Interactive Cardiovascular and Thoracic Surgery 3:129-131(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Conversion to total cavopulmonary connection 9 years after closure of a large ventricular septal defect
Takashi Miura,
Yukihisa Isomatsu*,
Toshiharu Shin'oka and
Hiromi Kurosawa
Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo, Japan
* Corresponding author. Division of Cardiovascular Surgery, Department of Surgery, Yokohama City University School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan. Tel.: +81-45-787-2645; fax: +81-45-786-0226
isomatsu{at}med.yokohama-cu.ac.jp
Received August 25, 2003;
received in revised form September 24, 2003;
accepted October 21, 2003
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Abstract
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We performed an extracardiac total cavopulmonary connection (TCPC) operation using tissue-engineered graft for a patient with elevated central venous pressure due to severe tricuspid valve insufficiency 9 years after closure of a large ventricular septal defect. Before the TCPC, this patient had a right atrial thrombus and pulmonary embolism for which thrombolytic therapy was ineffective. The patient has been receiving anticoagulation therapy with both warfarin sodium and aspirin for 10 months after TCPC operation to avoid thrombotic complications. TCPC may be an alternative in selected patients with failing biventricular repair.
Key Words: Total cavopulmonary connection; Tissue-engineered graft; Pulmonary embolism; Tricuspid insufficiency
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1. Case report
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The patient, a 14-year-old female, had undergone pulmonary artery banding at the age of 1 month and patch closure of a large ventricular septal defect (so-called ‘type C single ventricle’ by Van Praagh) at 5 years of age. She underwent removal of a right atrial thrombus, found accidentally in an outpatient unit, concomitant with DeVega type tricuspid annuloplasty at 10 years of age. Despite aspirin treatment thereafter, at the age of 12 she required repeat surgery consisting of removal of a right atrial thrombus with tricuspid valvuloplasty using with autopericardium and Maze III procedure. However, paroxysmal atrial flutter occurred and recurrent right atrial thrombus formation and pulmonary embolism developed for which thrombolytic therapy was ineffective. Results of catheterization 28 days before the TCPC operation indicated a primary diagnosis of severe tricuspid insufficiency. Mean superior vena cava (SVC) pressure was 19 mmHg, which was equivalent to systolic pressure of the right ventricle and mean pressure of the pulmonary artery (Table 1).
With the approval of the ethics committee at Tokyo Women's Medical University, we began the clinical application of TEG [1]. Informed consent was obtained from both the patient and her parents.
The TEG was constructed as previously described [1,2]. As the cell source, CD34-positive cells (1x108 mononucleocytes) [3]were isolated by Clinimax® (AmCell GmbH, Bergisch Gladbach. Germany) from autologous bone marrow cells, which were seeded onto a biodegradable scaffold [2].
With the patient under general anesthesia in the supine position, third revision by median sternotomy was made. After dissection of the great arteries and vena cavae, standard cardiopulmonary bypass was started with ascending aortic perfusion and direct bicaval drainage. TCPC anastomosis using TEG was performed under total bypass with beating heart. The transected SVC was anastomosed to the upper surface of the right pulmonary artery in an end-to-side fashion. The right atrium was opened and the mural thrombus (weight 70 g) completely removed. Annuloplasty of the tricuspid valve was performed to decrease the annular diameter to 10 mm, which could admit only coronary venous blood flow. Redundant right atrial wall was removed to preserve and maintain the function of the sinoatrial node, and the remaining right atrial wall was closed. The inferior vena cava (IVC) was transected at the inferior cavoatrial junction. A TEG (diameter 24 mm) was selected according to the IVC orifice size and was sutured to the IVC end-to-end. The caudal aspect of the central pulmonary artery was opened widely, then the other end of the TEG was sutured to the pulmonary artery with a conduit offset 5 mm toward the proximal pulmonary artery. Cardiopulmonary bypass time was 193 min.
Postoperative catheterization (44 days after TCPC conversion) showed no pressure gradient or stenosis across the vena cavae and the TEG, and that the cardiac index had increased from 1.9 preoperatively to 2.5 (Fig. 1 and Table 1). Discharge was on the 46th postoperative day. The patient has been receiving anticoagulation therapy with both warfarin sodium and aspirin for 10 months after operation.
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Fig. 1 Postoperative angiogram showed that the patent TEG had no stenotic portion and no aneurysmal change. Note that both the left and right pulmonary arteries were enhanced by blood flow from the inferior vena cava.
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2. Discussion
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By removing the excessively redundant right atrial wall and performing an extracardiac TCPC, the patient's clinical condition improved markedly. The cardiac index increase supported this observation (Table 1). Post-bypass hemodynamics was maintained without fenestration. Improved left ventricular function was confirmed by transesophageal echocardiogram, a mean SVC pressure of 17 mmHg that was lower than the preoperative value although measured immediately after pump-off, and good urination. Indeed, SVC pressure decreased to 12 mmHg at the 44th postoperative day. Hemodynamics was comparable to that of failing Fontan circulation due to a cylinder-like (non-contractile) right ventricle. The concept of our approach is similar to TCPC conversion for patients with failing Fontan circulation [4]. TCPC may be an alternative, even after biventricular repair, in selected patients.
Venous flow from the coronary sinus in this patient drained into the pulmonary artery through the right ventricle. Sano et al. reported a total right ventricular exclusion procedure consisting of resection of the right atrial and right ventricular free wall and TCPC [5]. In his procedure, coronary sinus blood flow was diverted into the left atrium through an atrial septal defect. We selected the right ventricle to be incorporated into pulmonary circulation to avoid a systemic embolism because of the patient's prior right atrial thrombus and pulmonary embolism. One and a half ventricle repair was another treatment option. However, the main purpose of this operation was to remove and minimize the redundant and arrhythminogenic right atrial wall that was prone to be an origin of thrombus. Two previous operations were, despite anticoagulation therapy after each, not efficient in preventing a right atrial thrombus, presumably because tricuspid regurgitation was not controlled sufficiently.
Of concern is the fate of TEG in this patient. The biodegradable scaffold employed here is designed to disappear in 3–5 years and the entire structure of the extracardiac conduit will be replaced by autologous tissue. Therefore, we believe that TEG during a TCPC operation has several theoretical advantages [1], one of which is growth potential. Anticoagulation therapy after extracardiac TCPC using TEG in our institute employs both warfarin sodium and aspirin for the first 6 months and aspirin alone for 6 months thereafter. However, to avoid thrombotic complications in this patient, both warfarin sodium and aspirin will be continued until 12 months after TCPC operation. She has done well since the TCPC operation, although follow-up has been only 10 months. A longer follow-up period is required to clarify the late clinical outcome for TEG.
doi:10.1016/S1569-9293(03)00235-4
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References
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- Isomatsu Y, Shin'oka T, Matsumura G, Hibino N, Konuma T, Nagatsu M, Kurosawa H. Extracardiac total cavopulmonary connection using tissue-engineered graft. J Thorac Cardiovasc Surg. 2003;126:1958–1962[Abstract/Free Full Text]
- Matsumura G, Hibino N, Ikada Y, Kurosawa H, Shin'oka T. Successful application of tissue engineered vascular autografts; clinical experience. Biomaterials. 2003;24:2303–2308[CrossRef][Medline]
- Bhattacharya V, McSweeney PA, Shi Q, Bruno B, Ishida A, Nash R, Storb RF, Sauvage LR, Hammond WP, Wu MH. Enhanced endothelialization and microvessel formation in polyester grafts seeded with CD34(+) bone marrow cells. Blood. 2000;95:581–585[Abstract/Free Full Text]
- Mavroudis C, Backer CL, Deal BJ, Johnsrude C, Strasburger J. Total cavopulmonary conversion and maze procedure for patients with failure of the Fontan operation. J Thorac Cardiovasc Surg. 2001;122:863–871[Abstract/Free Full Text]
- Sano S, Ishino K, Kawada M, Kasahara S, Kohmoto T, Takeuchi M, Ohtsuki S. Total right ventricular exclusion procedure: An operation for isolated congestive right ventricular failure. J Thorac Cardiovasc Surg. 2002;123:640–647[Abstract/Free Full Text]
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Abstract
1. Case report