J Thorac Cardiovasc Surg 2005;129:210-212
© 2005 The American Association for Thoracic Surgery
A simple surgical technique for interventional transcatheter completion of the total cavopulmonary connection
Igor E. Konstantinov, MD, PhDa,*,
Lee N. Benson, MD, FRCPCb,
Christopher A. Caldarone, MDa,
Jia Li, MD, PhDb,
Mikiko Shimizu, MDb,
John G. Coles, MD, FRCSCa,
Glen S. Van Arsdell, MD, FRCSCa,
William G. Williams, MD, FRCSCa
a Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
b Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
Received for publication April 8, 2004; revisions received April 14, 2004; accepted for publication April 20, 2004.
* Address for reprints: Igor E. Konstantinov, MD, Division of Cardiovascular Surgery, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8 Canada (E-mail: igorkonst{at}hotmail.com).
Since the initial description of interventional completion of total cavopulmonary connection (TCPC),1 few surgical maneuvers to prepare the heart for subsequent transcatheter univentricular repair have been reported.2,3 Herein, we describe a simple technique that permits surgical preparation on the beating heart.
 |
Technique
|
|---|
The present technique evolved during experimentation in a porcine model. After approval by the Institutional Animal Care and Use Committee of the Research Institute in the Hospital for Sick Children, 4 Yorkshire pigs weighing 15, 20, 25, and 30 kg underwent a 2-staged procedure as described below. Superior vena cava (SVC) and inferior vena cava (IVC) were encircled with silk tapes in the first 3 animals to provide support for the covered stent (NuMed Inc, Hopkinton, NY). These support tapes were replaced with external stents (CP stent 8219, NuMed Inc) in the last animal.
Stage 1: Surgical preparation
Standard premedication, anesthesia induction, endotracheal intubation, muscle relaxation, and ventilation were achieved. Anesthesia was maintained with 1.5% to 2% isoflurane. The heart was exposed through a midline sternotomy. Heparin (300 IU/kg) was administered intravenously, and bicaval cannulation for cardiopulmonary bypass (CPB) was achieved. After institution of CPB, the caval veins were occluded by tourniquets, the right atrium (RA) was crossclamped below the sinus node, and the SVC was divided (Figure 1, A and B). A bidirectional cavopulmonary shunt was performed with the heart beating. The cardiac end of the divided SVC was anastomosed to the unopened inferior wall of the right pulmonary artery (RPA; Figure 1, B and C). A 16-mm-long stent (CP stent 8219, NuMed Inc) was opened longitudinally and placed around the cardiac stem of the SVC, and a similar 22-mm-long stent was placed around the IVC above the diaphragm (Figure 1, C). The approximated edges of each stent were secured together with 2-0 Prolene sutures (Ethicon, Inc, Somerville, NJ) to re-establish circular continuity (Figure 1, C and D). CPB was weaned and discontinued.
View larger version (46K):
[in this window]
[in a new window]
|
Figure 1. Stage 1: surgical preparation. The superior vena cava (SVC) is mobilized and transected high above the sinoatrial (SA) node (A). The SVC is anastomosed to the right pulmonary artery (RPA). With the right atrium (RA) crossclamped below the SA node, the proximal end of the SVC is enlarged (B) and anastomosed blindly to unopened RPA (C). After establishing of the bidirectional cavopulmonary shunt, 2 stents are placed around the atriocaval junctions (C). Both stents are visible on fluoroscopy (D). Ao, Aorta; LPA, left pulmonary artery; RV, right ventricle.
|
|
Stage 2: Interventional catheter completion
Venous access was established percutaneously through the right femoral vein. A long 8F dilator (Mullins, Cook Inc, Bloomington, Ind) was guided through the RA into the stent-banded SVC stump. A straight 18-gauge transseptal needle (Cook Inc) perforated the anastomosis into the RPA. With the needle as a guide, the dilator was advanced into the RPA. The needle was then removed, and an extra-stiff interventional wire (Amplatz type, 0.035 in, Cook Inc) was positioned into the SVC. The dilator was removed, and a 14F Mullins sheath (Cook Inc) was guided into the RPA (Figure 2, A). Through the long sheath, a covered 50-mm-long cavopulmonary stent (NuMed) was guided to straddle the SVC and IVC external stents and dilated (Figure 2, B). Balloon dilatation of the covered stent against the previously placed external stents was performed (Figure 2, B). The TCPC was established on balloon deflation and removal (Figure 2, C). Angiography demonstrated a patent TCPC (Figure 2, D).
View larger version (69K):
[in this window]
[in a new window]
|
Figure 2. Stage 2: interventional catheter completion. The catheter is introduced into the right atrium (RA), and the right pulmonary artery (RPA) is perforated (A). A covered stent graft is expanded against the superior and inferior stents (B). The inferior vena caval (IVC) blood flow is diverted to the pulmonary circulation by means of the covered stent graft (C). Contrast is injected into the completed total cavopulmonary connection (D). Ao, Aorta; LPA, left pulmonary artery; RV, right ventricle; SVC, superior vena cava.
|
|
|
Results
|
|---|
All 4 animals survived and maintained normal sinus rhythm throughout both stages of the procedure. Successful TCPC was established in all animals without bleeding, stent displacement, or perforation.
|
Discussion
|
|---|
Sidiropoulos and colleagues2 reported a technique that combined a bidirectional cavopulmonary shunt and an intra-atrial lateral wall polytetrafluoroethylene baffle (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz) with multiple perforations to allow blood flow from the IVC into the atrium. The cardiac end of the SVC was subtotally banded. This method requires aortic crossclamping and IVC blood flow through the small perforations that might close while the patient awaits TCPC completion. Klima and colleagues3 reported experimental techniques, in which the unidirectional cavopulmonary shunt to the RPA was established off pump by means of a polytetrafluoroethylene graft and connected to the IVC through a self-expanding stent graft. Cheatham and associates4 and Murphy and coworkers5 have recently reported a similar approach by using a hemi-Fontan connection.
This new technique has the following advantages compared with previously described methods. It does not require cardiac arrest. A bidirectional cavopulmonary shunt can be established with the use of CPB but, if desired, without CPB aided by a temporary SVC-to-RA shunt. A fenestration of the intracardiac covered stent can be performed if needed. The stent graft could be dilated by using a catheter later in life to accommodate a patient's growth. The external caval stents are visible on fluoroscopy, providing an excellent marker for later percutaneous TCPC completion, as well as a buttress for the covered graft to expand within, allowing for a more reliable hemostatic seal. Finally, the IVC stent allows placement of the covered graft away from the hepatic veins.
|
References
|
|---|
- Hausdorf G, Schneider M, Konertz W. Surgical preconditioning and completion of total cavopulmonary connection by interventional cardiac catheterization: a new concept. Heart. 1996;75:403-409.[Abstract/Free Full Text]
- Sidiropoulos A, Ritter J, Schneider M, Konertz W. Fontan modification for subsequent non-surgical Fontan completion. Eur J Cardiothorac Surg. 1998;13:509-512.[Abstract/Free Full Text]
- Klima U, Peters T, Peuster M, Hausdorf G, Haverich A. A novel technique for establishing total cavopulmonary connection: from surgical preconditioning to interventional completion. J Thorac Cardiovasc Surg 2000;120:1007-1009.[Free Full Text]
- Cheatham JP, Galantowicz M, Torres W, Tower AJ, Hill SL, Kleinman CS, et al. The use of custom-made covered NuMed CP stents in the treatment of congenital heart disease [abstract]. Catheter Cardiovasc Interv. 2002;57:100.
- Murphy JD, Murdison KA, Nehgme RA, Pizzaro C, Norwood WI. Catheter facilitated completion of Fontan procedure [abstract]. Circulation. 2003;108(suppl IV):704.
This article has been cited by other articles:
|
|
|
|
 
B. Alsoufi, F. Alfadley, A. Al-Omrani, A. Awan, M. Al-Ahmadi, M. Al-Fayyadh, Z. Al-Halees, and C. C. Canver
Hybrid Management Strategy for Percutaneous Fontan Completion Without Surgery: Early Results
Ann. Thorac. Surg.,
February 1, 2011;
91(2):
566 - 573.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
O. Metton, D. Calvaruso, B. Stos, W. B. Ali, and Y. Boudjemline
A new surgical technique for transcatheter Fontan completion
Eur J Cardiothorac Surg,
January 1, 2011;
39(1):
81 - 85.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
I. E. Konstantinov
Editorial comment: Transcatheter completion of Fontan circulation: primum non nocere!
Eur J Cardiothorac Surg,
January 1, 2011;
39(1):
85 - 86.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Sallehuddin, A. Mesned, M. Barakati, M. A. Fayyadh, F. Fadley, and Z. Al-Halees
Fontan completion without surgery
Eur J Cardiothorac Surg,
August 1, 2007;
32(2):
195 - 201.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Technique
Results