Ann Thorac Surg 2006;81:1146-1147
© 2006 The Society of Thoracic Surgeons
How to do it
Total Cavopulmonary Connection: Open Anastomosis of an Extracardiac Conduit With Vacuum-Assisted Venous Drainage
Ryo Aeba, MD
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Ryohei Yozu, MD,
Masanori Morita, CP,
Toru Matayoshi, CP
Division of Cardiovascular Surgery, Keio University, Tokyo, Japan
Accepted for publication December 17, 2004.
* Address correspondence to Dr Aeba, Division of Cardiovascular Surgery, Keio University, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582 Japan (Email: aeba{at}sc.itc.keio.ac.jp).
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Abstract
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Insertion of a tube conduit for total cavopulmonary connection is sometimes technically demanding due to the crumpled stump of the inferior vena cava caused by a tourniquet of the inferior vena cava near the division line. Herein we describe an alternative in which the anastomosis is completed during removal of the tourniquet with the application of vacuum-assisted venous drainage. This new technique may alleviate, if not completely eliminate, a concern associated with total cavopulmonary connection with extracardiac conduit in small patients.
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Introduction
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Total cavopulmonary connection using an extracardiac conduit technique has become one of the most commonly used modifications of Fontan-type operations [1, 2]. However, the insertion of a tube conduit is sometimes technically demanding due to the crumpled stump of the inferior vena cava (IVC) caused by a tourniquet of the IVC near the division line. We present a new technique using an open anastomosis of the IVC and a tube conduit with the application of vacuum-assisted venous drainage.
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Technique
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After general anesthesia is administered and the patient is prepared and draped, a midline sternotomy is performed. For patients with a previous bi-directional cavopulmonary shunt the pericardial adhesions are dissected only around the IVC and the neighboring right branch pulmonary artery. Cardiopulmonary bypass is established after cannulation of the ascending aorta, superior vena cava, and IVC. Straight and pliable venous cannula (Thin-Flex Single Stage Venous Drainage Cannula [Edwards Lifesciences LLC, Irvine, CA]) are used. The tip of the IVC venous cannula is positioned as usual, 2 cm below the diaphragm level. A tourniquet is applied to the IVC at the diaphragm level. The IVC is divided at the cavo-atrial junction, and the atrial stump is primarily closed by sutures. A slightly oversized polytetrafluoroethylene tube graft is selected and trimmed. Venous drainage is augmented with a vacuum-assisted negative pressure of between 40 and 60 mm Hg. An air bubble sensor is interposed in the venous drainage tube to recognize excessive air drawing, which could potentially lead to air blockage of the tube. The tourniquet for the IVC is released in order to achieve an open anastomosis of the graft with the IVC. Essentially no venous blood is spilled from the IVC stump. The cardiotomy sucker tip is placed in the IVC lumen to further facilitate the bloodless anastomosis technique that is needed (Fig 1). The other end of the conduit is anastomosed to a transverse incision in the inferior aspect of the right branch pulmonary arterial wall. Again, vacuum-assisted venous drainage is potent enough to eliminate the need for vascular clamping of the pulmonary artery. Finally, cardiopulmonary bypass is terminated.
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Fig 1. Surgeon's view of an open anastomosis with a tube graft and the inferior vena cava stump. Note a full expansion of the inferior vena cava wall and the placement of the sucker in the inferior vena cava lumen, thus assuring the surgeon's more precise suture performance.
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Comment
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Extracardiac conduit total cavopulmonary connection has been increasingly accepted as the procedure of choice for modified Fontan operations, because the hemodynamic properties in the reconstructed systemic venous route are excellent, and the suture load on the atrial wall is minimal. These characteristics promise better long-term morbidity and mortality. As an increasing number of patients undergo total cavopulmonary connection at a younger age, a small-sized tube graft is inevitably implanted, although an over-sized tube graft is desirable for such growing patients. The conventional technique with a tourniquet of the IVC near the division line may result in a heavily crumpled IVC stump. This makes the end-to-end anastomosis technique of the IVC stump and the tube graft highly demanding, especially in cases with a significant size mismatch between the two. The open technique allows a full expansion of the IVC wall and the placement of the sucker in the IVC lumen, thus assuring the surgeon more precise suture performance in such a difficult situation.
The open technique with vacuum-assisted venous drainage has been used in adult patients undergoing cardiac transplantation with bi-caval anastomosis [3], in which the IVC drainage was through the femoral vein. In our case, a direct IVC cannulation rather than peripheral venous drainage was used because of the small sizes that were involved. Our experience shows that direct IVC cannulation does not necessarily exclude an open IVC technique. Potential drawbacks of this technique include air blockage of the circuit tube and failure to suck some of the hepatic venous blood. Each surgical team applying this technique should individualize the position and type of the IVC cannula to achieve optimal venous drainage.
In summary, open IVC anastomosis with vacuum-assisted venous drainage through direct access is a feasible, safe, and useful procedure even in pediatric patients. This new technique may alleviate, if not completely eliminate, a concern associated with extracardiac conduit total cavopulmonary connection in small patients.
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References
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- Azakie A, McCrindle BW, Van Arsdell G, et al. Extracardiac conduit versus lateral tunnel cavopulmonary connections at a single institutionimpact on outcomes. J Thorac Cardiovasc Surg 2001;122:1219-1228.[Abstract/Free Full Text]
- Nakano T, Kado H, Ishikawa S, et al. Midterm surgical results of total cavopulmonary connectionclinical advantages of the extracardiac conduit method. J Thorac Cardiovasc Surg 2004;127:730-737.[Abstract/Free Full Text]
- Aklog L, Sepic J, Filsoufi F, Byrne JG, Adams DH. Open inferior vena caval anastomosis during bicaval heart transplantation Ann Thorac Surg 2002;73:671-672.[Abstract/Free Full Text]
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Abstract
Introduction
