Ann Thorac Surg 2002;73:280-282
© 2002 The Society of Thoracic Surgeons
Case report
Multidose cardioplegia in a complex arterial switch procedure
Renee S. Hartz, MD*a,
Serafin Y. DeLeon, MDa,
Jaime G. Dorotan, MDa,
Elaine M. Urbina, MDa
a Department of Surgery and Division of Pediatric Cardiology, Tulane University Medical Center and Tulane University Medical School, New Orleans, Louisiana, USA
Accepted for publication March 27, 2001.
* Address reprint requests to Dr Hartz, Tulane University Medical Center, Department of Surgery, 1430 Tulane Ave, SL22, New Orleans, LA 70112, USA
e-mail: rhartz{at}tulane.edu
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Abstract
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Integrated cardioplegia techniques have gained wide acceptance by surgeons performing adult cardiac surgery, because patients being referred are likely to have poor ventricular function and energy-depleted hearts. In addition, the increasing complexity of available procedures has led to an increased threat of reperfusion injury and calcium contracture ("stone heart") after prolonged ischemia. In this report, we describe the case of a newborn with transposition of the great arteries that survived almost 6 hours of ischemic time and has normal ventricular function postoperatively. We attribute this outcome to the myocardial protection employed throughout the procedure which allowed successful correction of a technical problem.
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Introduction
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Improvements in cardioplegia composition and delivery have dramatically improved outcomes of complicated cardiac surgical procedures. Although less literature exists concerning various cardioplegia delivery systems in infants than in adults, we believe that the lessons learned in surgery for acquired heart disease can often be applied to congenital cardiac surgery. In this regard, we believe in an integrated approach, ie, one that allows various combinations of warm, cold, antegrade, retrograde, continuous and intermittent cardioplegia. The following case report illustrates successful application of these techniques in a newborn undergoing surgery for transposition of the great arteries.
A 1-day-old 3100-gram infant presented to our newborn unit with cyanosis and was being maintained on a prostaglandin infusion (0.05 µg/kg/min). Echocardiography revealed typical d-transposition of the great arteries (DTGA). However, both coronaries appeared to arise from the right posterior sinus with the left coronary traversing between the aorta and pulmonary artery. The surgical decision was made to proceed with the arterial switch procedure but to convert to an atrial switch operation if there proved to be a single coronary ostium.
Operation was performed at 6 days of life. External observation revealed that the left coronary artery appeared to be coming off separately from the left posterior sinus, so we elected to proceed with the arterial switch procedure. Cardiopulmonary bypass was initiated through a single venous cannula in the right atrial appendage and the patent ductus arteriosus was divided. The aorta was clamped and antegrade cold blood cardioplegia ("Induction" in Table 1)
was given. The right atrium was opened and bicaval cannulation was accomplished through the atriotomy. The left side was vented through the atrial septal defect with an intracardiac suction device, and retrograde cardioplegia was given through a hand-held cardioplegia catheter (9 Fr) (Edwards Lifesciences, Irvine, CA) which was repeated at 15 to 20 minute intervals. Topical cooling was also employed.
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Table 1. Components of Induction (and Maintenance) Cardioplegia and of Warm Reperfusate ("Buckberg") Cardioplegiaa
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Following transection of the aorta, a dimple in the left posterior coronary sinus (sinus 1) created the false impression that the left coronary artery arose at this location (Fig 1).
In developing the coronary button for the right coronary artery, the left coronary remained with very little rim of aortic wall. The right coronary artery had a good aortic cuff. After a straightforward right coronary reimplantation to the right anterior sinus of the pulmonary artery, a tedious end-to-end anastomosis of the left coronary artery to the left anterior sinus was performed. Warm antegrade cardioplegia was given following an ischemic time of 246 minutes at moderate systemic hypothermia (28°C). The aortic cross-clamp was then removed and, at this time, the right ventricle was pink and well perfused but the left ventricle was blue-black and tense. There was no notable cardiac electrical activity.
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Fig 1. Coronary anatomy. Note "dimple" in left sinus which created the impression of a separate left ostium. (Ao = aorta; L = left; PA = pulmonary artery; R = right.)
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When it became clear that the anastomosis for the left coronary artery was stenotic, the cross-clamp was reapplied. One dose of antegrade cold cardioplegia was given, followed by cold retrograde every 15 to 20 minutes. The anastomosis was enlarged by incising the neoaorta, and extending the incision through the anastomosis into the proximal left coronary artery. A piece of a pericardium was excised and used as a patch to enlarge the coronary artery anastomosis. Following an additional ischemic time of 96 minutes, warm substrate-enhanced cardioplegia ("Reperfusate" in Table 1) was given antegrade and retrograde. Cardiopulmonary bypass support was continued for an additional 70 minutes, after which the patient was successfully weaned from cardiopulmonary bypass. Total cardiopulmonary bypass time was 489 minutes and ischemic time was 343 minutes.
The left ventricle appeared well perfused and there was good contractility of both ventricles on transesophageal echocardiography. Inotropes consisted of isoproterenol (0.05) mcg/kg/min, dopamine (5 mg/kg/min) and milrinone (0.5 mg/kg/min). The sternum was left open and the skin was closed with a thin Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) patch.
The postoperative course was uneventful and inotropes were weaned over 24 hours. Transesophageal echocardiogram, repeated on postoperative day 3 during the delayed sternal closure, showed good biventricular contractility and normal (E to A ratio 1.5). Cardiac catheterization performed at 9 months of age demonstrated normal left ventricular function (Fig 2)
and patent left coronary artery anastomosis.
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Comment
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Over 10 years ago, we reported the advantages of single versus multiple dose cardioplegia for the arterial switch operation [1]. At the time, there was a definite incidence of coronary artery injury using the stiff catheters available for direct coronary perfusion. However, improvements in retrograde catheters have allowed their safe use in neonates, therefore providing surgeons an unhurried repair of complex lesions.
More recently, we reported that an "integrated" cardioplegia approach allows most patients to safely undergo complex cardiac surgical procedures [2], and have strongly encouraged surgeons not to rely on a single type of cardioplegia delivery for all cases. Specifically, we have demonstrated that retrograde cardioplegia does not protect the right ventricle when the catheter is advanced distally in the coronary sinus [3], and that energy-depleted hearts require resuscitation before a period of ischemia [4]. Although the technique used in our patient was not completely "integrated" (no warm induction was given), the combination of antegrade, retrograde, warm, and cold was undoubtedly important. A total of 2,740 mL of blood cardioplegia (4:1) was administered to this 3-kg neonate, of which 640 mL were warm reperfusate. The "hot shot" coupled with a long period of vented normothermic bypass resuscitated the myocardium sufficiently that extracorporeal membrane oxygenation and high-dose inotropes were avoided.
We report this case as an example of successful salvage of a patient who would probably have otherwise expired, and attribute the outcome to a myocardial protection strategy which allowed timely and aggressive correction of a technical problem. Congenital heart surgery teams, especially perfusion staff, must have thorough knowledge of all types of cardioplegia delivery systems, and must be prepared to deliver the various additives required to replete an energy-depleted heart.
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References
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DeLeon S., Idriss F.S., Ilbawi M.N., et al. Comparison of single versus multidose blood cardioplegia in arterial switch procedures. Ann Thorac Surg 1988;45:548-553.[Abstract]
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Allen B., Murcia-Evans D., Hartz R. Integrated cardioplegia allows complex valve repairs in all patients. Ann Thorac Surg 1996;62:23-30.[Abstract/Free Full Text]
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Allen B., Winklemann J., Hanafy H., et al. Retrograde cardioplegia does not perfuse the right ventricle. J Thorac Cardiovasc Surg 1995;109:1116-1126.
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Hanafy H., Allen B., Winklemann J., et al. Warm blood cardioplegic induction: an underused modality. Ann Thorac Surg 1994;58:1589-1594.[Abstract]
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Abstract
Introduction
