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Eur J Cardiothorac Surg 1999;16:S89-S92
© 1999 Elsevier Science NL

Cava endoluminal balloon occlusion as an adjunct technique to perform less invasive cardiopulmonary bypass procedures

Departments of Cardiothoracic Surgery and Anesthesiology, Hospital de Santa Cruz, Carnaxide 2780, Portugal

^* Corresponding author. Tel.: +351-1-4165-901; fax: +351-1-4165-919

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Objectives: A cardiopulmonary bypass technique was developed with the aim of achieving a less invasive approach to right-sided lesions of the heart or to avoid extensive dissection in reoperations. Methods: Cavae endoluminal balloon occlusion (CEBO) was achieved with balloon catheters, introduced through cannulas inserted in the right jugular and one of the femoral veins. This procedure can be used in association with a standard femoral cardiopulmonary bypass or with the port-access technique. Results: Twenty-two patients were operated, through a right thoracotomy, for atrial septal defect (19) and tricuspid valve regurgitation associated with mitral valve pathology (3). There were two intra-operative complications, partially related with the development of this technique and lack of appropriate designed material. There was no mortality and a shorter and easier postoperative care was achieved in almost all patients. Conclusions: The CEBO technique is an useful and safe adjunct to perform miniinvasive or complex reoperations on the right side of the heart

Key Words: Mini-invasive surgery • Cardiopulmonary bypass • Atrial septal defects

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Less invasive open-heart procedures are assuming an important role for the treatment of several cardiac conditions [1–3]. To open the right-sided cavities of the heart, the two vena cava os have to be temporarily occluded, to achieve complete venous blood drainage, during cardiopulmonary bypass [4]. For that purpose, the most commonly used method is to surround, externally, each vena cava with loops.

In this report we present our results using an alternative to the latter approach in which balloons introduced through cannulas inserted in the jugular and femoral veins are used to occlude the venae cavae Thus, all the steps required to achieve full bypass are performed without chest incisions.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
From April 1996 to December 1997, 22 patients with atrial septal defect (19) and mitral and tricuspid valve pathology (3) were operated using this technique. Their clinical and pathologic conditions are described in Tables 1 and 2 . Informed consent was obtained in all patients.

For cardiopulmonary bypass the femoral artery perfusion was performed with cannulas of sizes ranging from 14 to 23 Fr. For venous drainage, the superior (SVC) and inferior (IVC) venae cavae were cannulated through the right jugular and femoral veins, respectively using 14 or 17 Fr diameter arterial cannulas for the former and 20–28 Fr diameter venous cannulas for the latter.

Using airtight Y connectors in the venous cannulas, balloon occlusion catheters were inserted to reach the right atrium and occlude the orifices of the venae cavae. Because of the lack of appropriate designed balloons, 5F, 50 cm length balloon atrioseptostomy catheters (model 830515F, Baxter, Irvine, CA), with a maximum diameter of 20 mm were used for the SVC occlusion, and 8Fr 100 cm length occlusion balloon catheters (ref. 17-205, Medi-tech, Watertown, MA) with a maximum diameter of 33 mm were used for the IVC occlusion. Under control of transesophageal echocardiography (TEE) each balloon was partially inflated and placed at the entrance of the venae cavae in the right atrium, 2 or 3 cm away from the tip of the venous cannulas. The superior balloon was placed inside the origin of the SVC leaving the IVC balloon in the right atrium just above the entrance of the IVC. (Fig. 1).

View larger version (35K): [in this window] [in a new window]   Fig. 1. Cavae endoluminal balloon occlusion in cardiopulmonary bypass technique.

Mild hypothermia and standard pump flows were achieved in all cases.

A sub-mammary right thoracotomy was done with a skin incision with a length of 3–7 cm in the ASD cases and up to 15 cm in the valve cases, depending on the complexity of the correction to be performed and on the thickness of the thoracic wall. The pleural cavity was entered through the 4th right intercostal space. Also depending on the complexity of the procedure the intercostal space was widened from 2 to 6 cm trying to spread the ribs as less as possible to diminish the post-operative pain. This incision was used only for instrumentation.

To minimize the risk of gaseous embolism and facilitate the debubbling procedures, the right hemithorax was filled with CO₂. A small feeding tube was connected to a 5F trocar passed through the fifth intercostal space in the highest position of the pleural cavity and a continuous infusion of 100% CO₂ was started at a flow rate of 3–5 l/min. Patient ventilation was adjusted, if necessary, to keep pCO₂ levels within normal levels. In some cases a 10 mm port was placed in the posterior axillary line, at the 5th or 6th intercostal space, for video-thoracoscopic improvement of both visualization and illumination.

2.2 Atrial septal defect (ASD)
With both venae cavae occluded, ventricular fibrillation was induced with an external fibrillator, connected to a temporary endocavitary pace-maker lead placed in the right ventricle under TEE control, and the right atrium was opened. With suction of the coronary sinus blood flow, exposure was good and surgery proceeded with routine methods. Before complete closure of the defect, the left atrium was allowed to fill with blood. The need for venting was accessed using TEE. The RA was closed and debubbling was performed with a needle in the RA and LA, if required.

2.3 Valve surgery
The Heartport (Heartport, Redwood City, CA) system was used with balloon occlusion of the ascending aorta and perfusion of antegrade crystalloid cardioplegia. Neither the percutaneous pulmonary venting nor the Heartport catheter for retrograde cardioplegia were used. The venae cavae are occluded with the balloons and the RA opened. Retrograde cardioplegia was given through a catheter inserted under direct vision. Valve repair was performed as usual; the left atrium being opened with a lateral incision. Exposure was generally good, and could be enhanced with mild inflation of the left lung. To give knots, a knot pusher was used, when required. A venting catheter was left in the LV and the LA was allowed to fill and closed on a routine fashion.

The heart was defibrillated with external pads. Weaning of bypass was done after rewarming. If required, a temporary pacing lead was passed through the neck venous cannula. The edges of the pericardium are approximated and one or two chest tubes are left in place. The groin and chest incisions were closed in a routine fashion. The SVC cannula was removed after protamine infusion and external pressure was applied to assure homeostasis.

All patients had routine post-operative management.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
The ASDs were closed either by direct suture 10 or with autologous 3 or bovine 6 pericardial patches. In the two ostium primum patients, the septal commissure of the left AV valve was partially closed with interrupted sutures.

In the valve patients, a mitral valve replacement, a replacement of a mitral valve prosthesis and a direct suture of dehiscence of mitral valve prosthesis were performed with standard techniques. All patients with tricuspid valve pathology had, annuloplasty with a prosthetic ring

The length of the different procedure is described in Table 3 .

Early in the experience there were two intraoperative complications. The first was a laceration of the femoral artery, caused by the cannula, which required a 2 cm dacron graft replacement. The second was a left ventricle wound caused by a guide wire. This patient required the anterior extension of the minithoracotomy up to the sternum and closure of the left ventricle wound.

In two patients, a residual ASD was found at the end of cardiopulmonary bypass by echocardiography and they were immediately closed at a second run of cardiopulmonary bypass.

After surgery, mechanical assisted ventilation was required in average for 7 h, ranging from 2 to 22 h. Average bleeding was 348 ml (maximum 940 ml).

The median stay in ICU was 24 h, ranging from 15 to 50 h, and hospital stay was on average 5 days, ranging from 2 to 12 days.

Follow-up is 100% complete and 15 months long on average, with a maximum of 21 months. During the follow-up period two patients, ages 65 and 72 were readmitted due to pneumonia and pericardial effusion.

The most common complaint was paresthesis on the inner face of the thigh and occurred in seven patients, early in our experience.

All patients are in functional class I of the New York Heart Association.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 
Conventional surgery is a reliable and safe approach to correct right-sided heart lesions [5]. It is performed through median sternotomy or right lateral thoracotomy and requires loops around the vena cavae. Alternatively, cannulas with distal balloon-tips introduced through the right atrium under direct vision are used. In either case to insert the cannulas the operative field has to be sufficiently large [6,7]. These incisions are required to accomplish the cardiopulmonary bypass and to perform the intracardiac correction [8]. During reoperations venae cavae cannulation and application of snares around them require delicate dissection and the bleeding potential is high.

The CEBO technique allows full control of venous drainage, during cardiopulmonary bypass. The cannulas are easily inserted and the balloons are readily identified and their location in the cavae is reliable. By TEE we measure the size of each vena cava and the balloons are inflated with saline to achieve this size. In case of residual blood leakage around the balloon shows on Doppler exam, the balloon can be either relocated or additional inflation performed. In the neck we have observed no procedure related complications neither in the operative period nor in the follow-up.

The location of the inferior vena cava balloon is slightly more complex, since obstruction of the supra-hepatic veins has to be avoided. We achieve that by inflating the balloon in the right atrium and then pulling it down, as a cork to occlude the IVC.

The groin approach is the more delicate part of the procedure as judged by the incidence of paresthesias observed early, in our experience. We recommend that the groin vessels should be approached by an experienced surgeon, thus preventing local complications. Still many patients have had paresthesias of the thigh, which were prevented only after we introduced minimal dissection, approaching only the anterior surface of the groin vessels without passing loops around the vessels.

As mentioned above, two serious complications occurred, early in our series of patients operated with this technique. The first, the femoral artery laceration was, most likely due to the fact that initially the arterial cannulas were inserted through a transverse incision on a fully dissected femoral artery with, in addition, proximal and distal loops. Once we have adopted the Seldinger technique such complications are unlikely. The second problem we have experienced was a left ventricle rupture due to a guide wire. This is a rare complication that is avoidable with proper control and more gentle manipulation and should not occur. Still it was possible to solve it, by extending the incision transversely, through the sternum and by averting the heart to suture the wound.

Patients being reoperated are well known to have higher risks for mortality and morbidity. The dissection of the atrium and vena cava is difficult and has potential for bleeding. Specially in multivalvular disease with tricuspid regurgitation the risks of reoperation are higher. The technique we describe avoids all manipulation and the need for dissection of the atria, thus eliminating the operative risks described.

In miniinvasive approaches the CEBO technique allows reduction of the size of the thoracotomy, close ASDs through the intercostal space without spreading the ribs thus avoiding chest pain in the post-operative period and having a very small incision with very good aesthetic result. TEE control performed immediately after CPB allows to recognize residual defects and their immediate repair.

Minor paresthesias of the thigh remain the only complaint patients refer. Because the aim of our approach is to have no pain we consider these symptoms as adverse effects. In many different conditions, such as coronary revascularization equivalent complaints after saphenous vein harvesting are never referred as such.

With appropriate materials the technique can be used in youngsters, referred for surgery before school age, but further developments need to be achieved to improve the efficacy of the method.

The CEBO provides an excellent adjunct technique to miniinvasive approach as well as for those patients in whom dissection of the vena cavae is difficult or dangerous.

The present results prove that our goals of efficacy and safety are achievable even in a complex patient population with a wide range of ages and different types of pathology. The results of umbrella closure of atrial septal defects, although very promising, will have to be compared with those of miniinvasive approaches.

	Footnotes

 
Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet The Experts', Dresden, Germany, December 3–5, 1998.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion References

 

1. Shetty D, Dixit M, Gan M, Das M, Harish R, Kappoor L, Swandranath KV. Video-assisted closure of atrial septal defects. Ann Thorac Surg 1996;62:940.[Free Full Text]
2. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
3. Burke Rp, Wernovsky G, van der Velde M, Hansen D, Castaneda AR. Video-assisted thoracoscopic surgery for congenital heart disease. J Thorac Cardiovasc Surg 1995;109:499-508.[Abstract/Free Full Text]
4. Shetty D, Dixit M, Gan M, Das M, Harish R, Kappoor L, Swandranath KV. Minimally invasive direct atrial septal defect closure. Ann Thorac Surg 1997;63:1833.
5. Mavroudis C. VATS ASD Closure: a time not yet come. Ann Thorac Surg 1996;62:638-639.[Free Full Text]
6. Chang C, Lin P, Chu J, Liu H, Tsai F, Lin F, Chiang C, Su W, Yang M, Tan P. Video-assisted cardiac surgery in closure of atrial septal defects. Ann Thorac Surg 1996;62:697-701.[Abstract/Free Full Text]
7. Chang C, Lin P. Minimally invasive direct atrial septal defect closure. Ann Thorac Surg 1997;63:1831-1832.[Free Full Text]
8. Izzat M, Yim A. Minimally invasive direct atrial septal defect closure. Ann Thorac Surg 1997;63:1831.[Free Full Text]

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