Bidirectional glenn operation without cardiopulmonary bypass: Operative protocol and early results

Nội dung text: Bidirectional glenn operation without cardiopulmonary bypass: Operative protocol and early results

1. JOURNAL OF MEDICAL RESEARCH BIDIRECTIONAL GLENN OPERATION WITHOUT CARDIOPULMONARY BYPASS: OPERATIVE PROTOCOL AND EARLY RESULTS Nguyen Tran Thuy¹, Ngo Thi Hai Linh¹, Doan Quoc Hung² ¹Cardiovascular Center, E Hospital ²Hanoi Medical University The bidirectional Glenn (BDG) shunt operation serves as temporary treatment of single-ventricle phys- iology before the eventual Fontan procedure. Some cases can be performed without the support of a cardiopulmonary bypass (CPB) machine. In this study, we present the surgical outcomes of off-pump BDG operations with the use of temporary veno-atrial shunt to decompress the superior vena cava (SVC) during clamping. From June 2013 to June 2015, 23 patients underwent off-pump BDG opera- tions at Cardiovascular Center, E Hospital. All patients were operated on using a venoatrial shunt to decompress the SVC. Satisfactory results with mean oxygen saturation increased from 79.6 ± 11.2 % to 87.2 ± 4.7 %. The superior vena cava (SVC) clamping time was 14 ± 2.4 minutes (ranging from 12 to 21 minutes). No neurological complications or deaths occurred after the surgery and the postop- erative period was uneventful. In conclusion, the use of venoatrial shunt to decompress SVC during the off-pump BDG operation is safe and produces good surgical outcomes. Its wider adoption can the deleterious effects associated with CPB. The operation is easily reproducible at low cost and overcome. Keywords: congenital heart disease, bidirectional Glenn operation, without cardiopulmonary bypass I. INTRODUCTION Bidirectional Glenn shunt operation is oppoed to providing mixed ateriovenous performed as the initial step in the treat- blood, as in the Blalock – Taussig shunt sur- ment of functional single-ventricle physi- gery (aortopulmonary shunt) [1 - 3]. ology before the completion of the Fontan Off-pump BDG operations without a procedure. The purpose of this surgery is temporary shunt to decompress the SVC to provide balanced venous blood flow into will cause an elevation in the cerebral blood two pulmonary arteries for oxygenation, as volume, leading to increased intracranial pressure and eventually, thereby, brain re- Corresponding author: Nguyen Tran Thuy, E Hospital duced blood flow to the brain and damage Email: drtranthuyvd@gmail.com [3; 4] Received:09 May 2017 The BDG operation is conventionally Accepted: 16 November 2017 performed with the support of CPB at the expense of higher cost and disadvantages JMR 111 E2 (2) - 2018 75
2. JOURNAL OF MEDICAL RESEARCH of CPB. Therefore, globally, there has been chamber size, the functional status of the a variety of reports on BDG operations with- heart valves, pulmonary artery (PA) size. out CPB [1; 5; 6]. The have show that in off- + Cardiac catheterization: measure pump BDG operation, pulmonary arterial PA size, anatomy, pressure and resistance. pressure is lower and the hospital length of - Definitive diagnosis was established stay of off-pump group is shorter than that based on the following: physical examina- of the on-pump group [7; 8]. tion, Doppler echocardiography, cardiac However, there have been no official re- catheterization, blood tests, electrocardiog- ports on this issue in Vietnam. In this study, raphy and chest x-ray. we present the surgical protocol to perform - Surgical consultation, hospital admis- off-pump BDG operation using the SVC-RA sion, and preoperative medical therapy. pressure lowering system and present early - When all conditions had been assured, outcomes of this newly applied technique the patients underwent surgery according to [9], [10]. the same protocol in anesthesia, operative techniques, and postoperative resuscita- II. SUBJECTS AND METHODS tion. In the operating room, hemodynamic 1. Subjects parameters were recorded. Subjects were patients who had attri- - Technical procedure: butes suitable for BDG operation, without + General anesthesia, intubation. any intracardiac defects requiring correc- Premedication with Midazolam, Fentanyl, tion including: pulmonary artery-plasty, atri- Rocuronium. Patients were on controlled al septal extension, atrioventricular valvu- mechanical ventilation with Vt = 150 ml and loplasty, etc. the respiratory rate of 18 per minute. The anesthesia was maintained by Isoflurane, 2. Methods Fentanyl, and Rocuronium. A femoral vein The study disign was a retrospective ob- catheter was placed for drug distributions servational study and monitoring of the right atrial pressure. Patients were prepared for the survey A right internal jugular vein catheter was through the following steps: inserted for SVC pressure monitoring. An - Physical examination: Clinical symp- invasive arterial pressure line was also toms (evaluating the severity of heart fail- placed. ure, using the NYHA classification, and the - Surgical steps: level of cyanosis), SpO2, and medical his- + Whole body antiseptic applica- tory. tion, from the chest to the legs; - Laboratory tests: + Median sternotomy; + Routine blood tests, electrocardi- + Dissect the SVC and ligate the ography, and chest x-ray. azygos vein; + Echocardiography: evaluate left + Dissect the right branch of PA, ventricular function, abnormal wall motion, and measure PA pressure; 76 JMR 111 E2 (2) - 2018
3. JOURNAL OF MEDICAL RESEARCH + Set up the system to decrease echocardiography, routine laboratory tests SVC-PA pressure (complete blood count, electrolytes, arterial + Trial right PA clamp for several blood gases, ...) were done. All complica- minutes to check the changes in transcuta- tions and actions taken were recorded. neous oxygen saturation (SpO2). Systemic + After the ICU stay, patients were heparin with the dose of 1 mg/kg to achieve transferred to Pediatric Cardiology Depart- the ACT of more than 200 seconds. Set up ment for further treatment until discharge. the system to decrease SVC-PA pressure 3. Ethics with the head of the patients elevated 15 All study procedures complied with the degrees, inject methylprenisolone (20 mg/ ethical principles of biomedical research. kg) intravenously, SVC clamp to anstomose Participants consented to take part in the with right PA, maintain the difference be- study and were told that they could with- tween mean arterial pressure and mean draw at any time. Participants’ information SVC pressure during clamping higher than was kept secure and confidential. 40 mmHg. During surgery, hemodynamic stability III. RESULTS was maintained by fluid replacement and From June 2013 to June 2015, we per- inotropes: adrenaline 0.1 mcg/kg/min and formed off-pump BDG operation on 23 pa- Milrinone 0.3 mcg/kg/min. tients. The mean SVC clamp time was 14 ± + Make end-to-side SVC-PA anas- 2.4 minutes (ranged from 12 - 21 minutes). tomosis by 7.0 prolene suture During clamping, the mean central venous + Remove cannulae, achieve he- pressure ranged from 24 to 40 mmHg (av- mostasis, insert drains, electrodes, close erage 31.5 ± 6.1 mm Hg). Preoperative PA the pericardium if possible pressure ranged 11 - 25 mmHg (average + Close the sternotomy by steel su- 16.3 ± 3.2 mmHg). There was no conver- ture, soft tissue was closed using running sion to CPB machine. suture or interrupted absorbable suture in Indications of patients undergoing BDG patients with high risks of infection. operations are summarized in Table 1. + In the intensive care unit, an Table 1. Indications of patients undergoing BDG operations Other surgeries Patients (n) Percent (%) Single-ventricle physiology 11 47.8 Double outlet right ventricle with transposition of the great 5 21.7 arteries Transposition of the great arteries, pulmonary stenosis, 6 26.2 large ventricular septal defect Atrioventricular disassociation, double outlet right ventricle 1 4.3 JMR 111 E2 (2) - 2018 77
4. JOURNAL OF MEDICAL RESEARCH Early results The mean ventilator time after surgery was 2.6 ± 1.2 hours (1 - 6 hours), the ICU length of stay was 13.2 ± 3.1 (10 - 18 hours); no death occurred. Echocardiography evaluation at discharge showed no anastomosis stenosis, and postoperative electrocardiography (ECG) revealed no arrhythmia. Mean postoperative PA pressure was 13.6 ± 2.5 mmHg. Table 2. Postoperative complications Complications Patient (n) Percent (%) Chylothorax 1 4.3 Pneumonia 2 8.6 Pulmonary effusion requires drainage 1 4.3 Surgical wound infection 1 4.3 Reoperation 1 4.3 Neurological deficits 0 0 Reoperation due to thrombus at the Glenn anastomosis Table 3. Pre and postoperative Hct, SpO2 Parameters Preoperative Postoperative p Hct (%) 0.53 ± 0.11 0.43 ± 0.05 0.001 SpO2 (%) 79.96 ± 11.2 87.2 ± 4.7 0.011 The hospital length of stay ranged from in encephalography. Rodriguez found that 6 to 9 days (average 7.1 ± 1.3 days). Echo- clamping the SVC decreases the systolic cardiography showed no significant pres- pressure of cerebral arteries and subse- sure gradient through the SVC-RPA anas- quently decreases the brain's oxygen sup- tomosis and also showed good velocity ply [2 - 4]. To avoid these complications of blood flow; ECG showed normal sinus many studies have reports on the used a rhythm in all patients, and no neurological temporary shunt to decompress the SVC complications were recorded. and improve perfusion of the brain. Table 4 is summary of all studies in the IV. DISCUSSION past 15 years examining BDG operations Several studies have documented the without CBP. Lamberti polished his research decrease in oxyhemoglobin in brain tissue, on seven patients in 1990 and subsequent- a 50% reduction in blood flow in the mid- ly, there was a series of other studies exam- dle cerebral artery with significant changes ining off-pump BDG surgery [1; 5; 9]. 78 JMR 111 E2 (2) - 2018
5. JOURNAL OF MEDICAL RESEARCH Table 4. Studies on off-pump BDG surgery Study Year Number of study Temporary shunt patients Lamberti 1990 7 SVC – RA Lal 1996 6 SVC – RA Murthy K S 1999 5 SVC – PA Jahangiri 1999 6 No Villagra F 2000 5 No Tiereli 2003 30 SVC – RA/PA Maddali 2003 2 SVC – RA Liu 2004 20 SVC – RA/PA Luo 2004 36 SVC – RA Maeba 2006 18 SVC – RA/PA Kotani 2006 14 SVC – RA Hussain 2007 22 No Kandakure 2010 218 SVC – RA Total 13 studies 389 RA: right atrium; PA: pulmonary artery; SVC: superior vena cava (Until now, there have been no official reports on this technique in Vietnam). In the study of Ulisses Alezandre Crotti, the mean age of on-pump group was 66 months and that of off-pump group was 50 months (p = 0.17 using Mann-Whitney test). This sug- gests the differences in age, gender, weight, types of defects between on-pump and off-pump group are not important factors in choosing the use of peripheral circulation. The choice of a temporary shunt depends on the experience and ability of the surgeons, and anesthegist, as well as the conditions of the surgical center. Our technique uses a tem- porary veno-atrial shunt with the following steps: placing a venous graft at the junction of SVC and azygos vein, which effectively decreases the pressure of the clamped SVC and avoids the possibility of SVC stenosis. In addition, the head-elevated position during operation facil- itates the adequate decompression of SVC and provides enough space surgical. JMR 111 E2 (2) - 2018 79
6. JOURNAL OF MEDICAL RESEARCH Figure 1. Description of a veno-atrial shunt used in our technique SVC: superior vena cava; RPA: right pulmonary artery; LPA: left pulmonary artery; RA: right atrium. According to our experiences, with surgeons and anesthetist is key to a suc- the veno-atrial shunt, SVC pressure after cessful off-pump BDG operation [6]. clamping did not exceed 40 mmHg. Post- During SVC clamping, the blood flow to operative chylothorax and dysfunction of the brain is reduced; therefore, to maintain the diaphragm occured at low incidences good cerebral perfusion during off-pump because, with our technique, the dissect on BDG surgery, the authors proposed the field of SVC was short; avoids and the injury concept of transcranial pressure, which is to phrenic nerve and the refocus surround- the difference between mean aterial pres- ing lymphatics. Performing Glenn operation sure and mean SVC pressure during SVC on patients who already have a Blalock – clamping (transcranial pressure = mean ar- Taussig shunt or patent arteriosus ductus terial pressure – central venous pressure) (PAD) is more convenient as the aortopul- [7]. This pressure has to be maintained at a monary shunt continuously supplies blood minimum of 30 mmHg during SVC clamping for the lungs during the reconstruction of to assure adequate cerebral perfusion. Ve- Glenn anastomosis and maintains the good no-atrial shunt reduced SVC pressure and stable oxygen saturation. The choice of improved cerebral perfusion [3; 4]. SVC and atrial cannula size were based on Monitoring of parameters of brain func- the size of the patients SVC and right atri- tion to provide additional information about um, and patient’s weight, skin area in CPB. hemodynamic effects of SVC clamping During surgery, the cooperation between on brain tissue transcranial Doppler ultra- 80 JMR 111 E2 (2) - 2018
7. JOURNAL OF MEDICAL RESEARCH sound, near-infrared spectroscopy, and BDG surgery with CPB [2; 3; 12]. The dif- encephalography [6]. However, these tests ferent factors in our study are comparable were not available during this study so the to those Crotti.The mean duration to extu- authors monitored brain function by assess- bation of the off-pump group was 3 hours ing mean arterial pressure and central ve- and that of on-pump group was 11 hours (p nous pressure. = 0.83). The mean length of stay in the ICH Corticosteroid was used to minimalize was 3 days and 5 days in the on-pump and brain edema and neurological insults. Body off-pump group, respectively (p = 0.29). The temperature was kept at approximately 33 average hospital length of stay of the former - 34⁰C in order to reduce the metabolism group was 9 days, of the latter group was of brain cells and adjust for the reduced 5 days, and of the whole study group was pressure of cerebral blood flow during SVC 7 days. In Mohamed, the off-pump group clamping. Inotropes and crystalloid replace- were extubated earlier, and had shorter ment were used to maintain adequate cere- length of stay in the ICU and shorter hospi- bral blood flow and a transcranial pressure tal length of stay than on-pump group. higher than 30 mmHg during SVC clamping In our study, all cases had shunts that [8]. supplied blood to the lungs; and the patent Hypoxia was regulated by increasing arteriosus ductus, collaterals, aortopulmo- fraction of inspiratory oxygen (FiO2), in- nary shunt (Blalock-Taussig) had the shunt creasing mean arterial pressure by using ligated to avoid the increased left ventricu- inotropes, and providing enough circulating lar after load, improve cardiac function, and fluid and to improve blood flow. decrease the severity of atrioventricular Postoperative treatment to the lung de- valve regurgitation [9]. Mean postoperative creas pulmonary vascular resistance and pulmonary arterial pressure was 13.6 ± 2.5 increas blood return to the SVC. Pulmonary mmHg, which was the ideal pressure after dilation medications (milrinone, iloprost BDG operation. According to Tables 3 and ...) helped to decrease pulmonary arterial 4, the oxygen saturation was significantly pressure and end-diastolic left ventricular improved after surgery (p < 0.011) and the pressure [1]. Prolonged mechanical ventila- hematocrit decreased substantially post- tion time resulted in increased intrathoracic operatively (p < 0.001). In 23 study partici- pressure and negatively affected the blood pants, there were six cases with early post- return to the SVC and blood flow through operative complications, which accounted the shunt, early weaning and extubation for 26.1% of the total sample (Table 2), and helped circument these problems. The only one cases with more than one compli- mean time on ventilator in our study was cation. According to Chang [9], the incidenc- 2.6 ± 1.2 hours (1 - 6 hours), which is com- es of postoperative complications, such as parable to other studies [1]. Short ventilato- superior vena cava syndrome, low cardiac ry time is also a big advantage of off-pump output syndrome, arrhythmia, were high, BDG operation compared to conventional while in research in our center and by oth- JMR 111 E2 (2) - 2018 81
8. JOURNAL OF MEDICAL RESEARCH er authors [10], the incidences of the above significantly higher than that of the off-pump mentioned complications were very low. group (p < 0.01). The early mortality rates There were no case requiring reoperation in of on-pump and off-pump groups are 0% our study; in other research the rate of this and 4%, respectively. The causes of death complication was 6%. There was a case re- in on-pump group were low cardiac output quiring reoperation; especially three days syndrome, heart failure, and neurological after BDG surgery, facial edema occurred complications. Comparing the results from and echocardiography revealed thrombi this study, to ours the off-pump group had inside SVC. In reoperation, we found that better postoperative recovery, shorter time there were thrombi along the central venous on mechanical ventilator, shorter length of catheter and at the Glenn anastomosis. The stay in the ICU and hospital, and fewer post thrombi were removed and the central ve- surgical complications compared to those nous catheter was replaced. The reason undergroing the on-pump Glenn procedure. for this thrombi formation may be from in Without the CPB machine, patients can the previous surgery, during the separation avoid unwanted effect including: increased of SVC when we cut a part of the central pulmonary vascular resistance, blood dilu- venous catheter that lies in right atrium tion, air embolism and a host of other un- (Catheter which is too long will cause the desirable effects. Tireli [13] 2003, confirmed difficulty for operation and cannot measure that in the off-pump BDG operation, pulmo- SVC pressure), In general, the incidences nary arterial pressure was lower and the of postoperative complications in our study hospital length of stay of off-pump group are comparable or lower than other studies was shorter than the those of on-pump [11; 12]. group. All patients were on heparin in the In our study, there were no deaths in off- first 24 hours, and aspirin was used subse- pump group and two deaths in the on-pump quently. Patients were monitored regularly, group. There were no cases with chylotho- and all of them maintained good oxygen rax in the off-pump group, but eight patients saturation; no neurological complications in the on-pump group suffered from this occurred. complication. Only two patients in off-pump Reducing medical cost a global priority. group had early complications, while 14 pa- According to Hussain (2007), the cost of an tients in the on-pump group did. One advan- on-pump BDG surgery is 1200 USD and that tage of the Glenn procedure without periph- of an off-pump BDG operation is only 250 eral circulation is the significant reduction USD [8]. To date, the cost of a BDG shunt in post surgical complications compared to institution with CPB (49 million VND) is 7 on-pump group. Our results are compara- times higher than that of the same operation ble to those of Mohamed’s study. The rates without CPB (7 million VND) at our Cardio- of hemorrhage requiring reoperation in two vascular Center. The off-pump BDG opera- groups are significantly different (p = 0.044); tion technique reduced cost by omitting use the rate of chylothorax in on-pump group is of CPB, reducing use of blood products and 82 JMR 111 E2 (2) - 2018
9. JOURNAL OF MEDICAL RESEARCH reducing the suctioning system after steril- support of cardiopulmonary bypass? J Tho- ization. Postoperative period and hospital rac Cardiovasc Surg, 119, 634 - 635. length of stay were shorter, and the rates 4. C. G. Rodriguez RA, Semelhago of pulmonary effusion, chylothorax and dia- L, Splinter WM, (1997). Cerebral effects phragm paralysis were lower. Lastly no neu- in superior vena cava obstruction: the role rological complications were documented. of brain monitoring. Ann Thorac Surg, 64, 1820 - 1822. V. CONCLUSION 5. M. G. Mahadev Dixit, M.Ch., Anu- After performing off-pump BDG shunt radha Dubey, M.Ch., (2007). Off Pump Bi- institution in 23 patients from June 2013 to directional Glenn performed through a tho- June 2015, at Cardiovascular Center - E racotomy. Ind J Thorac Cardiovasc Surg, Hospital, we concluded that off-pump BDG 23, 180 - 183. operation using veno-atrial shunt to decom- 6. N. R. F Onyekwulu, P Kandakure press the SVC was safe, and produced sat- (2011). Anesthesia For Off Pump Bidirec- isfactory surgical outcomes. This technique tional Glenn Shunt Surgery: Case Report. can avoid the disorders caused by CPB, The Internet Journal of Anesthesiology, 30 significantly improve oxygen saturation, and 1 - 3, the quality of life, and reduce mortality rate 7. K. B. Jahangiri M, Shinebourne EA, after Fotan procedure. Lincoln C (1999). Should the bidirectional Acknowledgements Glenn procedure be performed through a thoracotomy without cardiopulmonary by- I would like to express my deepest grat- pass?. J ThoracCardiovasc Surg, 118, 367 itude to the Cardiovascular Center, E Hos- – 368. pital for supporting us in the data collection 8. A. B. Syed Tarique Hussain, Savita process. Sapra, Rajnish Juneja (2007). The bidirec- REFERENCES tional cavopulmonary (Glenn) shunt without 1. A. K. D. P R Kandakure (2012). Ve- cardiopulmonary bypass: is it a safe option? noatrial Shunt-Assisted Cavopulmonary Interact CardioVascThorac Surg, 6, 77 - 82. Anastomosis. Asian Cardiovasc Thorac 9. C. A. e. al (1993). Early bidirection- Ann, 18, 569 – 573. al cavopulmonary shunt in young infants: Postoperative course and early results. Cir- 2. L. Y. Liu J, Chen H, Shi Z, Su Z, Ding culation, 88, 149 - 158. W (2004). Bidirectional Glenn procedure 10. C. J. e. al (2003). Effects of con- without cardiopulmonary bypass. Ann Tho- trolled antegrade pulmonary blood flow on rac Surg, 77, 1349 – 1352. cardiac function after Bidirectional cavopul- 3. W. N. Rodriguez RA, Cornel G. monary anastomosis. Ann Thorac Surg, 76, (2000). Should the bidirectional Glenn pro- 1917 - 1921. cedure be better performed through the 11. R. C. Kona Samba Murthy, Shivaprakasha K. Naik (1999). Novel JMR 111 E2 (2) - 2018 83
10. JOURNAL OF MEDICAL RESEARCH Techniques of Bidirectional Glenn Shunt 199. Without Cardiopulmonary Bypass. Ann 13. B. M. Tireli E, Kafali E, et al (2003). Thorac Surg, 67, 1771 - 1774. Peri-operative comparison of different tran- 12. Z. J. F. Xie Bin, Devi Prasad Shetty sient external shunt techniques in bidirec- (2001). Bidirectional Glenn Shunt: 170 Cas- tional cavo-pulmonary shunt. Eur J Cardio- es. Asian Cardiovasc Thorac Ann, 9, 196 - thoracic Surg, 23, 518 – 524. 84 JMR 111 E2 (2) - 2018