Eur J Cardiothorac Surg 2006;29:112-113
© 2006 Elsevier Science NL
A Gore-Tex ‘new-innominate’ vein: a surgical option for complicated bilateral cavopulmonary shunts
Vladimiro L. Vida
*
,
Juan Leon-Wyss,
Flor Garcia,
Aldo R. Castañeda
Pediatric Cardiac Surgery Unit of Guatemala (UNICAR), 9 Avenida, 8-00, Zona 11, Guatemala Ciudad, Guatemala
Received 12 September 2005;
received in revised form 25 September 2005;
accepted 17 October 2005.
* Corresponding author. Tel.: +502 4711563; fax: +502 4724053. (Email: vladimirovida{at}interfree.it).
 |
Abstract
|
|---|
A bilateral bidirectional cavopulmonary shunt was performed in a cyanotic 14-month-old girl who had tricuspid and pulmonary valve atresia, with right pulmonary artery (RPA) hypoplasia (3 mm), bilateral superior vena cavae and a ductus arteriosus-dependent pulmonary blood flow. Because of 62% postoperative arterial oxygen saturation and a right superior vena cava (RSVC) pressure of 30 mmHg, a 5 mm Gore-Tex tube was interposed to connect the two superior venae cavae. The creation of a ‘new-innominate’ vein allowed decompression of the right superior vena cava and an increase in arterial oxygen saturation to 86%.
Key Words: Prosthetic graft • Innominate vein • Cavopulmonary shunt
|
1. Clinical summary
|
|---|
A 14-month-old girl was referred to our Institution for cyanosis (arterial oxygen saturation, SaO2 of 60%). An echocardiogram showed (1) situs inversus, (2) tricuspid valve atresia, (3) pulmonary valve atresia, (4) a large atrial septal defect and (5) a right ductus arteriosus-dependent pulmonary blood flow. The pulmonary arterial branches were confluent: the left pulmonary artery (LPA) diameter was 7 mm at its origin while the right pulmonary artery (RPA) measured only 3 mm from its origin to its hilar bifurcation. The innominate vein was absent; a persistent right superior vena cava (RSVC) connected with the morphologic right atrium through the coronary sinus. The persistent RSVC measured 7 mm, while the left superior vena cava (LSVC) measured 5 mm and connected directly to the morphologic right atrium.
The patient underwent cardiac catheterisation, which confirmed the echocardiographic findings and demonstrated a mean central pulmonary artery pressure of 12 mmHg (measured through the ductus arteriosus).
Using normothermic cardio-pulmonary bypass (CPBP), bilateral bidirectional end-to-side cavopulmonary shunts (BCPS) were constructed. The patient was weaned from CPBP without difficulties and with stable hemodynamics. The LSVC pressure was 12 mmHg while the pressure in the RSVC (anastomosed to the hypoplastic RPA) was 30 mmHg; SaO2 was 62%. Without CPBP, a 5 mm Gore-Tex graft (3 cm in length) was anastomosed to both SVCs in order to decompress the RSVC system (Fig. 1
). Subsequently, the pressure in the RSVC decreased to 13 mmHg and the SaO2 increased to 86%. The patient was extubated in the intensive care unit 15 h after surgery. The postoperative course was uneventful and the child was discharged home in stable conditions postoperative on day 8, on oral digoxin, furosemide and coumadin. An echocardiogram at discharge showed that the interposed Gore-Tex tube was patent permitting shunting of blood from the RSVC to the LSVC because of the marked hypoplasia of the RPA. Ten months after the operation, the child was in a stable clinical condition with an SaO2 of 82%. An echocardiogram showed a left ventricular ejection fraction of 65% and no gradients across any of the anastomoses. The interposed Gore-Tex tube was still patent, but now the flow from each SVCs entered directly into the respective lung, since the RPA had increased from an initial diameter of 3 mm before the operation to a diameter of 6 mm 10 months after the operation.
View larger version (157K):
[in this window]
[in a new window]
|
Fig. 1. Intraoperative view: A: aorta, LPA: left pulmonary artery, LSVC: left superior vena cava, P: prosthetic graft, and RSVC: right superior vena cava.
|
|
|
2. Discussion
|
|---|
The BCPS as a first or second stage procedure before embarking on a total cavopulmonary connection ("Fontan-type" procedure) has been used to normalise volume loading of the single ventricle at an early age [1]. The presence of bilateral SVC may represent a technical challenge in the performance of the BCPS connection [2]. In addition, bilateral BCPS have been also found associated with a higher operative mortality, an increased risk of thrombus formation, and a lower conversion rate to the "Fontan-type" circulation, if compared to a standard BCPS [3,4]. Also, the size discrepancy between the two SVCs, a low mean oxygen saturation immediately after the operation and hypoplasia of pulmonary artery branches have also been identified as significant risk factors for increased postoperative mortality and morbidity in children with bilateral BCPS [3]. The postoperative arterial SaO2 of 62% and the elevated pressure within the RSVC (30 mmHg), because of the marked hypoplasia of the RPA, demanded an immediate remedy. The interposition of a Gore-Tex graft between both SVCs seemed a reasonable solution to this problem, allowing an immediate decompression of the RSVC and an improvement in SaO2. The other surgical option of taking down the right cavopulmonary anastomosis and to perform a direct anastomosis between the two SVCs was considered but had to be discharged because the distance between both SVCs was quite large and a kinking of one of the SVCs was considered unavoidable. The possibility of patching the hypoplastic pulmonary artery had also been considered, but the hypoplasia extended and included the hilar branches, which not lend itself to a right pulmonary artery patch-plasty.
The risk of thrombosis of prosthetic materials interposed within the SVC system has been reported as up to 30% at 3-year follow-up studies [5]; for this reason, continued oral anticoagulation with coumadin was recommended in this patient. Ten months after the operation, the 5 mm Gore-Tex tube was still widely patent, permitting a very stable clinical course of the patient and also a significant increase in the RPA diameter. The interposition of the 5 mm Gore-Tex tube between both SVCs in this patient proved a feasible and satisfactory solution which offered excellent mid-term results. However, more experience with a larger group of patients and a longer follow-up period is required to define more reliably the physiological benefits of this surgical solution.
|
References
|
|---|
- Pridjian AK, Mendelsohn AM, Lupinetti FM, Beekman III RH, Dick II M, Serwer G, Bove EL. Usefulness of the bidirectional Glenn procedure as staged reconstruction for the functional single ventricle. Am J Cardiol 1993;71(11):959-962.[CrossRef][Medline]
- Mayer Jr. JE, Helgason H, Jonas RA, Lang P, Vargas FJ, Cook N, Castañeda AR. Extending the limits for modified Fontan procedures. J Thorac Cardiovasc Surg 1986;92(6):1021-1028.[Abstract]
- Iyer GKT, Van Arsdell GS, Dicke FP, McCrindle BW, Coles JG, Williams WG. Are bilateral superior vena cavae a risk factor for single ventricle palliation?. Ann Thorac Surg 2000;70:711-716.[Abstract/Free Full Text]
- Forbes TJ, Rosenthal GL, Reul Jr. GR, Ott DA, Feltes TF. Risk factors for life-threatening cavopulmonary thrombosis in patients undergoing bidirectional superior cavopulmonary shunt: an exploratory study. Am Heart J 1997;134(5 Pt 1):865-871.[Medline]
- Shintani Y, Ohta M, Minami M, Shiono H, Hirabayashi H, Inoue M, Matzumiya G, Matzuda H. Long-term graft patency after replacement of the brachiocephalic veins combined with resection of mediastinal tumors. J Thorac Cardiovasc Surg 2005;129(4):809-812.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
A. Amodeo and R. M. Di Donato
The Unifocal Bilateral Bidirectional Cavopulmonary Anastomosis
Ann. Thorac. Surg.,
December 1, 2007;
84(6):
2134 - 2135.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Talwar, S. K. Choudhary, and B. Airan
Gore-Tex 'new-innominate vein' for complicated bilateral cavopulmonary shunts.
Eur. J. Cardiothorac. Surg.,
August 1, 2006;
30(2):
414 - 414.
[Full Text]
[PDF]
|
|
|
Top
Abstract
1. Clinical summary
