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(BQ) Part 1 book Reoperations in cardiac surgery has contents: Investigation before reoperations for congenital heart disease, investigations before reoperation for acquired heart disease, anaesthesia for cardiac reoperations, reoperations in the presence of infection,... and other contents.
J Stark and A.D Pacifico (Eds.) Illustrations by M Courtney Reoperations in Cardiac Surgery Foreword by David C Sabiston, Jr With 388 Figures Springer-Verlag London Berlin Heidelberg New York Paris Tokyo Hong Kong Jaroslav Stark, MD, FRCS, FACS Consultant Cardiothoracic Surgeon, The Hospital for Sick Children, Great Ormond Street, London WCIN 3JH, UK Albert D Pacifico, MD Professor and Director, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, University Station, Birmingham, Alabama 35294, USA ISBN-13:978-1-4471-1690-5 e-ISBN-13:978-1-4471-1688-2 DOl: 10.1007/978-1-4471-1688-2 British Library Cataloguing in Publication Data Reoperations in cardiac surgery I Man Heart Surgery I Stark, J (Jaroslav), 1934II Pacifico, A.D.(Albert D.) 617'.412 ISBN-13:978-1-4471-1690-5 Library of Congress Cataloging-in-Publication Data Stark,·J (Jaroslav) Reoperations in cardiac surgery / J Stark and A.D Pacifico (eds.) ; foreword by D Sabiston p cm Includes bibliographies and index ISBN 0-387-19552-1 Heart-Reoperation Congenital heart disease-Reoperation I Pacifico, Albert D II Title [DNLM: I Heart Surgery Surgery Operative WG 169 S795r) RD598.35.R46S73 1989 617' 12 dc19 DNLMIDLC 89-6080 for Library of Congress CIP This work is subject to copyright All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation broadcasting, reproduction on microfilms or in other ways, and storage in data banks Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid Violations fall under the prosecution act of the German Copyright Law © Springer-Verlag Berlin Heidelberg 1989 Softcover reprint of the hardcover 1st edition 1989 The use of registered names, trademarks etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book In 'every individual case the respective user must check its accuracy by consulting other pharmaceutical literature Filmset by Photographics, Honiton, Devon 2128/3916-543210 (Printed on acid-free paper) Foreword Nearly a century has passed since Rehn performed the first successful cardiac operation by closing a right ventricular stab wound in a gravely ill patient Moreover, it has been more than fifty years since Gross successfully corrected the first congenital cardiac malformation in 1938 by suture ligation of a patent ductus arteriosus The introduction of the Blalock operation for tetralogy of Fallot by Blalock in 1944 greatly advanced the management and prognosis of a critically ill group of cardiac patients, and the success of this procedure further stimulated the development of concepts and techniques for the surgical management of other severe congenital cardiac defects Until the successful use of extracorporeal circulation by Gibbon in 1953, it was often necessary to perform cardiac operations which were palliative rather than curative procedures With the advent of additional new and improved techniques, correction of many hitherto incurable cardiac disorders became possible and reoperation under these circumstances became frequent Cardiac surgery is very fortunate in having two master surgeons, whose distinctive contributions and clinical proficiency are recognized worldwide, to edit this extraordinary and unique text They have placed emphasis on a number of specific complications of primary cardiac procedures which lead to the necessity for reoperation Problems associated with postoperative infections, thrombotic disorders, stenoses of suture lines, deterioration of prosthetic materials and mechanical valves, rejection of transplanted organs and tissues, and a host of additional complications are described together with their appropriate surgical management The ·Editors have selected 14 other authorities in both acquired and congenital disease to record their experiences and solutions to these vexing problems The initial chapters concern the necessity to obtain preoperatively as much information as possible on the cardiac lesions requiring correction Specific attention is given to the roles of angiocardiography, digital subtraction angiography, cardiac catheterization, echocardiography, chest roentgenography, computed transaxial tomographic scanning (CT), magnetic resonance imaging, electrocardiography, and other appropriate techniques The authors deserve special commendation for the thoroughness found in each section as well as the excellence of the illustrations which depict the stepwise correction of the various problems Similarly, examples of the diagnostic studies are beautifully reproduced with their significant features being made obvious to the reader Each subject is carefully referenced with a select and up-to-date bibliography It is apparent that the authors have given each subject maximal thought and attention in the preparation of this very laudable text Each of the common cardiac procedures is included as are a number of less frequently encountered but nevertheless very significant problems requiring vi Foreword reoperation The reader is particularly struck with the obvious familiarity of each contributor with the subject presented, which provides gratifying confidence to those undertaking these reoperations In summary, Reoperations in Cardiac Surgery is a very timely contribution edited by two of the most renowned contemporary cardiac surgeons with additional contributors of similar stature Of maximal current significance, this masterwork will predictably become a widely used and frequently cited reference as well as an essential part of the library of all cardiac surgeons May 1989 David C Sabiston, Jr Preface More cardiac operations are performed each year The incidence of reoperations is also increasing There are several reasons for this increase: failure of mechanical and biological valve substitutes, conduits and coronary bypass grafts, erroneous diagnosis, incomplete repair and infection In surgery of congenital heart defects replacement of the original prosthetic valve is required if the child outgrows the prosthesis Reoperation may also be part of a staged repair for a complex lesion or may be required for residual or recurring defects The purpose of this book is to provide information about the diagnosis of early and late complications, the indications for reoperation and the optimal timing of reoperation The main emphasis is on the description of safe surgical techniq"ues The book is divided into three sections The general part includes chapters on diagnosis, anaesthesia, surgical approaches to the heart and great vessels, reoperations in the presence of infection, postoperative mediastinitis, pacemakers, and heart and heart-lung transplantation The second section describes surgical techniques used for reoperations of congenital heart defects All common defects are included To avoid repetition and too lengthy text some combinations of lesions are not discussed separately They are described either in the congenital or the acquired heart defect section although they can have both aetiologies The third section on acquired heart disease includes chapters on coronary arteries, mitral and tricuspid valves, arrhythmia and thoraco-abdominal aneurysms The authors describe the techniques which gave them, over the years, the best results Some alternatives are mentioned without an attempt to cover all published techniques The text relies on Michael Courtney's illustrations He worked very closely with the Editors and was able to transform sketches made by individual authors into instructive three-dimensional illustrations With a few exceptions all drawings are oriented as the heart is seen by the operating surgeon This book should provide information to a young surgeon who does not have a large experience with reoperations We hope that it will also be useful to established surgeons, especially in the chapters on the less common lesions or complications It may also be of interest to cardiologists, cardiac anaesthetists, radiologists, intensive care personnel and nurses We believe that a well-performed original operation will lead to a minimal number of complications However, when residual or recurring defects cause haemodynamic problems, correctly timed and expertly performed reoperations may return the patient to normal health and an active life We hope that the book will contribute to this goal J Stark, MD, FRCS, FACS Consultant Cardiothoracic Surgeon A.D Pacifico, MD Director, Division of Cardiothoracic Surgery Acknowled2ements We would like to express our thanks to Dr G.R Graham, former Clinical Physiologist at The Hospital for Sick Children, Great Ormond Street, for his suggestion to write this book Our thanks are due to all the contributors for preparing the text, for allowing considerable e~itorial changes to achieve uniformity and for their co-operation in working with one artist Michael Courtney made a great contribution to this book His clear understanding of the points we wanted to illustrate and his ability to transfer them into highquality illustrations will, we hope, be appreciated by the readers Our thanks are due to our secretaries, Miss V Parkhouse, Miss P Hunter, and especially Mrs S Croot, Research Secretary in the Cardiothoracic Unit at The Hospital for Sick Children, Great Ormond Street, who has helped with the collection of the material, researched literature, and edited and transcribed all the manuscripts March 1989 J Stark, MD, FRCS, FACS Consultant Cardiothoracic Surgeon A.D Pacifico, MD Director, Division of Cardiothoracic Surgery Contents Contributors xix Abbreviations xxiii Section I: General Investigation Before Reoperations for Congenital Heart Disease F N Taylor Introduction Staged Procedures Residual Lesions Clinical Considerations Non-~nvasive I~ves.tigation Invasive Investigation Recurrent Lesions Changes Resulting from Growth, and Deterioration in Prosthetic Function Prognosis After Completion of Intended Management Conclusion : 5 10 13 Investigations Before Reoperation for Acquired Heart Disease Celia M Oakley Introduction Methods of Investigation Non-invasive Investigation Invasive Investigation Reasons for Failure of Previous Operations Wrong Indication or Wrong Operation Valve Disease After Pericardiectomy Special Problems , ; The Myocardium Marfan's Syndrome Myxoma and Other Cardiac Tumours Pregnancy Traumatic Heart Disease Emergencies 14 15 16 17 17 17 17 18 19 19 19 25 26 26 27 27 28 29 29 x Contents Mechanical Disasters Prosthetic Valve Thrombosis "Encapsulation" Infective Endocarditis Reoperation After Previous Coronary Bypass Surgery Pericardial Syndromes Postoperative Pericardial Collection Conclusion , 29 30 31 33 35 35 35 Anaesthesia for Cardiac Reoperations M Scallan Introduction Preoperative Assessment Anaesthesia Monitoring Specific Conditions Reoperation for Coronary Artery Bypass Grafts Valvar Heart Disease Congenital Heart Disease Postoperative Complications Conclusion 39 39 39 40 40 41 41 41 42 42 42 Approaches to the Heart and Great Vessels at Reoperation J Stark 43 Introduction Sternal Re-entry Prevention Operative Technique Results Re-thoracotomy Conclusion Reoperations in the Presence of Infection L H Cohn Introduction General Considerations Indications for Surgery Prosthetic Valve Endocarditis Infected Aortocoronary Bypass Infected Cardiac Suture Line Surgical Technique Reoperation in the Presence of Infected Prosthetic or Bioprosthetic Valves Surgical Technique for the Infected Cardiac Suture Line Surgical Treatment of Infected Coronary Bypass Graft Results Conclusions and Summary 43 44 44 45 51 51 52 55 55 55 56 56 57 57 58 58 64 64 65 66 Pacing: Indications, Technique of Insertion and Replacement of Leads and Generators P G Rees 67 Introduction ' 67 Description of Generators 67 Chapter 13 Reoperations After Repair of Tetralogy of Fallot A.D Pacifico Introduction The tetralogy of Fallot was first successfully repaired at the University of Minnesota in 1954 using controlled cross-circulation from another human being (Lillehei et al 1955) The first successful repair using a pump oxygenator was done at the Mayo Clinic in 1955 (Kirklin et al 1955) Patch enlargement of the infundibulum (Warden et al 1957) and of the pulmonary valve annulus (Kirklin et al 1959) was reported in the early years of surgical experience, while the use of a right ventricular-pulmonary artery conduit for tetralogy of Fallot with pulmonary atresia appeared later (Rastelli et al 1965; Ross and Somerville 1966) The subclavianpulmonary artery anastomosis for palliation of tetralogy was introduced in 1945 (Blalock and Taussig 1945) This was followed by a variety of systemic-pulmonary artery shunt procedures (Potts et al 1946; Davidson 1955; Waterston 1962; de Leval et al 1981) Relief of pulmonary stenosis by means of a closed palliative operation was described in 1948 (Sellors 1948; Brock 1948) The classic approach to repair of tetralogy of Fallot consists of relieving infundibular and valvar pulmonary stenosis and closing the VSD through a right ventriculotomy incision (Kirklin and Barratt-Boyes 1986) Alternatively, a trans- atrial-transpulmonary approach may be employed (Edmunds et al 1976; Binet et al 1983; Pacifico et al 1987) Specific guidelines were developed at the University of Alabama at Birmingham (UAB) to facilitate intraoperative decision-making regarding the need for transannular patching (Pacifico et al 1977; Blackstone et al 1979a) and also to allow prediction of post-repair right ventricular pressure from the preoperative cineangiogram (Blackstone et al 1979b) Reoperation after initial repair of tetralogy of Fallot is uncommon This occurred in 1.9% of 414 patients who underwent repair of tetrology of Fallot between 1967 and 1977 at UAB (Katz et al 1982) No reoperations were necessary in this experience after the first postoperative years This publication and those by Poirier et al (1977), Fuster et al (1980), Zhao et al (1985) and Lillehei et al (1986) describe the late survival, symptomatic status and need for reoperation after initial repair of tetralogy of Fallot (see Table 13.2) Reoperation may be required to close a residual VSD, relieve residual right ventricular outflow tract obstruction (RVOTO), repair or replace an incompetent tricuspid valve, repair a right ventricular outflow tract aneurysm, close a residual ASD, repair a residual surgical shunt, enlarge a stenotic branch pulmonary artery or pulmonary artery bifurcation, and 172 Reoperations in Cardiac Surgery relieve residual pulmonary insufficiency with orthotopic pulmonary valve replacement Table 13.3 lists the procedures performed at reoperation in 80 patients following initial repair of tetralogy of Fallot Table 13.4 shows the hospital mortality among a combined series of 122 reoperated patients The overall mortality of 13.1 % was greater than that for primary repaIr It must be emphasised at the outset that initial thorough and complete preoperative diagnostic studies and accurate intraoperative reparative methods are essential to minimise the need for subsequent reoperation Cineangiography with angled views (Bargeron et al 1977) is still necessary to provide accurate definition of the anatomy The number, size and location of the VSD must be precisely demonstrated The size of the pulmonary valve annulus, the main and branch pulmonary arteries and the presence of bifurcation or branch pulmonary artery stenoses should be accurately delineated Knowledge of the ratio of the diameter of the left and right pulmonary arteries before the upper lobe branch divided by the diameter of the aorta at the diaphragm (McGoon ratio) (Fig 13.1) allows estimation of the post-repair right/left ventricular peak pressure ratio (PRV/LV) (Fig 13.2) when a transannular patch is employed An incremen- 1.5 , , ' ' 0: ~ III !~ 0.5 o oo~.~~",L . ' '-col:-' ~~",w ~ow ~",' ' '-~o' ' ~W"'~~O a a N RPA DescThAo + C\I , , , , ::t" LPA DescThAo DIAMETER Fig 13.2 tal increase in post-repair P RV / LV may also be added when the pulmonary valve annulus is left intact and its magnitude is related to the Z value (Fig 13.3) The Z values shown on the vertical axis in Fig 13.3 describe the number of standard deviations away from the mean normal value (Z = 0) of a similar sized patient (Table 13.1) In actual practice we estimate the post-repair P RV / LV (assuming a transannular patch will be employed) from the preoperative cineangiogram (as in Fig 13.1) and from the nomogram in Fig 13.2 The diameters of the left and right pulmonary arteries are separately measured RV _Ao- Fig 13.1 Reoperations After Repair of Tetralogy of Fallot 0.7 :r: u ~ z 0.6 0.5 !! ~ ~ CL'" 0.'1 J 0.3 ~ 0.2 '"u 0.1 f!Z w ~ -2 -I z Fig 13.3 just proximal to the take-off of the upper lobe branch The diameter of the descending aorta at the level of the diaphragm is also measured (arrows in Fig 13.1) The McGoon ratio is calculated as the sum of the right and left pulmonary artery diameters divided by the diameter of the descending thoracic aorta and this is plotted on the horizontal axis of the nomogram shown in Fig 13.2 The predicted PRV/LV is determined from the McGoon ratio and the nomogram in Fig 13.2 If the predicted PRV/ LV is greater than about 0.75 then the pulmonary branches are considered too small for a satisfactory result from primary repair In this circumstance we would recommend an initial systemic-pulmonary artery shunt, usually with a Gore-Tex interposition graft, to stimulate enlargement of the pulmonary arteries (Kirklin et al 1977) If the predicted postrepair PRV/LV is 1.5 However, Uretzky et al (1982) found no clear correlation between the symptomatic status and the Op/Os One of their reoperated patients had an isolated residual VSD with a Op/Os of only 1.3 and was New York Heart Association functional Class III This patient became asymptomatic after reoperation Among 28 patients whose reoperation included closure of a residual VSD, the mean Op/Os was only 1.3 Therefore, even a small residual shunt after repair of tetralogy of Fallot may be poorly tolerated, particularly when in associ- Table 13.2 Reoperation after repair of tetralogy of Fallot Series Lillehei et al 1986 Fuster et al 1980 Zhao et al 1985 Poirier et al 1977 Katz et al 1982 No of hospital survivors 106 396 294 285 414 Period 1954-1960 1955-1964 1960-1982 1964-1970 1967-1977 "Includes 30 first reoperations and second reoperations Reoperations No % 10 9.4 4.8 13.3 1.8 1.9 19 39" Follow-up (years) Maximum Median 31 22 22 12 11.2 8.5 5.1 Reoperations After Repair of Tetralogy of Fallot 175 Table 13.3 Procedures performed at reoperation in 80 patients Lesion Zhao et al 1985 (n = 39) Uretzky et al 1982 (n = 41) Total No No No % Closure of VSD Repair of RVOTO Repair of pulmonary insufficiency Repair of tricuspid valve incompetence Right ventricular aneurysm repair Other" 12 18 11 22 33 20 9 Total 55 % 16 28 12 41 18 12 100 68 % \3 40 30 19 11 18 33 24 15 15 100 123 100 "Includes closure of residual patent ductus (1) or systemic-pulmonary artery shunt (4) and repair of shunt aneurysm (I), closure of ASD (6), ligation of bronchial collateral arteries (2), replacement of ascending aorta (I), repair of aortic valve incompetence (1), replacement of an incompetent mitral valve (I), and removal of a calcified homograft (I) ation with other defects such as pulmonary incompetence, RVOTO or tricuspid insufficiency Residual RVOTO Repair of residual RVOTO is the second commonest procedure performed at reoperation after initial repair of tetralogy of Fallot (Table 13.3) Zhao et al (1985) identified the type of right ventricular outflow tract reconstruction at the initial operation as an independent significant determinant of the need for reoperation However, the type of outflow tract patch material was unrelated The likelihood of reoperation at 10 years was 6% ± 3% if simply a right ventricular and/or a separate pulmonary artery patch was employed, 11% ± 4% if no right ventricular outflow tract patch was necessary, and 21 % ± 5% if a transannular patch was employed In the last subset, the lesions responsible for reoperation were related to persistent RVOTO and no patient required reoperation for isolated pulmonary incompetence Residual RVOTO may be at the infundibulum, pulmonary valve and/or annulus or the main branch pulmonary arteries It may be the sole residual defect after primary repair or, more often, may be associated with other defects as described above (Uretzky et al 1982) Doppler echocardiography usually provides a reliable estimate of the magnitude of residual obstruction and also the presence of associated abnormalities A peak systolic gradient of ;;;;.50 mmHg is considered significant and is generally an indication for reoperation, particularly in the symptomatic patient However, Uretzky et al (1982), reported no correlation between the severity of RVOTO and the symptomatic status of patients before reoperation Eight of their eleven patients who underwent reoperation for RVOTO had additional defects High-quality angiography with multiple angled views should be performed prior to reoperation to define clearly the anatomic status of the right ventricular outflow tract, pulmonary valve and annulus, and the main, bifurcation and branch pulmonary arteries (Bargeron et al 1977) Such studies performed prior to initial repair are essential to permit initial complete surgical correction of additional levels of obstruction (e.g bifurcation stenosis) that might otherwise have remained unrecognised and to reduce the incidence of late RVOTO Pulmonary Insufficiency Pulmonary valve incompetence is present in all patients who have had trans annular patching as part of their repair, and in some patients without transannular patching because of incomplete coaptation of their diseased pulmonary valve leaflets or excision of a leaflet at the time of repair The diagnosis can often be confirmed by auscultation and an estimate of the magnitude of pulmonary incompetence 176 can be made non-invasively by colour Doppler echocardiography Wessel and colleagues (1980) have demonstrated that pulmonary valve incompetence results in reduced exercise capacity regardless of the post-repair right ventricular systolic pressure Fuster et al (1980) evaluated the clinical status of 396 hospital survivors between 12 and 22 years postoperatively Significant pulmonary valve incompetence contributed to some type of disability in only 1% of this group It was associated with a 5% incidence of cardiomegaly Bove et al (1983) have demonstrated impaired right ventricular function late postoperatively by radionuclide angiography Graham and colleagues (1976) have shown significantly greater right ventricular end-diastolic volumes in patients after transannular patching compared with those without patching All of these considerations support the idea that a trans annular patch should be used only when necessary and also raise serious concern regarding the very long-term effects of important pulmonary valve incompetence Although repair of pulmonary insufficiency was performed in 11 of 39 patients who underwent reoperation in the series reported by Zhao et al (1985), and in of 41 patients in the series reported by Uretzky et al (1982), none of these patients required reoperation for isolated pulmonary insufficiency (Table 13.3) Misbach and colleagues (1983) reported their experience with 12 patients who underwent pulmonary valve replacement 4.5 months to 11 years after initial repair of tetralogy of Fallot All patients had progressive right ventricular failure which was not responsive to medical management and none had severe RVOTO, residual VSDs or persistent systemic-pulmonary artery shunts When pulmonary regurgitation is present in asymptomatic patients, they not recommend operation since this haemodynamic abnormality is usually well tolerated They agree, however, that as longer follow-up occurs, the question of the proper timing of pulmonary valve replacement in asymptomatic patients may become important This may be similar to the proper timing of aortic valve replacement in asymptomatic adults with severe aortic regurgitation Echocardiographic assessment of right ventricular function and size, coupled with serial exercise Reoperations in Cardiac Surgery testing, may be helpful in making this decision Symptomatic patients with isolated severe pulmonary regurgitation clearly benefit from pulmonary valve replacement At U AB, we currently recommend careful long-term follow-up of patients receiving transannular patches as part of repair of their tetralogy of Fallot Orthotopic pulmonary valve insertion is currently advised by us when progressive cardiac enlargement is demonstrated, even in asymptomatic patients Although the precise timing of this is difficult, when the plain chest radiograph shows that the right ventricle is enlarged grade (on a scale of 0-6) we would recommend orthotopic pulmonary valve insertion Tricuspid Valve Insufficiency Tricuspid valve insufficiency after repair of tetralogy of Fallot has varied aetiology and is usually not the sole residual cardiac defect Tricuspid valve repair or replacement is usually done concomitantly with repair of additional associated residual defects The diagnosis and magnitude of incompetence can be established non-invasively by colour flow Doppler echocardiography Operation is advised when incompetence is severe and symptoms of heart failure and/or exercise intolerance are present Complete and accurate diagnosis of possible coexistent residual defects should be established by cardiac catheterisation studies, and concomitant repair of these defects should be carried out Severe tricuspid valve insufficiency in a symptomatic patient is an indication for reoperation to repair or replace the tricuspid valve However, when reoperation is advised for another residual defect and more than mild tricuspid valve incompetence coexists, the valve should be inspected intraoperatively and concomitantly repaired Right Ventricular Aneurysm A right ventricular outflow tract aneurysm can occur after repair of tetralogy of Fallot with pericardial or Dacron transannular patches 177 Reoperations After Repair of Tetralogy of Fallot as well as in patients in whom the right ventriculotomy incision was closed primarily Three of eight patients who received reoperation in the UAB experience were reoperated upon for aneurysm of the right ventricular outflow tract The peak right/left ventricular pressure ratio measured in the operating room immediately after the initial repair was 0.79 in one, 0.85 in another, and 1.0 in the third Each, therefore, had concomitant RVOTO Two of these three patients initially had a transannular patch and one had primary closure of a right ventriculotomy incision (Katz et al 1982) Similarly, in the report of Uretzky et al (1982), each of five patients who received reoperation for right ventricular outflow tract aneurysm also had other residual lesions The mean peak right/left ventricular pressure ratio before reoperation was 0.97, being 0.34 in one patient and> 1.0 in the remaining four Three of these five patients had primary closure of their right ventriculotomy incision and no outflow tract patch In the remaining two, a Dacron patch was used in one and a pericardial patch in the other to reconstruct the right ventricular outflow tract It is clear from these and other experiences that the development of right ventricular outflow tract aneurysm is primarily related to persistently high right ventricular pressure after repair Its development is not biased by the type of material used to reconstruct the outflow tract and it may occur in patients with primary closure of their right ventriculotomy incision The indication for operation is usually coexistent RVOTO, and the guidelines are indicated above When an aneurysm is enlarging, as evidenced by chest radiograph and echocardiographic findings, repair is advised even when RVOTO is absent, because of the threat of rupture Residual ASD The atrial septum should be inspected at the initial operation and any naturally occurring defect or surgically created defect for venting should be closed The accuracy of the closure is verified by inflation of the lungs, which fills the left atrium, while the right side of the septum is inspected for a residual defect Adherence to this policy should prevent the need of reoperation for residual ASD Reoperation is advised when a significant (Op/Os > 1.5) residual shunt is present Residual Surgical Shunt A residual shunt from a previously constructed systemic-pulmonary artery shunt should be closed when a Op/Os > 1.5 is present This may be accomplished by cardiac catheterisation and the use of intravascular coils Surgical Technique Repair of Residual or Recurrent VSD The surgical approach is via a secondary median sternotomy incision using the guidelines indicated in Chapter (see p 47) After establishing cardiopulmonary bypass with direct cannulation! of the ascending aorta and each vena cava, moderate hypothermia is induced, the aorta is cross-clamped and cold cardioplegic solution is administered into the aortic root Classically, recurrent or residual defects have been approached through the right ventricle, but I prefer a right atrial approach, particularly when the lesion is an isolated one The purse-string sutures for cannulation of each vena cava and the position of the right atriotomy are shown in Fig 13.4 The right atriotomy is made parallel to and about 2.0 cm to the right of the atrioventricular groove (Fig 13.4) Since the inferior vena caval cannula is placed to the right of the caval midline, the incision may be carried inferiorly to the left of or anterior to the caval cannulation site Stay sutures of 4-0 silk are placed from the right atrial flap to the subcutaneous tissue on the left side of the incision and also from the atrial wall on the right side of the incision to the subcutaneous tissue on the right This nicely exposes the right atrium A disposable sump tip vent! is placed through a stab incision I DLP, Grand Rapids, Michigan 178 Reoperations in Cardiac Surgery Fig 13.4 in the atrial septum to vent the left atrium (see Fig 13.5) Silk (5-0) sutures are placed on the tricuspid valve leaflets and tagged with a shodded curved clamp in order to provide gentle retraction Usually two sutures are placed on the septal leaflet and two on the anterior leaflet Exposure is facilitated by the use of cardioplegic solution, which provides a rather soft myocardium In some patients additional retraction is required and is best obtained with small eyelid retractors or rightResidual VSD angle retractors This approach provides good exposure of the perimembranous area as well as the inlet and mid-muscular septum Exposure of a subpulmonary VSD is less good from this approach, but in some cases it may also be satisfactory The commonest location for a residual VSD is in the posteroinferior quadrant, near the area of the conduction tissue This may be related to the surgeon's desire to avoid the area ·of the conduction tissue by placing the sutures more superficially The next most common site of disruption of the VSD patch is in the anterosuperior quadrant, which may be related to the infundibular resection and which may leave this area with fragile muscular tissue devoid of endocardium When this is recognised at the initial operation, supplemental pledgetted mattress sutures should be employed Uncommonly, a single overlooked additional defect or multiple muscular VSDs are responsible for the need for reoperation This situation can be avoided by preoperative high-quality left ventricular angiocardiograms demonstrating a profile of the ventricular septum Residual or recurrent defects are best repaired using a separate Dacron patch, unless they are quite small A residual defect in the anterior aspect of the original patch suture line is shown in Fig 13.5a The muscular tissue adjacent to the defect is generally tough from the development of endocardial fibrosis on its Patch Fig 13.5 edges The defect is closed with a Dacron patch sutured to the toughened muscular edge anteriorly and then to the edges of the previously placed patch which form the border of the residual defect (Fig 13.5b) Continuous 4o polypropylene suture is used When the defect is very tiny, it is repaired with a continuous suture of polypropylene or with pledgetted mattress sutures When the residual VSD is not a part of the original tetralogy type of VSD, but rather a second overlooked muscular or inlet defect, it is closed with a Dacron patch using continuous 4-0 Prolene suture The temptation for direct suture repair of residual defects should be resisted Following repair of the residual defect, the vent which had been placed across the atrial septum is removed and the defect in the atrial septum closed The right atriotomy is closed 179 Reoperations After Repair of Tetralogy of Fallot with continuous polypropylene suture and the usual de-airing method employed Cardiopulmonary bypass is then discontinued Among the 28 patients with residual VSD reported by Uretzky et al (1982), 18 (64%) were repaired by direct suture to the original patch An augmentation patch was employed In four (14%) and a new patch in six (22%) Although there were no statistical differences between these different techniques, none of the patients had recurrent VSD after an augmentation patch was used These authors, therefore, agree with us and with Castaneda and colleagues (1974) that this is the preferred method Repair of RVOTO Fig 13.7 The method used to relieve residual RVOTO depends upon the precise site of obstruction When solely at the infundibular level, it can be relieved by infundibulectomy, usually performed through an incision in the right ventricular infundibulum (Fig 13.6a) The parietal and septal insertions of the infundibular septum, if obstructive, are mobilised and partially excised An enlarging patch of Dacron or bovine pericardium is used to widen this area (Fig 13.6b) When residual pulmonary valve stenosis contributes to RVOTO, the fused commissures (if present) are incised as shown in Fig 13.7a,b, and the orifice measured with Hegar dilators In some circumstances the anatomy of the bicuspid pulmonary ~alve restricts the development of an orifice size similar to the annulus size, and therefore excision of one of the pulmonary leaflets is required The pulmonary annulus should also be measured with Hegar dilators through a pulmonary arteriotomy This dimension is related to the normal pulmonary annulus size for a patient of similar body surface area (Table 13.1) So that the pulmonary valve will remain functional, we generally enlarge the annulus only when it is smaller than standard deviations from the mean normal value , but this is taken in context with the predicted postrepair P RVILV as described above (see p 172) If the decision is made to enlarge the annulus, Table 13.4 Hospital mortality fo r reoperation Hospital mortality Series Lillehei et al 1986 Fuster et al 1980 Zhao ct al 1985 Poirier et al 1977 Katz ct al 1982 Uretzky et al 1982 Fi~ 13.6 Total No No 10 19 39 41 1 20.0 21.0 12.8 20.0 12.5 7.3 122 16 13.1 % Reoperations in Cardiac Surgery 180 this preserves right ventricular myocardium and provides relief of RVOTO (Pacifico et al 1987) If the main pulmonary artery is narrow , it is widened with a patch of bovine pericardium (Fig 13.8b) Although autologous pericardium is preferred , it is generally not suitable for use during reoperation The valve is excised if it will be non-functional Stenosis at the origin of the left pulmonary artery is managed by extending an incision in the main pulmonary artery through the stenotic origin (Fig 13.9a) This is then widened with a patch of bovine pericardium (Fig 13.9b) Stenosis of the origin of the right pulmonary artery is more difficult to repair but is generally managed by an incision extending from the main pulmonary artery through the stenotic origin and widening of the area with a bovine pericardial patch Sometimes, the ascending aorta may be completely transected to facilitate exposure (Fig 13.10a,b) Stenosis of the pulmonary artery bifurcation may be managed by an incision extending from the main pulmonfig 13.8 ary artery into the left pulmonary artery which then communicates with an incision onto the the incision is carried through the annulus onto right pulmonary artery (Fig 13.11a) A single the right ventricular infundibulum, as shown patch is used to widen the branch pulmonary in Fig 13.8a Unless the infundibulum is hypoplastic and tubular, the incision onto the right ventricular infundibulum is limited to that which permits passage of a Hegar dilator with a Z-value of +2 (for the pulmonary valve) as b fig 13.~ fig 13.10 Reoperations After Repair of Tetralogy of Fallot lSI Fig 13.11 Fig 13.12 arteries and a second patch is used to widen the main pulmonary artery, as shown in Fig 13.11b The use of an orthotopic pulmonary valve replacement is strongly considered when transannular patching is required and there are uncorrectable pulmonary arterial problems which are likely to result in high post-repair pulmonary artery pressure In addition, poor right ventricular function or associated tricuspid valve incompetence are additional factors which support the use of pulmonary valve replacement at the time of right ventricular outflow tract reconstruction Although some groups currently use a fresh sterile aortic homograft valve or an antibiotic sterilised graft, we prefer the use of a cryopreserved homograft because of the simplicity of maintaining an inventory of various sizes and its demonstrated good longterm function (O'Brien et al 1987) The appropriate size cryopreserved aortic homograft valve is selected, defrosted and rinsed (Kirklin et al 1985) This is trimmed as a cylinder The distal end of the homograft is sutured within the main pulmonary artery proximal to its bifurcation (Fig 13.12a) The proximal end is sutured to the pulmonary valve annulus or between it and the inferior edge of the infundibular septum A pericardial patch is employed to widen the right ventriculotomy incision and this is sutured to the anterior aspect of the homograft valve (Fig 13.12b) The main pulmonary artery in the area between the homograft suture lines is left open to avoid the potential risk of tamponade When very severe hypoplasia and stenosis of the pulmonary artery bifurcation is present, the entire bifurcation is replaced with a cryopreserved pulmonary valve homograft in continuity with the main pulmonary artery and bifurcation In this circumstance, it is often wise to transsect the ascending aorta to provide optimal exposure The left and right pulmonary arteries are transected (Fig 13.13a) and the respective branches of the cryopreserved pulmonary artery bifurcation are anastomosed in end-to-end fashion (Fig 13 13b) The transected aorta is then reanastomosed, the proximal aspect of the homograft is attached to the level of the pulmonary annulus and the right ventriculotomy incision is enlarged with a pericardial patch (Fig 13.13c) In the series reported by Uretzky et al (1982) of 41 patients undergoing reoperation Reoperations in Cardiac Surgery 182 Pulmonary homograft c b Fig 13.13 after initial repair of tetralogy of Fallot, repair of RVOTO was accomplished in 11 These procedures included secondary infundibulectomy (3), enlargement of an existing right ventricular outflow tract patch (1), placement of a new right ventricular outflow tract patch (3), placement of a right ventricular-pulmonary artery valved conduit (3) and pulmonary artery reconstruction (2) One patient had both infundibulectomy and pulmonary artery reconstruction distance from the hinged part of the septal leaflet, abnormal function of the septal leaflet may result At the time of transatrial-transpulmonary repair of tetralogy of Fallot, we carefully inspect tricuspid valve closure after completion of repair and prior to closure of the right atriotomy incision The tricuspid valve is usually perfectly competent, but in some cases leakage is identified at one of the commissures and may be repaired by commissuroplasty Uncommonly, the tricuspid valve annulus is dilated and an annuloplasty is performed at the initial operation If the degree of dilatation is mild, a local annuloplasty is accomplished as shown in Fig 13.14 This converts the trileaflet valve to a bileaflet valve and obliterates the small posterior leaflet When annular dilatation is more than moderate, or persistent high right ventricular pressure is expected, then a uniform annuloplasty is accomplished using a Carpentier annuloplasty ring The ring should be ~ 28 mm since smaller sizes will probably have significant gradients in adult-sized patients When tricuspid valve replacement is required, a St Jude Medical prosthesis is preferred Our experience with tricuspid valve replacement has been good and independent of the substitute device employed (Pacifico 1987) Heterograft prostheses, however, are to be avoided because of inadequate durability in young patients Repair of Pulmonary Insufficiency The technique of orthotopic pulmonary valve replacement with a cryopreserved aortic homograft valve is described under Repair of RVOTO above and illustrated in Fig 13.12 Repair of Tricuspid Valve Insufficiency Tricuspid valve insufficiency following repair of tetralogy of Fallot may occur for a number of reasons In some patients the septal leaflet of the tricuspid valve becomes distorted by the patch used to close the VSD It is important that the sutures attaching the VSD patch to the septal leaflet be placed very close to the tricuspid valve annulus If they are placed some 183 Reoperations After Repair of Tetralogy of Fallot Repair of ASD a The usual initial limited dissection is made by incompletely mobilising the heart, and after establishing cardiopulmonary bypass and snugging the caval tapes the right atrium is opened The aorta is cross-clamped and cold cardioplegic solution infused into the aortic root The ASD is closed with a continuous suture of 4-0 Prolene, care being taken to obtain bites of strong septal tissue A patch is used only for particularly large secundum defects or for those of the ostium primum or sinus venosus types b Coronary sinus Repair of Residual Surgical Shunt Fig 13.14 Of the 41 patients who underwent reoperation in the series reported by Uretzky et al (1982), had procedures performed to relieve tricuspid valve incompetence Two patients had distortion of the tricuspid septal leaflet, had a tricuspid cusp tear, ruptured chordae tendineae, and annular dilatation Repair of the tricuspid valve was accomplished in and excision of the tricuspid valve with prosthetic valve replacement was required in Among the 39 patients who underwent reoperation in the report of Zhao et al (1985), tricuspid valve incompetence was present in patients, at the first reoperation and at the second reoperation Tricuspid valve replacement was performed in of the patients Repair of Right Ventricular Aneurysm When a right ventricular aneurysm is present, initial dissection is limited to that necessary for cannulation The area of the aneurysm is approached after cardiopulmonary bypass is established Residual RVOTO is usually present and is repaired by the methods described above with excision of the previously placed aneurysmal transannular patch and partial excision of any aneurysmal infundibular myocardium See Chapter 20 (p 285) for additional technical details When closure by cardiac catheterisation technique cannot be accomplished, surgical closure is performed similar to that at primary repair Waterston shunts are closed by detaching the right pulmonary artery from the ascending aorta and enlarging the pulmonary artery with a patch at the site of the shunt if required Blalock-Taussig and Gore-Tex interposition shunts are dissected and doubly suture ligated A residual Potts shunt is closed usually by patching by exposure through the left pulmonary artery after isolating the head vessels during a period of hypothermic circulatory arrest (Kirklin and Devloo 1961) Postoperative Care Postoperative care is similar to that provided for repair of other cardiac defects The use of autotransfused chest drainage, as described in Chapter 17 (see p 243), is helpful to reduce the need for homologous transfusion Results Data reported in the literature not permit precise estimates of hospital mortality after repair of each category of residual defect In general, however, reoperation carries a greater 184 risk than initial repair of tetralogy of Fallot Table 13.4 shows an overall hospital mortality of 13.1 % for 122 reoperated patients from six series reported in the literature These include early surgical experiences, and results in the modern era can be expected to be considerably better In support of this, Uretzky et al (1982) reported deaths among 12 reoperations during the period 1962-1970, compared with deaths among 29 reoperations between 1971 and 1979 (p = 0.02) However, the risks involved clearly underscore the need for complete and accurate preoperative and intraoperative methods to minimise the frequency of reoperation The 38 patients surviving reoperation in the series reported by Uretzky et al (1982) were followed for 1-18 years (mean 5.3 years) after reoperation Of the 41 patients in the series, 28 (68%) were New York Heart Association Class I, (5%) Class II, and (5%) Class III Five (12%) patients subsequently underwent an additional reoperation and one sudden late death occurred Orthotopic pulmonary valve replacement may, as years pass, become more frequently necessary because of the late effects upon the right ventricle of long-standing pulmonary incompetence This may be particularly pertinent in the group of patients whose initial repair included trans annular patching At UAB between 1967 and 1982, secondary orthotopic pulmonary valve replacement was performed in 14 patients with tetralogy of Fallot with no hospital deaths The majority of these were performed coincident with repair of other associated residual lesions Misbach and colleagues (1983) reported experience with 12 patients who required reoperation for isolated pulmonary insufficiency unaccompanied by other residual defects A mechanical prosthesis was employed in two cases, a bovine pericardial bioprosthesis in seven, and a porcine bioprosthesis in three When the pulmonary artery and right ventricular outflow tract were large, the prosthesis was directly inserted at the pulmonary valve annulus level In other cases, a new outflow tract patch was placed to enlarge the pulmonary valve annulus and a larger sized prosthesis inserted Each patient survived operation, and all but one with residual severe tricuspid valve incompetence were relieved of symptoms Reoperations in Cardiac Surgery At UAB, we prefer the orthotopic insertion of a cryopreserved aortic homograft valve, as shown in Fig 13.12 The method of procurement, preservation and storage have previously been described (Kirklin et al 1985) At UAB, 150 cryopreserved homo grafts were employed between 1981 and 1986, 120 within extracardiac conduits and 30 as orthotopic conduits (Kirklin et al 1987) Actuarial freedom from reoperation and replacement was 94% at 43 months Two patients required reoperation In one a 21 mm homograft valved conduit was used to replace an obstructed 12 mm homograft valved conduit initially placed at months of age The second reoperation occurred 3.5 years after the initial placement of a 16 mm homograft valved extracardiac conduit None of the patients with orthotopic conduits have required rereplacement during this period References Bargeron LM Jr, Elliott LP, Soto B, Bream PR, Curry GC (1977) Axial cineangiography in congenital heart disease Circulation 56: 1075-1083 Binet JP, Patane L, Nottin R (1983) Correction of tetralogy of FalJot by combined transatrial and pulmonary approach Mod Probl Paediatr 22: 152-156 Blackstone EH, Kirklin JW, Pacifico AD (1979a) Decisionmaking in repair of tetralogy of FalJot based on intraoperative measurements of pulmonary arterial outflow tract J Thorac Cardiovasc Surg 77: 526-532 Blackstone EH, Kirklin JW, Bertranou EG, Labrosse CJ, Soto B, Bargeron LM Jr (1979b) Preoperative prediction from cineangiograms of postrepair right ventricular pressure in tetralogy of FalJot J Thorac Cardiovasc Surg 78: 542-552 Blalock A, Taussig HB (1945) The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia JAMA 128: 189-202 Bove EL, Byrum CJ, Thomas FC et al (1983) The influence of pulmonary insufficiency on ventricular 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Long-term evaluation (12 to 22 years) of open heart surgery for tetralogy of Fallot Am J Cardiol 46: 635-642 Graham TP Jr, Cordell D, Atwood GF et al (1976) Right ventricular volume characteristics before and after palliative and reparative operation in tetralogy of Fallot Circulation 54: 417-423 Katz NM, Blackstone EH, Kirklin JW, Pacifico AD, Bargeron LM Jr (1982) Late survival and symptoms after repair of tetralogy of Fallot Circulation 65: 403-410 Kirklin JK, Kirklin JW, Pacifico AD (1985) Homograft replacement of the aortic valve Cardiol Clin 3(3): 329-341 Kirklin JW, Barratt-Boyes BG (1986) Cardiac surgery Morphology, diagnostic criteria, natural history, techniques, results, and indications Wiley, New York Kirklin JW, Devloo RA (1961) Hypothermic perfusion and circulatory arrest for surgical correction of tetralogy of Fallot with previously constructed Potts' anastomosis Dis Chest 39: 87-91 Kirklin JW, Dushane JW, Patrick RTet al (1955) Intracardiac surgery with the aid of a mechanical pump-oxygenator system (Gibbon type): report of eight cases Proc Staff Meet Mayo Clin 30: 201-206 Kirklin JW, Ellis FH Jr, McGood DC, DuShane JW, Swan HFC (1959) Surgical treatment for the tetralogy of Fallot by open intracardiac repair J Thorac Surg 37: 22-46 Kirklin JW, Bargeron LM Jr, Pacifico AD (1977) The enlargement of small pulmonary arteries by preliminary palliative operations Circulation 56: 612-617 Kirklin JW, Blackstone EH, Maehara T et al (1987) Intermediate-term fate of cryopreserved allograft and xenograft valved conduits Ann Thorac Surg 44: 598-606 Lillehei CW, Cohen M, Warden HE et al (1955) Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentalogy of Fallot, and pulmonary atresia defects: report of first ten cases Ann Surg 142: 418-455 Lillehei CW, Varco RL, Cohen M et al (1986) The first open heart corrections of tetralogy of Fallot A 26-31 year follow-up of 106 patients Ann Surg 204: 490-502 Misbach GA, Turley K, Ebert PA (1983) Pulmonary valve replacement for regurgitation after repair of tetralogy of Fallot Ann Thorac Surg 36: 684-691 O'Brien MF, Stafford EG, Gardner MA, Pohlner PG, McGiffin DC (1987) A comparison of aortic valve replacement with viable cryopreserved and fresh allograft valves with a note on chromosomal studies Thorac Cardiovasc Surg 94: 812-823 185 Pacifico AD (1987) Ebstein's anomaly In: Dunn 1M (ed) Cardiac valve disease in children Elsevier, New York, pp 309-312 Pacifico AD, Kirklin JW, Blackstone EH (1977) Surgical management of pulmonary stenosis in tetralogy of Fallot J Thorac Cardiovasc Surg 74: 382-395 Pacifico AD, Sand ME, Bargeron LM Jr, Colvin EC (1987) Transatrial-transpulmonary repair of tetralogy of Fallot J Thorac Cardiovasc Surg 74: 382-395 Poirier RA, McGoon DC, Danielson GK et al (1977) Late results after repair of tetralogy of Fallot J Thorac Cardiovasc Surg 73: 900-908 Potts WJ, Smith S, Gibson S (1946) Anastomosis of the aorta to a pulmonary artery JAMA 132: 627-631 Rastelli GC, Ongley PA, Davis GD, Kirklin lW (1965) Surgical repair for pulmonary valve atresia with coronarypulmonary artery fistula: report of case Mayo Clin Proc 40: 521-527 Ross DN, Somerville J (1966) Correction of pulmonary atresia with a homograft aortic valve Lancet II: 1446-1447 Rowlatt UF, Rimoldi HJA, Lev M (1963) The quantitative anatomy of the normal child's heart Pediatr Clin North Am 10: 499-588 Sellors TH (1948) Surgery of pulmonary stenosis A case in which the pulmonary valve was successfully divided Lancet I: 988-989 Uretzky G, Puga Fl, Danielson GK, Hagler DJ, McGoon DC (1982) Reoperation after correction of tetralogy of Fallot Circulation 66 (suppl I): 1-202-208 Warden HE, DeWall RA, Cohen M, Varco RL, Lillehei CW (1957) A surgical-pathologic classification for isolated ventricular septal defects and for those in Fallot's tetralogy based on observations made on 120 patients during repair under direct vision J Thorac Surg 33: 21-44 Waterston DJ (1962) Treatment of Fallot's tetralogy in children under one year of age Rozhl Chir 41: 181-187 Wensley DF, Karl T, Deanfield JE, de Leval MR, Macartney FJ, Stark J (1987) Assessment of residual right ventricular outflow tract obstruction following surgery using the response to intravenous propranolol Ann Thorac Surg 44: 633-636 Wessel HU, Cunningham Wl, Paul MH, Bastanier CK, Muster AJ, Idriss FS (1980) Exercise performance in tetralogy of Fallot after intracardiac repair J Thorac Cardiovasc Surg 80: 582-593 Zhao H, Miller DC, Reitz BA, Shumway NE (1985) Surgical repair of tetralogy of Fallot Long-term follow-up with particular emphasis on late death and reoperation J Thorac Cardiovasc Surg 89: 204-220 ... Endocarditis Pacemaker Insertion Postoperative Care 16 1 16 1 16 1 16 1 16 3 16 3 16 3 16 4 16 4 16 4 16 5 16 5 16 6 16 7 16 8 16 8 16 9 16 9 16 9 16 9 13 Reoperations After Repair of Tetralogy... Results 17 1 17 1 17 4 17 4 17 5 17 5 17 6 17 6 17 7 17 7 17 7 17 7 17 9 18 2 18 2 18 3 18 3 18 3 18 3 18 3 14 Reoperations After Mustard and Senning Operations J Stark Introduction ... Deaths Following the Primary Operation 14 3 14 3 14 3 14 4 14 5 15 1 15 1 15 4 15 8 15 8 15 8 15 8 Contents xiii 12 Reoperations After Closure of Ventricular Septal Defects M.R de Leval Introduction