Y-connector in the arterial circuit. We think that our technique might be a good solution to this rare but troublesome problem after total circulatory arrest.
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References
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Abstract
Introduction
