Bicaval Cannulation Research Articles

Peripheral vs. Central Cannulation in Cardiac Reoperations: Technical Considerations and Outcomes.

ObjectiveTo compare peripheral and central cannulation techniques in cardiac reoperation.MethodsThis retrospective study included 258 patients undergoing cardiac reoperation between January 2013 and July 2018. Patients were divided into two groups according to the cannulation type. The first group included 145 (56.2%) patients operated with standard central cannulation through aorta and right atrium or bicaval cannulation. In this group, cardiopulmonary bypass was instituted after sternotomy. The second group consisted of 113 (43.8%) patients operated with peripheral cannulation through femoral artery, vein, and internal jugular vein. In this group, cardiopulmonary bypass was started before sternotomy and after systemic heparinisation. The two groups’ operative complications and postoperative outcomes were compared.ResultsProcedure-related injury was higher in the central cannulation group than in the peripheral cannulation group (8.3% vs. 1.8%, respectively, P=0.038). Cardiopulmonary bypass time was shorter in the central cannulation group (P=0.008) and total operation time was similar between the groups (P=0.115). Postoperative red blood cell requirement was higher with central cannulation (P=0.004). Operative mortality (2.8% vs. 0, P=0.186), hospital mortality (4.3% vs. 2.7%, P=0.523), and one-year survival rate (90.3% vs. 94.7%, P=0.202) were similar between the groups.ConclusionPeripheral cannulation reduces cardiac injury and blood transfusion in cardiac reoperation. The cannulation type does not affect postoperative complication, mortality, and one-year survival.

Four hours of veno-venous extracorporeal membrane oxygenation using bi-caval cannulation affects kidney function and induces moderate lung damage in a mouse model

BackgroundImprovement of single site cannulation for extracorporeal membrane oxygenation (ECMO) therapy is pivotal for reduction of patient morbidity and mortality in respiratory failure. To further improve the cardiopulmonary outcomes and reduce end organ damage, we established a murine model for single site cannulation with a double lumen cannula.ResultsWe created a hemodynamically stable double lumen cannula and successfully implanted it through the jugular vein into the upper and lower vena cava. This allowed adequate drainage of the blood. Blood gas analysis showed excellent oxygenation and CO2 reduction. There was no excessive bleeding. No signs of right heart congestion were present which was confirmed in the histological analysis of the liver. Histology demonstrated moderate lung damage and mild acute kidney injury. Neutrophil infiltration was similar in ECMO and sham kidneys.ConclusionsVeno-venous extracorporeal circulation deteriorates kidney function and promotes moderate pulmonary damage.

Lung transplantation for pulmonary hypertension with giant pulmonary artery aneurysm

BackgroundAneurysm of the main pulmonary artery trunk (PAA) is a rare but severe complicating factor in patients suffering from pulmonary arterial hypertension (PAH). Many centers consider PAA an indication for a heart-lung transplantation. We aimed to summarize our institutional experience with a lung-only strategy in this complex group of patients. MethodsWe performed a retrospective single-center analysis of patients with PAH and a severe PAA who underwent lung transplantation between January 1996 and November 2018. ResultsA total of 127 patients with PAH underwent lung transplantation during the study period. Seven patients presented with severe PAA (mean diameter, 70.4 mm). Donor lungs were procured together with the main pulmonary artery (PA). In the recipient, cardiopulmonary bypass with bicaval cannulation was established, and bilateral pneumonectomy together with resection of the entire PA trunk was performed. The right donor lung was implanted, and the attached PA trunk was pulled through behind the superior vena cava and ascending aorta. Anastomosis was performed just above the level of the pulmonary valve. Thereafter, the left lung was implanted by reconnecting the left PA to the main PA trunk. All but 1 patient, who died from sepsis on postoperative day 13, were successfully discharged. ConclusionsTo the best of our knowledge, this is the largest published experience of patients with PAH and severe PAA who underwent lung transplantation. We show that these patients are eligible for double lung transplantation and do not require heart-lung transplantation.

Intensivists Performed Percutaneous Bicaval Double-Lumen Echo-Guided Extracorporeal Membrane Oxygenation Cannulation at Bedside in Newborns and Children: A Retrospective Analysis.

To describe a single institution experience on echo-guided percutaneous bicaval double lumen extracorporeal membrane oxygenation cannulation performed at the bedside by intensivists. Retrospective observational study. Extracorporeal membrane oxygenation team of a tertiary care children's hospital. All patients 0-14 years old undergoing venovenous extracorporeal membrane oxygenation from January 1, 2013, to January 1, 2018. None. Thirty children underwent 32 extracorporeal membrane oxygenation runs. Median age at enrollment was 2 months (interquartile range, 0-20.5 mo), 65.6% of the runs (21 patients) were performed in newborns (n = 13, 40.6%) or infants (n = 8, 25%). Median preextracorporeal membrane oxygenation index was 66.9 (interquartile range, 50-85.6). Major comorbidities were present in 50% of patients. All patients were cannulated percutaneously. In two cases cannulation occurred from the left internal jugular vein. Extracorporeal membrane oxygenation was effective in increasing pH, arterial oxygen saturation, PaO2, and lowering PaCO2. The overall differences in pre and postextracorporeal membrane oxygenation values were statistically significant, while stratifying patients according to the cannula diameter (mm)/major diameter of the cannulated internal jugular vein (mm) ratio (> 0.67 or ≤ 0.67), statistical significance was reached only for the highest ratio. Complications were observed in three runs: two cannula tip dislocations in the right atrium and one limited flow in the only case in which an Avalon cannula was not used. In 20 cases (62.5% of 32 runs), the cannulated vessel was patent at follow-up or autopsy. A ratio less than or equal to 0.67 or greater than 0.67 did not influence the occurrence rate of complications, nonpatency of the internal jugular vein, death for intracranial bleeding and death at 30 days from extracorporeal membrane oxygenation discontinuation. Overall cumulative survival at 30 days from extracorporeal membrane oxygenation discontinuation was 60% (95% CI, 40-75), with a survival advantage in the case of ratio greater than 0.67 (65%; 95% CI, 44-80 vs 25%; 95% CI, 0-60). The described technique proved to be feasible, safe, and effective. Further investigation is needed.

Complicated Evolution of Superior Vena Cava Syndrome Post Cardiac Surgery

Introduction: Superior vena cava syndrome (SVCS) is the clinical manifestation of superior vena cava (SVC) obstruction, with a severe reduction in venous backflow to the right atrium. Symptoms classically include neck, facial and upper limb swelling, development of swollen collateral veins on the front of the chest wall, shortness of breath, coughing, headache, stridor and other neurological complaints, which may all be exacerbated by different postures. CASE REPORT: A 31-year-old man, with a sinus venosus atrial septal defect (SVASD) and partial anomalous pulmonary venous return (PAPVC), was undergone to surgery, in the postoperative course showed a superior vena cava syndrome (SVCS). A second surgery to solve this complication was performed nevertheless, some days after this intervention, the patient developed SVCS symptom’s once again. A new strategy with a large stent implantation in the superior vena cava had acceptable results. The patient kept asymptomatic during four months. Discussion: This syndrome is a rare complication after cardiac surgery; it is associated mostly with bicaval cannulation; various causes such as localized hematoma, swollen absorbable hemostat, and narrowing of the SVC by surgical sutures have been reported. There are no exact guidelines for the clinical management of SVCS. The treatments include long-term anticoagulation, thrombolysis, percutaneous transluminal balloon angioplasty, stent implantation, and open surgical reconstruction. CONCLUSION: This article highlights the importance of bear in mind the potential risk of SVCS during cardiac surgery with bicaval cannulation, whereby the proper precautions must be taken into account. Another outstanding fact of this case report shows the value of working with interventional cardiology department as a team to reach successful results in the benefit of the patients.

VD11 FROZEN ELEPHANT TRUNK BY USING E-VITA PROSTHESES AND BENTALL PROCEDURE IN A GIANT DESCENDING THORACIC AORTA ANEURYSM

We present the case of a 54-year-old male patient with a 12 cm post-decoarctation aneurysm of the descending thoracic aorta with bicuspid aortic valve stenosis and ventricular septal defect. Right femoral artery and bicaval cannulation were used for Cardiopulmonary bypass. Antegrade cerebral perfusion with moderate hypotermia (25°C) was achieved with the innominate and left carotid artery cannulation. The aortic arch replacement was performed by using Frozen Elephant Trunk technique with a 40 mm E-Vita Open Plus prosthesis and a separated Plexus 4-branches prosthesis. The reimplantation of the left subclavian artery was performed by a 9 mm Gore hybrid vascular graft. A St.Jude 23 mm mechanical valve conduit was used for the Bentall procedure. The ventricular septal defect was closed with direct suture. Cardiopulmonary bypass, aortic cross-clamp and cerebral perfusion times were 258,186 and 109 minutes, respectively. Post-operative course was uneventful and CT scan showed the good result of the procedure.

Surgical Treatment of Cardiac Myxomas: A 23-Case Experience

Although seen rarely compared to all tumors, cardiac tumors are tumors which may have a mortal course with possible complications. The most common cardiac tumor in adults is myxoma with its benign character. The results of cardiac tumors resected with open cardiac surgery in our center are reported in this study. Twenty-three cardiac tumor patients electively operated on in our clinic between January 2010 and August 2017 were retrospectively included in the study. Information of the patients participating in the study were registered. The patients were between 25 and 67 years of age, and 18 were female (72.3%), and 5 were male (21.7%). The average age of the patients was 42.1 ± 8.9 years. Echocardiography was used for diagnosis in all patients. There was no common complaint for the patients, with the complaints changing according to tumor location. All patients were operated on by means of cardiopulmonary bypass with aortic cross-clamp and bicaval cannulation. Preoperative demographical characteristics and perioperative and postoperative data were registered for the patients and were evaluated statistically. Nineteen of the tumors (82.6%) were in the left atrium, and 4 were (17.4%) in the right atrium. Diameter of the tumors changed between 2.5 × 1.5 and 8.5 × 6.5 cm. The tumoral structure was resected together with the solid tissue located in its root in all patients operated on. Pericardial patch was used for 11 (47.8%), and primary closure was used for 12 (51.2%) of the defects. Early and late mortality was not observed in any patient. To prevent possible complications of cardiac myxomas, they need to be resected together with the surrounding healthy tissue as soon as possible after the diagnosis. Cardiac myxomas can be operated on with a tolerable operation risk. Echocardiography should be made annually for any possible relapse after operation.

Lipomatous hypertrophy of the atrial septum \u2013 a benign heart anomaly causing unexpected surgical problems: a case report

BackgroundLipomatous hypertrophy of the atrial septum (LHAS) is an anomaly of the heart. It is characterized by an infiltration of adipocytes into myocytes of the interatrial septum, sparing the fossa ovalis, which gives a characteristic hourglass-shaped image. Due to the progress in imaging techniques, it can be recognized more frequently, but it is still often misdiagnosed.Case presentationWe present a case of 65-year-old woman with an incidentally discovered lipomatous hypertrophy of the atrial septum during cardiac surgery, which has caused the technical problems for surgeons with bicaval cannulation and visualization of the operated structures of the heart. Due to the unclear shadow in the lung parenchyma, the patient had preoperative computed tomography (CT) done, but the study report focused only on the lung description, neglecting visible changes in the structure of the heart. Based on the standardly performed intra-operative transesophageal echocardiography (TEE), as well as by analyzing the chest X-ray and CT scans, the diagnosis of LHAS was made. It allowed the surgeon to leave the mass intact, thus not increasing the risk of the baseline surgery.ConclusionsLHAS is a rare but increasingly recognized anomaly of the heart. Contemporary diagnostic methods allow to diagnose and make the right therapeutic decisions. The utility of TEE and analysis of X-ray images, in this case, allowed the surgeon to recognize LHAS, and because of its histologically benign nature and asymptomatic course, to leave this change intact. Surgical treatment should be limited only to cases of patients with life-threatening cardiovascular complications.

Early outcome of mini aortic valve replacement surgery

BackgroundMinimally invasive aortic valve surgery (MIAVS) has evolved into a well-tolerated, efficient surgical treatment option in experienced centers, providing greater patient satisfaction and lower complication rates. Potential advantages of MIAVR arise from the concept that patient morbidity and potential mortality could be reduced without compromising the excellent results of the conventional procedure which include improved cosmetic results, safer access in the case of reoperation, less postoperative bleeding, lower intensive care unit (ICU) and in-hospital stays, as well as the absence of sternal wound infection. These results were achievable also in high-risk patients. Reduced pain and hospital length of stay, decreased time until return to full activity and decreased blood product use have also been demonstrated. MethodsSixty patients with aortic valve disease randomized into two equal groups; group “A” underwent aortic valve surgery through a minimally invasive limited upper sternotomy. Group “B” underwent aortic valve surgery through a full median sternotomy. The Pain was evaluated on 2nd, 3rd day post-operatively and at the 3rd, 6th month after discharge. Echocardiographic data were performed preoperatively and at the 3rd, 6th month after discharge in all patients. Standard aortic and bicaval cannulation with cold antegrade crystalloid cardioplegia was adopted in group“B”, while in group “A” femoral vein with ascending aortic cannulation was adopted with antegrade blood cardioplegia. ResultsThere was no statistical difference between the two groups preoperatively regarding their age, sex, NYHA class, EF%, LA dimension, spirometric study. There was no operative mortality in both groups but few postoperative complications occurred in both groups. Total hospital stay, ICU stay, postoperative bleeding, inotropic requirement, ventilatory support, blood transfusion was less in group “A”, with better cosmetic appearance, and more cost effective. ConclusionsLimited upper sternotomy minimally invasive technique for aortic valve replacement provides excellent exposure of the aortic valve and offers a better cosmetic scar. In addition, minimally invasive limited upper sternotomy is as safe as full median sternotomy for aortic valve surgery, with fewer complications and postoperative pain, less ICU and hospital stay, fast recovery to work with limited movement restriction after surgery. It is better to use the limited upper sternotomy incision as an initial approach for aortic valve surgery.

Modification in Surgical Plan following Intraoperative Detection of Co-existent Right Atrial Thrombus by Transesophageal Echocardiography in Chronic Constrictive Pericarditis

ABSTRACT Introduction Chronic constrictive pericarditis (CCP) is common in developing countries, tuberculosis being the most common cause. Dyspnea and congestive symptoms are the most common nonspecific presenting symptoms that require further evaluation for clinching the diagnosis. Coexistent right atrial (RA) thrombus and CCP are rare occurrences. Preoperative detection of RA thrombus is very important to avoid the risk of pulmonary thromboembolism during pericardiectomy or cannulation for establishing cardiopulmonary bypass (CPB). Perioperative echocardiography may play a crucial role in this setting. We report a case of CCP in which preoperative transesophageal echocardiography (TEE) detected RA thrombus that led to change in surgical plan and provided continuous monitoring during surgery. Case Report A 14-year-old male presented with a history of abdominal distension and pedal edema for 5 months. Physical examination revealed raised jugular venous pulse with normal heart sounds and no murmurs. Transthoracic echocardiography (TTE) revealed constrictive physiology and thickened pericardium. After induction of anesthesia, TEE revealed an irregular hyperechoic mass (50 × 36 × 30 mm) in the RA free wall that was not detected on preoperative TTE and computerized tomography (CT). Thickened pericardium all around mandated limited pericardiectomy under TEE guidance to allow bicaval cannulation for establishing CPB. This was followed by surgical removal of the thrombus and remaining pericardiectomy using CPB. His postoperative period was uneventful and the patient was discharged home on postoperative day 7. Conclusion The TEE may be instrumental in diagnosis of coexistent RA thrombus in the case of CCP resulting in major change in surgical plan and providing perioperative monitoring to avert significant morbidity and mortality. How to cite this article Ganesan R, Kumar B, Munirathinam GK, Bhat I, Mahajan S. Modification in Surgical Plan following Intraoperative Detection of Co-existent Right Atrial Thrombus by Transesophageal Echocardiography in Chronic Constrictive Pericarditis. J Perioper Echocardiogr 2017;5(1):34-37.

Veno-venous extracorporeal membrane oxygenation: cannulation techniques.

The development of extracorporeal membrane oxygenation (ECMO) technology allows a new approach for the intensive care management of acute cardiac and/or respiratory failure in adult patients who are not responsive to conventional treatment. Current ECMO therapies provide a variety of options for the multidisciplinary teams who are involved in the management of these critically ill patients. In this regard, veno-venous ECMO (VV-ECMO) can provide quite complete respiratory support, even if this highly complex technique presents substantial risks, such as bleeding, thromboembolic events and infection. While VV-ECMO circuits usually include the cannulation of two vessels (double cannulation) in its classic configuration, the use of a single cannula is now possible for VV-ECMO support. Recently, experienced centers have employed more advanced approaches by cannulating three vessels (triple cannulation) which follows veno-arterio-venous (VAV) or veno-arterio-pulmonary-arterial cannulation (VAPa). However, 'triple' cannulation expands the field of application but increases the complexity of ECMO systems. In the present review, the authors focus on the indications for VV-ECMO, patient assessment prior to cannulation, the role of ultrasound-guided vessel puncture, double lumen single bicaval cannulations, and finally triple cannulation in VV-ECMO.

Left Brachiocephalic Vein Cannulation in Bicaval Venous Drainage Is Safe, Effective, and Technically Advantageous.

Direct cannulation of both venae cavae (bicaval venous cannulation) is the gold standard for right atrial isolation in intracavitary surgery, but there has been no consensus about an alternative site. Therefore, we studied an alternative method for bicaval venous drainage in which the left brachiocephalic vein (LBCV) is cannulated instead of the superior vena cava. From 2012 through 2014, we performed routine LBCV cannulation in 150 consecutive patients as part of bicaval venous drainage before right atrial isolation. We prospectively collected demographic information, operative data, total pump and LBCV cannula flows with their respective calculated and indexed rates, central venous pressures, and perioperative complications. All patients survived surgery. There were no adverse technical outcomes or functional deficits associated with the technique. The mean indexed LBCV cannula flow was 1,520 ± 216 mL/min/m(2), representing an LBCV cannula-to-calculated pump-flow ratio of 64%. The mean central venous pressure during right atrial isolation was 3.7 ± 1.9 mmHg. Cannulation of the LBCV is intrinsically a safe and reproducible procedure with proven hemodynamic adequacy. Its versatility can be an asset to surgical techniques and perfusion methods. Furthermore, the hemodynamic results in our series promise alternative intrathoracic and extracardiac cannulation sites for mini-extracorporeal circulation, on-pump beating-heart procedures, and short-term circulatory assist device implementation.

Surgical Unroofing for Anomalous Aortic Origin of Coronary Arteries

Anomalous aortic origin of a coronary artery (AAOCA) from an opposite sinus of Valsalva is an uncommon congenital defect that is typically only discovered on cardiac catheterization or on autopsy following sudden cardiac death. Conjectured mechanisms for the ischemia are generally believed to relate to the unique and easily obstructed geometry of the coronary ostium and the stenotic intramural coronary segment. Given the potentially devastating consequences of not repairing an AAOCA—that is, sudden cardiac death—these patients should undergo repair of the anomaly when it is discovered. Multiple options for surgically correcting the AAOCA have been developed, and the most used approaches include coronary artery bypass grafting, coronary reimplantation, and unroofing of the intramural segment. Here we present the technique for surgical unroofing of the intramural segment of an anomalous coronary artery of aortic origin.

Ablation Via the Left Atrial Appendage

Despite its proven efficacy, the left atrial lesion set of the Cox-maze III operation is not universally employed during coronary artery bypass or aortic valve surgery for patients with atrial fibrillation, in part due to the surgeon's reluctance to add bicaval cannulation and a left atriotomy not needed for the primary procedure.

Surgical repair of inferior sinus venosus defects: a novel approach with unsnared inferior vena cava.

BackgroundInferior sinus venosus defects (SVD) are very rare and difficult to image from transthoracic echocardiography. Surgical errors were occasionally reported in the repair of inferior SVDs.ResultsThe authors have operated on 12 inferior SVD patients using bicaval cannulation with unsnared inferior vena cava (IVC) and proved successful.ConclusionThis technique guaranteed a better exposure of surgical field and facilitate identifying the anatomical relationship between lower part of the SVD and IVC orifice, thus avoiding postoperative IVC - left atrial shunt and other surgical mistakes.

Surgical treatment of infra-cardiac total anomalous pulmonary venous connection in 13 neonates

Objective To evaluate the effectiveness of urgent surgical correction for infra-cardiac total anomalous pulmonary venous connection(TAPVC) in neonates. Methods From October 2009 to January 2015, 13 patients with infra-cardiac TAPVC received surgical correction.The age of patients ranged from 6 to 28 days[(15.08±7.42)days], the body weight ranged from 2.5 to 4.8 kg[(3.34±0.67) kg]. A median sternotomy was performed.Continuous cardiopulmonary bypass using bicaval cannulation with aortic cross-clamping and mild systemic hypothermia were used in all patients.Bi-atrial incision technique making anastomosis between the posterior left atrial wall and the vertical vein were employed in 3 cases.In the other 10 cases, the heart was elevated upward and to the right to expose the anomalous descending vertical vein to facilitate the anastomosis between the posterolateral left atrial wall and vertical vein. Results Emergent or subemergent operations were performed in all patients without surgical death.In the early stage after operation, delayed sternal closure was employed in 11 patients, pulmonary hypertension crisis occurred in 3 patients, small atrial septal defect was kept open for hemodynamic stabilization in 6 patients, temporary cardiac pacemaker for proper heart rate in 3 patients.All patients were uneventfully discharged except 2 patients died of severe low cardiac output syndrome.During the period of follow up, 2 patients presented with recurrent pulmonary infection and signs of pulmonary venous obstruction including the increased flow speed at the site of anastomosis.One of 2 patients was lost of follow up and the other patient was uneventfully discharged after the second operation.The rest 9 patients received postoperative follow up for 1 month to 5 years, echocardiography, X ray chest radiography, and electrocardiogram were performed during this period.As a result, all children had good cardiac function and with sinus rhythm on electrocardiogram and apparently reduced pulmonary congestion on radiography.No obstructive pulmonary venous return was observed on echocardiography. Conclusion Corrective operation for infra-cardiac TAPVC in neonate on urgent basis may provide favorite outcomes. Key words: Anomalous pulmonary venous connection; Cardiac surgical procedures; Congenital heart disease; Neonate

Mitral valve repair with decalcification of the annulus and pericardial patch repair via the trans-septal approach.

Median sternotomy was performed and cardiopulmonary bypass was established using bi-caval cannulation. Cardiac standstill was obtained with antegrade cardioplegia after cross-clamping the aorta. The caval tapes were snared and the right atrium (RA) was opened. An incision was made in the fossa ovalis and was extended into the left atrium (LA). Stay sutures were placed on the edge of the incision for exposure. Annulus sutures with 2-0 Ethibond were placed for better exposure.

CASE 5–2015

HE INADVERTENT INTRODUCTION of air during cardiac surgery into the ascending aorta before aortic cross-clamping is a rare but potentially catastrophic complication. 1 Cardiac surgeons and anesthesiologists must be prepared to deal with this emergency, because rapid and decisive action can prevent or attenuate severe neurologic injury that may result from an air embolism. The authors present a case of an air embolism during mitral valve repair surgery that was treated successfully with early detection and management. A continuous quality improvement process following a previous instance of air embolism contributed to the successful outcome. CASE PRESENTATION * A 62-year-old woman with a history of severe mitral regurgitation, chronic atrial fibrillation, and mildly dysfunctional left ventricular systolic function presented for mitral valve repair. The patient was monitored with an electrocardiogram, pulse oximetry, a left radial arterial catheter, a right internal jugular pulmonary artery catheter, bispectral index (BIS) monitor (Aspect Medical Systems, Newton, MA), and cerebral oximetry monitoring (FORE-SIGHT, CASMED, Branford, CT). After median sternotomy, the patient was cannulated for cardiopulmonary bypass with an ascending aortic cannula, separate bicaval venous cannulation, an aortic root catheter for antegrade cardioplegia, and a retrograde coronary sinus cardioplegia cannula. Immediately after initiation of cardiopulmonary bypass and before application of the aortic cross-clamp, air was noted in the cardioplegia line. The surgeon instructed the perfusionist to immediately stop flushing through the aortic root catheter. The aorta then was inspected by transesophageal echocardiography, which showed air in the aortic arch and descending aorta. The BIS monitor showed an abrupt reduction from 28 to 0 and then recovered in less than a minute. The cerebral oximetry monitor also showed an abrupt bilateral reduction from 66 to 45 with quick recovery. The patient was placed immediately placed in steep Trendelenburg position, the mean arterial pressure was raised to 120 mmHg, and the patient was cooled to 241C. One hundred percent inspired fraction of oxygen was used during the resuscitation period to reduce bubble size. Retrograde perfusion via the superior vena cava at a flow of 500 mL/min for 5 minutes was performed with the aortic root vent turned on to aspirate air. Cardiopulmonary bypass then was resumed and the aortic cross-clamp was applied. The patient was maintained at 281C for the next hour and then slowly rewarmed to 35 degrees. The remainder of the surgery was uneventful, and the patient was weaned from bypass using epinephrine at 50/ng/kg/min.

HVAD continuous flow assist device for ischemic ventricular septal rupture

HVAD continuous flow assist device for ischemic ventricular septal rupture

Heart Transplant: Transplantation for Congenital Heart Disease

Cardiac transplantation for congenital heart disease incorporates aspects of both reparative and replacement surgery. Although intracardiac congenital malformations are replaced, and therefore pose few obstacles to the transplant surgeon, extracardiac malformations (congenital, acquired, or iatrogenic) can present considerable challenges to the operative team. Before transplantation, a full comprehension of the operative plan for the management of each individual patient is essential for both the donor team (so that they may harvest donor tissue of appropriate amounts to allow for adequate reconstruction) and the recipient anesthesiasurgical team (so that they may have several contingency plans for the safe establishment of cardiopulmonary bypass and full cardiac support during cardiectomy). Several recent publications have addressed quite extensively various surgical strategies aimed at heart transplantation for complex congenital heart disease; accordingly, the focus of this article is to address those more “common” anatomical challenges, some of which may be encountered in particular by noncongenital heart surgeons, given the increasing incidence of adult patients with congenital disease who have end-stage heart failure. For congenital cardiac transplant candidates, a standard, systematic approach toward surgical planning is recommended. Key considerations include issues of atrial situs, anomalies of systemic venous return, anomalies of the great arteries, and particular problems related to prior catheterbased palliations. Where possible, maximizing the “preparation” (reconstruction) of the recipient anatomy that can be accomplished before implant of the donor heart helps to reduce the overall warm ischemic time (and if well timed, the overall ischemic time). For those recipients who are the beneficiaries of several prior palliative or corrective repairs, often the most expeditious approach—should the reoperative surgical field prove excessively hostile—is (1) performing the cardiectomy under deep hypothermic circulatory arrest simply to obtain a clearer sense of the underlying anatomy, (2) reconstruction to allow for bicaval (or tricaval) cannulation, and (3) reinstitution of bypass with rewarming