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J Thorac Cardiovasc Surg 1995;109:187-188
© 1995 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of Cardiothoracic Surgery
Medical College of Wisconsin
8700 West Wisconsin Ave.
Milwaukee, WI 53226
To the Editor:
Carbon dioxide insufflation of the pericardial space is an old technique used to lessen the prevalence and consequences of air embolism after open cardiac procedures. My former mentor, Dr. James V. Maloney, Jr., used the technique routinely during my years of training in the early 1970s, but I subsequently set it aside along with other supposed relics when I started my own practice. A recent operative situation provided opportunity for its recrudescence.
An elderly patient required mitral valve replacement and redo right coronary artery grafting after having undergone two previous coronary revascularization procedures. The second had been performed by me and included a sequential left internal thoracic artery graft to the anterior descending system and implantation of a cardioverter-defibrillator system with intrapericardial patches and sensing leads. The patient had marked left ventricular enlargement. Adhesions within the pericardial space were formidable. I elected not to dissect the left ventricle. The problem was to ensure complete de-airing after completion of the mitral valve replacement in a circumstance in which I was assured of leaving some air within the left ventricular cavity. One of my perfusionists, David Koerten, responded to my verbalized concern about de-airing by suggesting that I wash out the ventricle with carbon dioxide.
I have been using continuous warm retrograde blood cardioplegia to perform coronary revascularizations for about 2
years and have developed a simple sprayer to clear the operative field of blood. This consists of crystalloid solution driven by filtered carbon dioxide. Carbon dioxide is delivered from a pressurized tank with regulator, through a 0.2µm filter, and a 6-foot high-pressure line. In this circumstance, I connected the high-pressure line to an 8F red rubber catheter affixed with a Christmas tree adaptor. I threaded the catheter through the central orifice of the St. Jude Medical valve (St. Jude Medical, Inc., St. Paul, Minn.). While the traditional left atriotomy was closed, carbon dioxide was bubbled into the left ventricle at approximately 500 ml/min. Gas exited through the atriotomy as well as through a hole in the ascending aorta made for a proximal anastomosis of a replacement right coronary artery graft. The left atriotomy was left a bit loose to permit blood to vent. As I performed the proximal aortic vein graft anastomosis, I administered terminal continuous retrograde infusion of blood cardioplegic solution warmed to 37° C. Blood filled the aorta and the left ventricle through the aortic valve, made incompetent with external pressure. The carbon dioxide flush was discontinued as both aortic and atrial suture lines were closed. A needle vent was placed in the ascending aorta between the aortic anastomosis and the aortic valve, and the patient was placed in a deep Trendelenburg position. The crossclamp was removed. The heart began to beat spontaneously and eject immediately.
To my surprise and gratification, imaging of the left ventricle and left atrium via transesophageal echocardiography showed absolutely echo-free chambers. There were no floating bubbles, virtually always seen, even after aggressive de-airing of the aorta and apex of the left ventricle. The patient was weaned from cardiopulmonary bypass without incident. No suggestion of air in the right coronary graft was detected at any time, and the patient awakened promptly without evidence of neurologic compromise.
Since this experience, I have gone back to carbon dioxide displacement of the pericardium during all valve replacements and aortic procedures. I supplement this with intraventricular carbon dioxide displacement before removal of the aortic crossclamp. For mitral valve replacements I displace any residual air by flowing carbon dioxide into the ventricle transatrially through the repaired native valve or the prosthesis. For aortic valve replacements I deliver carbon dioxide retrogradely through the left ventricular apex. I have had three subsequent difficult mitral valve replacements that were redo procedures. I have elected to leave the left ventricles undissected in each circumstance and have de-aired in the manner described. In two of these patients, a superior septal incision was used. The red rubber catheter was brought out through both the interatrial septum and the right atrium. The technique could also be used for mitral valve surgery via right or left thoracotomy. In a recent article describing some difficult and beautifully managed redo mitral and aortic valve procedures, Michielon and Doty
1 comment on the trickiness of de-airing in these circumstances. Carbon dioxide displacement certainly could have been useful in these cases.
Transesophageal echocardiographic monitoring of these patients has demonstrated universally that the left atrium and left ventricle have been completely free of apparent air bubbles immediately on release of the aortic clamp and return of cardiac activity. This would appear to confirm efficacy beyond any subjective notions of clinical well-being.
Ironically, shortly after pulling this old technique off the shelf, I ran across a letter to the editor by Dr. William J. Kolff offering a similar insight to surgeons young and old. 2 He made reference to the use of carbon dioxide for de-airing ventricular support systems. Dr. Denton Cooley, in an accompanying editorial comment, tended to dismiss the current need for carbon dioxide displacement. I disagree. It is a remarkably effective, very simple tool to lessen the chance of air embolism to both heart and brain. Others may find it similarly useful.
References
This article has been cited by other articles:
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  P. Svenarud, M. Persson, and J. van der Linden Efficiency of a gas diffuser and influence of suction in carbon dioxide deairing of a cardiothoracic wound cavity model J. Thorac. Cardiovasc. Surg., May 1, 2003; 125(5): 1043 - 1049. [Abstract] [Full Text] [PDF]
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 P. Svenarud, M. Persson, and J. van der Linden Intermittent or Continuous Carbon Dioxide Insufflation for De-Airing of the Cardiothoracic Wound Cavity? An Experimental Study with a New Gas-Diffuser Anesth. Analg., February 1, 2003; 96(2): 321 - 327. [Abstract] [Full Text] [PDF]
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 E. M Nadolny and L. G Svensson Carbon dioxide field flooding techniques for open heart surgery: monitoring and minimizing potential adverse effects Perfusion, March 1, 2000; 15(2): 151 - 153. [Abstract] [PDF]
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 W. R. Webb, L. H. Harrison Jr, F. R. Helmcke, A. Camino-Lopez, N. A. Munfakh, H. A. Heck Jr, and P. V. Moulder Carbon Dioxide Field Flooding Minimizes Residual Intracardiac Air After Open Heart Operations Ann. Thorac. Surg., November 1, 1997; 64(5): 1489 - 1491. [Abstract] [Full Text]
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J. A. Odell, J. L. Blackshear, E. Davies, W. J. Byrne, C. F. Kollmorgen, W. D. Edwards, and T. A. Orszulak Thoracoscopic Obliteration of the Left Atrial Appendage: Potential for Stroke Reduction? Ann. Thorac. Surg., February 1, 1996; 61(2): 565 - 569. [Abstract] [Full Text]
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M. Kurusz, B. D Butler, J. Katz, and V. R Conti Air embolism during cardiopulmonary bypass Perfusion, November 1, 1995; 10(6): 361 - 391. [PDF]
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