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Ann Thorac Surg 2001;72:1772-1773
© 2001 The Society of Thoracic Surgeons

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How to do it

Venous drainage with a single peripheral bicaval cannula for less invasive atrial septal defect repair

^a Department of Cardiovascular Surgery, University Hospital (CHUV), Lausanne, Switzerland

Accepted for publication June 13, 2001.

* Address reprint requests to Dr Tevaearai, Department of Cardiovascular Surgery, BH10, CHUV, rue du Bugnon 46, CH 1011 Lausanne, Switzerland
e-mail: hendrik.tevaearai{at}hola.hospvd.ch

	Abstract

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New peripheral venous cannulae have recently been proposed for minimally invasive open cardiac surgery. We present a femoral venous cannula designed to simultaneously drain both superior and inferior vena cavae. Used in adult patients for atrial septal defect repair, the cannula allowed passive blood drainage of 70.6% ± 11.7% of theoretical cardiac output. Drainage was augmented to 93.4% ± 8.6% of theoretical cardiac output by means of a centrifugal pump.

	Introduction

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Enthusiasm for minimally invasive cardiac surgery has motivated alternative strategies for cardiopulmonary bypass (CPB). For example, in order to avoid congestion of the minithoracic opening, the use of peripheral venous and arterial cannulae is today a common option for less invasive cardiac procedures [1]. Recently, single coaxial cannulae have been proposed to simultaneously drain both superior (SVC) and inferior vena cavae (IVC) via a peripheral access (Fig 1). In vitro, we demonstrated the ability of single coaxial cannulae to drain as much as 5 L/min when positioned into a narrow collapsible latex tubing (data not published). In this report, we describe method of use, performance, and adequacy of single coaxial cannulae in CPB during atrial septal defect (ASD) repair via a minithoracotomy.

View larger version (18K): [in this window] [in a new window]   Fig 1. Presentation of the coaxial Carpentier cannulae used in the present study. (A) 24–29 French. (B) 30–33 French.

	Technique

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The surgical procedure involves a standard right minithoracotomy through the fourth intercostal space. The pericardium is opened and a snare is passed around the SVC and the IVC. Venous cannulation is performed via the iliofemoral vein after full anticoagulation with 3 mg/kg heparin (Liquemin, Hoffmann-La Roche, Basel, Switzerland), using the Seldinger technique. The tip of the cannula is positioned under echographic assistance as well as under direct control via the minithoracotomy using finger palpation. It is critical that the distal holes are within the SVC while the proximal holes remain within the IVC. CPB is then initiated and blood drainage is optimized by a centrifugal pump (Medtronic Biomedicus, Eden Prairie, MN) placed on the venous line between the cannula and the cardiotomy reservoir. Augmented negative pressure on the venous line is continuously checked to remain between -60 and -80 mm Hg in order to avoid chattering and potential risk of collapse of the vein around the cannula [1, 2]. Ventricular fibrillation is induced and both vena cava are then snare occluded around the cannula before the right atrium is opened.

We recently used the bicaval Carpentier cannula in 16 consecutive adult patients in whom an ASD was repaired through a right minithoracotomy. In each case, insertion and positioning of the venous cannula could be performed without major difficulties. No complications related to the perfusion procedures were observed. A passive blood drainage of 3.1 ± 0.4 l/min or 70.6 ± 11.7% of theoretical cardiac output, could be augmented to 4.2 ± 0.6 l/min or 93.4 ± 8.6% of theoretical cardiac output (p < 0.0001) by means of the centrifugal pump. Perfusion was adequate as assessed by a normal venous saturation during CPB. Clinical evolution was normal and postoperative echocardiography confirmed complete ASD closure in each patient.

	Comment

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Minimally invasive cardiac surgery involving selective cannulation of both vena cavae can be safely and adequately performed via a minithoracotomy using a single two-stage peripheral venous cannula in combination with a centrifugal pump to augment venous return. In the present study, venous drainage approached theoretical cardiac output using this type of cannula, and perfusion was adequate as assessed by a normal oxygen venous saturation during the entire procedure.

Having one single cannula for bicaval drainage offers the advantage of reducing congestion of the minithoracotomy and, subsequently, provides the opportunity for better lighting and vision of the surgical field, and higher freedom of handling for surgical instruments. However, because the intermediate portion of the cannula, situated between the two perforated segments, passes through the atrium, it may, in some circumstances, restrict vision of the interatrial septum. In those cases, this portion of the cannula can be moved slightly, as long as none of the holes are pulled into the opened atrium.

Passive blood drainage through coaxial bicaval cannulae is limited similarly to what is observed with any other peripheral cannula. Therefore, the assistance of a centrifugal pump placed on the venous line, or vacuum applied on the venous reservoir is required. However, kinetic venous drainage is particularly delicate when selective caval drainage is necessary, such as during surgery involving right atrium opening. In fact, excessive negative pressure may provoke chattering and trapping of the vein walls around the cannula holes, thus compromising blood drainage and subsequent quality and safety of perfusion. Therefore, we recommend maintaining the negative pressure on the venous line to approximately -70 mm Hg, not only to reduce the risk of vein collapse [2], but also to avoid cavitation and hemolysis [3]. Increasing central venous pressure should be considered when choosing this CPB technique since it can limit the risk of vein collapse [2] and improve maximal drainage capacity of the cannulae used for selective caval drainage [2]. However, since venous pressure is altered by the artificially low pressure induced by the centrifugal pump, central venous pressure cannot be monitored during this type of CPB.

In conclusion, the coaxial bicaval peripheral venous cannulae used in conjunction with kinetic drainage allows safe and efficient CPB during surgery involving isolation and opening of the right atrium.

	Acknowledgments

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The authors thank Dr Andrea D. Eckhart for grammatical assistance in writing the manuscript.

	References

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1. Jegger D., Tevaearai H.T., Horisberger J., et al. Augmented venous return for minimally invasive open heart surgery with selective caval cannulation. Eur J Cardiothorac Surg 1999;16:312-316.[Abstract/Free Full Text]
2. Tevaearai H.T., Mueller X.M., Jegger D., Augsburger M., Stumpe F., von Segesser L.K. Optimization of the pump driven venous return for minimally invasive open heart surgery. Int J Art Organs 1999;22:684-689.
3. Gregoretti S. Suction-induced hemolysis at various vacuum pressures: implications for intraoperative blood salvage. Transfusion 1996;36:57-60.[Medline]

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This Article Abstract Full Text (PDF) 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): Hendrik T. Tevaearai Xavier M. Mueller Patrick Ruchat Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tevaearai, H. T. Articles by von Segesser, L. K. Search for Related Content PubMed PubMed Citation Articles by Tevaearai, H. T. Articles by von Segesser, L. K. Related Collections Extracorporeal circulation