Ann Thorac Surg 2002;74:917-919
© 2002 The Society of Thoracic Surgeons
Case report
Total cavopulmonary connection via a thoracotomy
Miwa Nanaumi, MDa,
Toshihide Asou, MD*a,
Yuko Takeda, MDa,
Zong-Bo Lin, MDa,
Kuniyoshi Ohara, MDa,
Hirokuni Yoshimura, MDa
a Department of Thoracic and Cardiovascular Surgery, Kitasato University School of Medicine, Kanagawa, Japan
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Asou, Department of Thoracic and Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa 228-8555, Japan
e-mail: asou{at}med.kitasato-u.ac.jp
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Abstract
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We report a patient who underwent a total cavopulmonary connection with an extracardiac conduit through a right thoracotomy. The thoracotomy approach was useful in circumventing possible hazardous complications at the sternal reentry for the completion of a staged Fontan due to previous mediastinitis in this patient.
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Introduction
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Recently, excellent early results of Fontan operations have been reported. One of the reasons for improved results may include the introduction of a bidirectional Glenn shunt as a two-staged approach [1]. There are, however, some disadvantages to the two-staged strategy, including possible hazardous complications of resternotomy [2]. Especially in patients who developed mediastinitis when the bidirectional Glenn shunt was performed, technical difficulties may be encountered due to severe adhesion and risk of possible recurrence of mediastinitis. To circumvent those risks, we completed the Fontan circulation via a thoracotomy approach in a patient who had developed mediastinitis after the bidirectional Glenn shunt was performed.
The patient was a 4-year-old boy with pulmonary atresia, intact ventricular septum, and right ventricle (RV)-dependent coronary circulation. He had previously undergone several palliative procedures including a right modified Blalock-Taussig (BT) shunt through a right thoracotomy and a left modified BT shunt. At the age of 3 years, he underwent a bidirectional Glenn shunt and ligation of the BT shunt via a median sternotomy. After an uneventful postoperative course, he developed mediastinitis, requiring several days of open drainage and irrigation before closing the sternum.
When he was admitted to the Kitasato University Hospital to complete the Fontan operation, he was 4 years old and his body weight was 11.2 kg. Preoperative catheterization study revealed a mean pulmonary artery (PA) pressure of 9 mm Hg and the systemic arterial oxygen saturation of 86%. Angiography showed a tiny RV with sinusoidal communications with both the right and left coronary arterial system. The left PA required reconstruction because it was stenotic and suspended by the previous left BT shunt graft.
Because of adhesion and the risk of possible recurrence of mediastinitis in the substernal lesion, we performed the left PA repair first via a left thoracotomy and, 10 days later, the completion of the Fontan operation via a right thoracotomy. When performing total cavopulmonary connection (TCPC) using an extracardiac conduit, the right chest was entered through the fourth intercostal space. The lungs were moderately adherent to the chest wall and the pericardium. We dissected the lungs as little as possible so as not to damage the parenchyma and rather directly approached the right PA and the inferior vena cava (IVC).
Because of the possible existence of RV-dependent coronary circulation in this patient, we conducted a veno-venous bypass with perfusion cannula into the right atrium (RA) and venous drainage cannula inserted into the IVC to prevent myocardial ischemia during bypass using the reported method [3] (Fig 1).
The IVC was clamped and transected distal to the clamp and the proximal stump was sewn with a 5-0 polypropylene suture while a partial veno-venous bypass was initiated. An 18-mm stretched Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) graft was anastomosed to the distal stump of the IVC in an end-to-end fashion, then to the right pulmonary artery in an end-to-side fashion after another drainage cannula was inserted into the superior vena cava.
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Fig 1. Via a right thoracotomy approach, the inferior vena cava (IVC) was divided at the junction between the right atrium (RA) and the IVC under a partial veno-venous bypass with a perfusion cannula into the right atrium and the venous drainage cannula inserted into the IVC. The proximal end of the IVC was closed and the distal end was sutured with an 18-mm stretched polytetrafluoroethylene (PTFE) graft which was interposed between the IVC and the right pulmonary artery. Because of the possible existence of the right ventricle-dependent coronary circulation, a veno-venous bypass was utilized. (Ao = ascending aorta; SVC = superior vena cava.)
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When the patient came off the cardiopulmonary bypass, the pressure gradient across the PA beds was severe with a PA pressure of 17 mm Hg and a RA pressure of 1 mm Hg. Therefore, we established a fenestration between the conduit and the RA using a 4-mm short Gore-Tex graft. The patient was transported to the intensive care unit (ICU) with a PA pressure of 11 mm Hg and extubated 2 hours after entering the ICU. The chest tube was removed 2 days after surgery. The postoperative course was uneventful and the arterial oxygen saturation was 95% at room air. The patient was discharged from the hospital on the 9th postoperative day. The echocardiogram showed that the fenestration had spontaneously occluded 2 months after the surgery.
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Comment
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Excellent midterm results have been reported since the introduction of several modifications for Fontan operation, such as total cavopulmonary connection [4], fenestrated Fontan [5], and two-staged approach [1]. Although the two-staged approach resulted in remarkable progress in early and midterm results of Fontan operation in high-risk patients [1], there might be several disadvantages associated with resternotomy. Dobell and Jain [2] reported a high incidence of catastrophic bleeding with high mortality during sternal reentry. Due to increased experience with resternotomy, however, the number of patients developing problems related to resternotomy is supposed to have decreased in recent years [6]. Nevertheless, there are some patients at definite risk during sternal reentry [6]. One of those risk factors might be previous mediastinitis. Although techniques have improved due to accumulated experience, resternotomy in a patient with a history of mediastinitis still might be a challenge due to severe adhesion and the risk of recurrent infection. To circumvent those problems at redo operation, we applied a thoracotomy approach in a patient with a history of mediastinitis. Undoubtedly, we believe that the thoracotomy approach should be useful in a patient who had been treated with an omental or muscle flap for mediastinitis.
Some surgeons are likely to use a thoracotomy approach for open heart surgery on the mitral valve and some congenital heart diseases [7]. We applied this thoracotomy approach to a Fontan operation in a patient who had a history of mediastinitis. The thoracotomy provided an excellent surgical view in anastomosing an extracardiac conduit between the inferior vena cava and the right pulmonary artery. An extracardiac conduit Fontan operation allowed the heart to beat during the procedure and prevent air from entering into the heart so as to circumvent the weakest point in a thoracotomy approach, de-airing [8]. One of the disadvantages is compression of the lungs. Since the lungs are important for Fontan circulation, they should be manipulated as little as possible when entering the chest which was adherent to the lungs because of the previous thoracotomy. Moreover, lungs should be inflated as soon as possible when the bypass is discontinued and the whole systemic venous blood started to pass through the lungs.
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References
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- Masuda M., Kado H., Shiokawa Y., et al. Clinical results of the staged Fontan procedure in high risk patients. Ann Thorac Surg 1998;65:1721-1725.[Abstract/Free Full Text]
- Dobell A.R., Jain A.K. Catastrophic hemorrhage during redo sternotomy. Ann Thorac Surg 1984;37:273-278.[Abstract]
- Asou T., Matsuzaki K., Matsui K., Karl T.R., Mee R.B.B. Veno-venous bypass to prevent myocardial ischemia during right heart bypass operation in PA, IVS, and RV dependent coronary circulation. Ann Thorac Surg 2000;69:955-956.[Abstract/Free Full Text]
- De Leval M.R., Kilner P., Gewelling M., Bull C., McGoon D.V. Total cavopulmonary connection: logical alternative to atriopulmonary connection for complex Fontan operations; experimental studies and early clinical experience. J Thorac Cardiovasc Surg 1988;96:682-695.[Abstract]
- Bridges N.D. Fenestration of the Fontan baffle: benefits and complications. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 1998;1:9-14.[Medline]
- Russell J.L., LeBlanc J.G., Sett S.S., Potts J.E. Risks of repeat sternotomy in pediatric cardiac operations. Ann Thorac Surg 1998;66:1575-1578.[Abstract/Free Full Text]
- Cherian K.M., Pannu H.S., Sankar N.M., et al. Thoracotomy approach for congenital and acquired heart defects: its possible applications in the current era. J Card Surg 1996;11:37-45.[Medline]
- Petrossian E.D., Reddy V.M., McElhinney D.B., et al. Early results of the extracardiac conduit Fontan operation. J Thorac Cardiovasc Surg 1999;117:688-696.[Abstract/Free Full Text]
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Abstract
Introduction
