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Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations. Since few technical options are available for re-entry cardiac injuries in small inf...
Citations
... Simplified aortic cannulation is an alternative technique that can help avoid reentry injury. 5 The innominate artery is exposed at the level of the suprasternal notch, a 3.5-mm expanded e220 HOW TO DO IT polytetrafluoroethylene graft is anastomosed to the innominate artery, and a 10F cannula is inserted into the graft for whole-body perfusion. Right atrial cannulation is obtained by dividing the anterior aspect of the diaphragm, accessing the right atrial-IVC junction, without separating the sternal edges. ...
Repeat cardiac operations are common in patients with complex congenital heart disease. Inadvertent cardiotomy during redo sternotomy can increase intraoperative time and mortality. Establishing extracorporeal circulation prior to re-sternotomy may render redo congenital cardiac surgery cases safer and more expeditious. In the present report, we describe the technique of pre-emptive cannulation of the abdominal aorta (or right common iliac artery) and inferior vena cava. This approach may be a useful when femoral vessels are occluded due to multiple catheterizations or prior cannulations. In our practice, no re-entry injuries or other complications related to abdominal vessel cannulation have occurred.
... A variation on this technique, end-to-side anastomosis of an expanded polytetrafluoroethylene graft to the innominate artery has been described previously. [4] Venous return can be obtained by subxyphoid access to the inferior vena cava, or if other options prove unsatisfactory, by cardiotomy suction. Sternotomy can then be performed with the perfusion circuit established and ready to commence bypass as in this case, or preemptive initiation of bypass can be used to decompress cardiac structures even prior to sternotomy. ...
Improved survival from congenital heart disease has led to an increasing need for complex reoperation by reentrant sternotomy. Peripheral cannulation and initiation of cardiopulmonary bypass prior to sternotomy to avoid the risk of cardiac injury and massive hemorrhage is an option in adults and larger children, but femoral vessel size precludes this strategy in infants. We describe the management of a high-risk reentry sternotomy in an infant for repair of a giant pseudoaneurysm after prior homograft repair of tetralogy of Fallot, using surgical dissection for suprasternal cannulation of the innominate artery and subxyphoid cannulation of the inferior vena cava.
Objetivo: Estudar, a partir da literatura, um caso de Anomalia de Ebstein, expondo as características clínicas apresentadas no momento e a evolução do paciente, no estado do Espírito Santo. Detalhamentos do Caso: Masculino, 62 anos, buscou o serviço especializado queixando-se de fadiga e dispneia. Histórico patológico pregresso de hipertensão, obesidade, diabetes, insuficiencia cardíaca, dextrocardia, cardiomegalia, anomalia de Ebstein, fibrilação atrial paroxística e infarto agudo do miocárdio. Histórico familiar de cardiopatia e hábitos de etilismo e fumo. Na admissão apresentava-se com dispneia progressiva classificação funcional NYHA IV. Ao ecocardiograma transtorácico, aumento importante de câmaras direitas, disfunção diastólica grau I e anomalia de Ebstein. Foi operado com troca valvar tricúspide (prótese biológica nº33) e cirurgia de revascularização do miocárdio em descendente anterior, com tempo de circulação extra-corpórea em 142 minutos, sem intercorrências, evoluindo bem e recebendo alta. Atualmente paciente encontra-se em casa, em acompanhamento. Considerações Finais: A anomalia de Ebstein é uma cardiopatia congênita, geralmente conduzida e corrigida na infância, entretanto, há alguns casos individualizados em adultos. Seu manejo deve ser diferenciado conhecendo suas distinções anatômicas, variáveis hemodinâmicas e morbidades associadas, categóricos para um bom manejo do seu portador, revigorando sua qualidade de vida.
Ebstein anomaly is a cardiomyopathy of the right ventricular myocardium. The primary pathology in this disease is the failure of delamination of the tricuspid valve leaflets occurring to varying degrees resulting in an entire spectrum of tricuspid valve abnormalities. This, in turn, leads to tricuspid regurgitation, dilation of the right atrium and ventricle, and right heart failure. The disease has the most variable presentation of any congenital heart disease (depending on anatomic severity), ranging from heart failure in a severely cyanotic neonate to incidental detection in an adult.
Background:
Adhesions due to previous surgeries and some anatomical difficulties may make resternotomy dangerous in children. Femoral vessels are usually small and may not be suitable for cannulation. The aim of this report is to describe our experience with cervical cannulation during risky resternotomy in children.
Methods:
Between January 2014 and January 2018, cervical cannulation was performed in eight pediatric patients during sternal reentry. Their ages were between 3 months and 17 years (mean: 5.4 years). Three patients underwent stage III extracardiac Fontan operation with the diagnosis of hypoplastic left heart syndrome. Three patients had supravalvular aortic and/or pulmonary stenosis after previous arterial switch operation. One patient had proximal aortic arch stenosis and subvalvular aortic stenosis after interrupted aortic arch repair. The last patient had aortic root pseudoaneurysm and aortic insufficiency due to endocarditis. Through a separate cervical incision, a polytetrafluoroethylene graft was anastomosed to the common carotid artery and the arterial cannula was inserted into the graft. Antegrade selective cerebral perfusion (ASCP) was used in two patients.
Results:
During resternotomies, no major injury or bleeding occurred. Three-month-old patient who had previous interrupted aortic arch repair died despite extracorporeal membrane oxygenation support due to sepsis and multi-organ failure. Median intensive care unit stay and hospital stay were 3 days (1-40 days) and 17 days (7-60 days), respectively. Mean follow-up was 17.9 ± 15.8 months. All patients were in good clinical condition.
Conclusions:
Cervical cannulation may be a useful and safe technique during high-risk resternotomy in children. This technique may also simplify the performance of ASCP if necessary.
Aortic aneurysms in childhood are rare disease entities and are usually seen in patients with genetic connective tissue disorders such as Marfans, Ehler‐Danlos, and Loeys‐Dietz syndrome (LDS). Patients affected with LDS present early in life and have a rapid disease progression. We report a case of repair of an ascending and aortic arch aneurysm in an infant with Loeys‐Dietz syndrome.
Patients with acute or progressive heart failure in the setting of congenital heart disease may need mechanical circulatory support (MCS) to enhance survival while awaiting cardiac transplantation. Because the majority of MCS devices are implanted after prior cardiac operations, special precautions are necessary at the time of implant. MCS in single ventricle patients usually requires ventricular and aortic cannulation, with a systemic to pulmonary artery shunt for pulmonary blood flow. Limited outcomes data is available, with less than 15% of pediatric MCS patients having congenital heart disease. The Berlin EXCOR is the only durable device currently available for infants. Neurologic complications are the major cause of mortality, and survival during support is poor for infants <5 kg. Patients post-Fontan with acute cardiac failure and/or respiratory failure are at high risk for death before transplant and should be considered for MCS therapy. Several emerging miniature continuous flow devices will soon broaden the landscape of available pediatric devices.
The Berlin Heart Excor (BHE) assist device has become our standard mechanical support device for long-term support in children with heart failure. We report two useful surgical modifications for the implantation of the BHE in the pediatric population, improving ease of implantation as well as subsequent surgical procedures at the time of explantation or transplantation. The first modification entails the use of a polytetrafluoroethylene graft for cannulation via the innominate artery for arterial perfusion during cardiopulmonary bypass. This graft is preserved and reused for institution of bypass at the time of transplantation or explantation of the device after recovery. The second modification consists of an extension of the BHE arterial cannula using a length of knitted polyester graft. This allows for improved positioning of the arterial cannula in the ascending aorta or main pulmonary artery, facilitates vascular anastomosis, and improves hemostasis.
