Ann Thorac Surg 2009;87:e34-e36. doi:10.1016/j.athoracsur.2009.02.003
© 2009 The Society of Thoracic Surgeons
How To Do It
Bidirectional Glenn with Existing Transvenous Cardioverter-Defibrillator Leads
Christopher E. Mascio, MDa,*,
Christopher L. Johnsrude, MDb,
Edward S. Kim, MDb,
Erle H. Austin, III, MDa
a Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky
b Division of Pediatric Cardiology, Department of Pediatrics, University of Louisville, Louisville, Kentucky
Accepted for publication February 2, 2009.
* Address correspondence to Dr Mascio, Division of Thoracic and Cardiovascular Surgery, University of Louisville, School of Medicine, 201 Abraham Flexner Way, Ste 1200, Louisville, KY 40202 (Email: cmascio{at}ucsamd.com).
 |
Abstract
|
|---|
The population of patients with adult congenital heart disease is increasing. A significant number of these patients already have or will require placement of either a transvenous pacemaker or implantable cardioverter defibrillator. In addition to this, some with right ventricular dysfunction might benefit from volume unloading of the right ventricle by the construction of a superior cavopulmonary anastomosis. The usual technique for the bidirectional Glenn anastomosis precludes the presence of upper extremity transvenous hardware. We present a modified technique for the superior cavopulmonary anastomosis when pacing or cardioverter defibrillator leads are present.
|
Introduction
|
|---|
The most common group of birth defects are congenital heart defects, which occur in 8 of every 1000 births [1]. It is now estimated that adults with congenital heart disease outnumber children living with congenital heart disease [1]. Most children born with congenital heart disease undergo repair early in life. Many lesions require additional operations later in life, however, with some defects carrying a reoperation rate as high as 50% [2]. The presence of suture lines, patch fibrosis, and ventricular enlargement are substrates for troublesome dysrhythmias as these children age [3]. The prevalence of ventricular tachycardia has been reported to be as high as 14% in patients with tetralogy of Fallot, and ventricular tachycardia is thought to be the most common cause of sudden arrhythmic death in adults with congenital heart disease [3]. Scenarios similar to the patient that we present here are likely to increase in frequency in the near future.
A 57-year-old man with a history of congenital pulmonary stenosis presented with progressive cyanosis and erythrocytosis (hematocrit, 53%). His surgical history was significant for a Brock procedure (transventricular pulmonary valvotomy) at the age of 4 years. He also had a history of ventricular tachycardia, had undergone radiofrequency catheter ablation and placement of a transvenous implantable cardioverter defibrillator (ICD), and was being treated with antiarrhythmic agents.
An echocardiogram demonstrated a patent foramen ovale with right to left shunting, moderately depressed right ventricular function, moderate pulmonary insufficiency, and low normal left ventricular function. The patient required continuous supplemental oxygen and had severely limited exercise capacity due to his low oxygen saturation (resting oxygen saturation, 85%).
Because of his poor right ventricular function, simple closure of his patent foramen ovale was deemed inadequate to reduce cyanosis. We therefore decided to close the patent foramen ovale and perform both a superior cavopulmonary anastomosis and a pulmonary valve replacement. This would eliminate the right-to-left shunting and limit volume loading of the right ventricle. To preserve his preexisting transvenous ICD, the technique for the superior cavopulmonary anastomosis was modified.
|
Technique
|
|---|
After general anesthesia was initiated, the chest was prepared and draped and a repeat sternotomy was performed. The heart was completely dissected free from the pericardium, including the pulmonary arteries and the superior vena cava. Heparin was administered, and cannulation was performed in the aorta, the high superior vena cava, and the inferior vena cava. Cardiopulmonary bypass was commenced, and snares were placed around the superior vena cava and inferior vena cava cannulas. The heart was fibrillated and the right atrium was opened. The patent foramen ovale was closed with a running 4-0 polypropylene suture. The heart was defibrillated back into a sinus rhythm.
The modified bidirectional superior cavopulmonary anastomosis was performed next. The right pulmonary artery was controlled proximally and distally and was divided near the superior vena cava. The distal portion of the right pulmonary artery was anastomosed to the lateral/right side of the superior vena cava, and the medial portion of the right pulmonary artery was anastomosed to the medial/left side of the superior vena cava.
The ICD leads were visualized in the superior vena cava and avoided throughout creation of the superior cavopulmonary anastomosis. The pulmonary valve was then evaluated, and owing to extensive calcification, it was replaced with a 25 mm Carpentier-Edwards pericardial valve (Edwards Lifesciences, Irvine, CA). The roof of the right ventricular outflow tract was augmented with bovine pericardium.
Now that the patent foramen ovale was closed, the superior cavopulmonary anastomosis was complete, and the pulmonary valve was replaced, we then addressed the communication of the superior vena cava with the right atrium containing the ICD leads. An umbilical tape was placed between the superior cavopulmonary anastomosis and the right atrium and tied snugly around this portion of the superior vena cava to close this communication without compromising the integrity of the ICD leads (Fig 1).
View larger version (30K):
[in this window]
[in a new window]
|
Fig 1. Depiction of superior cavopulmonary anastomosis with existing implantable cardioverter defibrillator (ICD) leads. Illustration by CE Mascio. (RPA = right pulmonary artery; SVC = superior vena cava.)
|
|
The patient's postoperative course was complicated by a left pleural effusion, and he was discharged on postoperative day 11. He had normal oxygen saturation (> 93% without supplemental oxygen) and hematocrit, normal function of the ICD system, and markedly improved exercise tolerance.
He returned 2 years later for a cardiac catheterization and an electrophysiology study because of recurrent atrial tachycardia. Angiograms demonstrated patency of the superior cavopulmonary anastomosis and intact ICD leads traversing the anastomosis and continuing into the right atrium and right ventricle. Figure 2
demonstrates these structures before (Fig 2A) and after (Fig 2B) contrast injection. A trivial amount of contrast entered the right atrium after injection. The atrial tachycardia was eliminated with radiofrequency catheter ablation, and he is currently taking no antiarrhythmic medication. He does not require supplemental oxygen therapy and has normal exercise tolerance.
View larger version (81K):
[in this window]
[in a new window]
|
Fig 2. Angiography of the superior cavopulmonary anastomosis (A) before and (B) after contrast injection. (ICD = implantable cardioverter defibrillator; RPA = right pulmonary artery; SVC = superior vena cava.)
|
|
|
Comment
|
|---|
This report describes a modification of the bidirectional Glenn operation to preserve existing transvenous pacemaker or ICD leads. Glenn first reported his technique for a unidirectional superior cavopulmonary anastomosis in 1958 [4]. His original technique involved an off-bypass anastomosis between the end of the right pulmonary artery and the side of the superior vena cava. Once the anastomosis was complete, the superior vena cava was ligated just above its entrance to the right atrium.
Our procedure involved an end-to-side anastomosis of both ends of the right pulmonary artery to the superior vena cava. We also placed a tie around the superior vena cava just above the right atrium (Fig 1). A potential disadvantage to this technique is that laser extraction for endocarditis or lead malfunction would likely be difficult or impossible. We believe that these situations would necessitate either a repeat sternotomy or thoracotomy and placement of epicardial leads. The risk of thrombosis with this technique is unknown, and we chose to discharge this patient with warfarin therapy for 3 months because of his unique anatomy and bioprosthetic pulmonary valve.
This technique could become increasingly applied as the number of adults with congenital heart disease increases, especially given the progressive risks for life-threatening arrhythmias in these patients. Specifically, adults with a history of right heart pathology as children frequently have an indwelling ICD in addition to right ventricular dysfunction. This approach allows unloading of the right ventricle to occur without disturbing the ICD leads.
|
References
|
|---|
- Williams RG, Pearson GD, Barst RJ, et al. National Heart, Lung, and Blood Institute Working Group on research in adult congenital heart disease Report of the National Heart, Lung, and Blood Institute Working Group on research in adult congenital heart disease J Am Coll Cardiol 2006;47:701-707.[Abstract/Free Full Text]
- Monro JL, Alexiou C, Salmon AP, Keeton BR. Reoperations and survival after primary repair of congenital heart defects in children J Thorac Cardiovasc Surg 2003;126:511-520.[Abstract/Free Full Text]
- Walsh EP. Interventional electrophysiology in patients with congenital heart disease Circulation 2007;115:3224-3234.[Free Full Text]
- Glenn W. Circulatory bypass of the right side of the heart. IV. Shunt between superior vena cava and distal right pulmonary artery—report of the clinical application. N Engl J Med 1958;259:117-120.[Medline]
Top
Abstract
Introduction
