Direct Cannulation in Minimally Invasive Cardiac Surgery With Limited Resources.

BACKGROUND: With increasing patient interest in minimally invasive procedures, it is more important than ever for surgeons to be current on the most common minimally invasive techniques in cardiac surgery. As minimally invasive cardiac surgery has evolved, the strategies and approaches to cardiopulmonary bypass access have evolved. Peripheral cannulation is convenient but carries a risk of retrograde dissection, embolization, stroke, and ipsilateral limb ischemia, whereas central aortic cannulation has the advantage of antegrade flow. METHODS: We report our experience with direct arterial and venous cannulation through a thoracotomy approach without compromising the results. From January 2017 to December 2018, 140 consecutive patients were studied. Mean age was 26 ± 18 years (range, 11 months to 83 years), with 46 patients (32.8%) younger than 12 years and 12 patients weighing less than 10 kg. Spectrum of procedures include atrial septal defect closure (53%), mitral valve repair (14%), ventricular septal defect closure (9%), aortic valve replacement (10%), mitral valve replacement (6%), repair of partial anomalous pulmonary venous drainage (9%), myxoma excision (1%), and ventricular septal defect closure with pulmonary valvotomy (1%). RESULTS: None of the patients was converted from a minimally invasive to standard median sternotomy. One patient with ventricular septal defect died due to pulmonary hypertensive crises. No patient required reexploration for bleeding, and none had stroke or renal failure. There were no myocardial infarctions or aortic dissections. CONCLUSIONS: In our experience this approach is a reliable platform for a variety of minimally invasive cardiac surgical procedures and has resulted in low complication rates. The technique can be applied safely to both pediatric and adult populations. Also, it is very cost-effective because regular instruments and cannulas are used.

Giant bilateral posterior mediastinal liposarcoma excision.

A 50-year-old female, presented with severe dyspnoea and dysphagia only to solids. Chest-computed tomography (CT) scan revealed a giant bilateral intrathoracic mass in posterior mediastinum causing marked shift in the midline structures, squeezing the heart to sternum. CT-guided biopsy showed lipoma. The patient underwent left posterolateral thoracotomy for surgical removal of entire mass weighing 6 kg and measured 42 × 25 × 10 cm, with histologic examination reported as liposarcoma grade 1. It is the largest surgically treated intrathoracic liposarcoma documented in the modern literature.

Dextrocardia and corrected transposition of the great arteries with rheumatic tricuspid stenosis: a unique association.

A 37-year-old lady presented with difficulty in breathing, which had progressively worsened in the last few months. Investigations revealed dextrocardia, congenitally corrected transposition of aorta, severe left atrioventricular valve stenosis with regurgitation, and right atrioventricular valve regurgitation. Left atrioventricular valve stenosis with thickening of leaflets and commissural fusion were suggestive of rheumatic valvular heart disease. She underwent left atrioventricular valve replacement and right atrioventricular valve repair with annuloplasty ring. This is a unique association of rheumatic valvular disease in corrected transposition of great arteries with dextrocardia. Morphology made surgical correction very challenging. Surgical correction of such case has not been reported in literature so far.

Concomitant congenital heart defect repair and Nuss procedure for pectus excavatum.

The combination of complex congenital cardiac anomalies and pectus excavatum represents a technical challenge. Most concomitant repairs have been performed in adult patients. We report the uncomplicated concomitant repair of double-outlet right ventricle with absent pulmonary valve syndrome and the Nuss procedure for pectus excavatum in a 3-year-old child.

Sternal traction: simple technique to prevent tamponade/compression of the heart.

Routine closure of the sternum after cardiovascular surgery sometimes causes severe cardiac depression because of tamponade, leading to cardiogenic shock. We describe a full-thickness chest wall traction suture taken parasternally and tied to an intravenous fluid stand. Upward (outward) traction is applied to the anterior chest while the sternum is primarily closed, which allows physiologic improvement equivalent to delayed sternal closure. It is a safe and easily reproducible technique.

New technique of off-pump atrial septostomy for complex congenital cardiac anomalies.

OBJECTIVES: Atrial septostomy is essential for palliation of some complex congenital cardiac anomalies, such as transposition of the great arteries and left-/right-sided atrioventricular valve stenosis or atresia. Conventionally, balloon atrial septostomy is done in neonates. Beyond the neonatal period, surgical septostomy is done using cardiopulmonary bypass and can lead to increased morbidity and mortality. We report a new technique of atrial septostomy without cardiopulmonary bypass and its follow-up. METHODS: Eleven cases underwent atrial septostomy without using cardiopulmonary bypass from January 2009 to June 2010. Median age of patients was 7 months (2-12 months) and median weight was 6.3 kg (range 4.5-10 kg). Surgical septostomy was performed through the right atrial appendage with a Tubb's dilator, aided by intra-operative transesophageal echocardiography. Atrial septal defect (ASD) less than 5mm was enlarged with a Kerrison bone punch and then dilated with a Tubb's dilator. Associate procedures performed were off-pump Glenn in seven cases, pulmonary artery (PA) banding in three cases, and shunt with PA band in one case. RESULTS: All the restricted ASDs were successfully enlarged with adequate interatrial shunting without any gradient. Echocardiography revealed no evidence of introduction of air or particulate emboli, and no tricuspid valve injury or heart block. There was no postoperative mortality. Follow-up ranged from 1 to 18 months (median 11 months). Echocardiography showed good PA band gradient/well-functioning Glenn shunt and unobstructed ASD with good oxygen saturation. CONCLUSIONS: This technique demonstrates the surgical feasibility of a beating-heart atrial septostomy. It avoids the adverse effects of cardiopulmonary bypass, reduces morbidity, and has no mortality. It is safe, economical, and easily reproducible. To our knowledge, this technique has not been reported in literature so far.

Venoatrial shunt-assisted cavopulmonary anastomosis.

The bidirectional Glenn shunt operation is conventionally performed under cardiopulmonary bypass. Between June 2007 and September 2009, 218 consecutive patients underwent off-pump bidirectional Glenn shunt institution for single ventricle with pulmonary stenosis complex. Their mean age was 4.72 ± 1.80 years (range, 4 months to 6 years) and median weight was 10.12 kg (range, 4.1-19 kg). A temporary shunt was created between the innominate vein and the right atrium, with a 3-way connector for de-airing. Fifty-five patients had bilateral cavae. The mean internal jugular venous pressure on clamping the superior vena cava was 24.69 ± 1.81 mm Hg. Continuous end-tidal CO2 and O2 saturation were monitored. Adequate oxygen saturation and blood pressure were maintained by optimizing inotropics, volume, and inspired oxygen. The mean duration of ventilation was 10.17 ± 8.96 h (range, 1-73 h). There were no gross neurological complications. Postoperative pleural effusion developed in 6 (2.75%) patients, and 4 (1.83%) had nodal rhythm. Four (1.83%) patients died in the immediate postoperative period due to low cardiac output syndrome. Venoatrial shunt-assisted bidirectional Glenn shunt surgery can be performed safely by optimizing intraoperative management strategies. It is economical and avoids the deleterious effects cardiopulmonary bypass.

Veno-venous shunt-assisted cavopulmonary anastomosis.

OBJECTIVE: The bidirectional Glenn shunt is commonly performed under cardiopulmonary bypass for conditions that lead to a single ventricle repair. We report our experience of bidirectional Glenn shunt done without cardiopulmonary bypass. METHODS: Between June 2007 and May 2009, 186 consecutive patients underwent off-pump bidirectional Glenn shunt for a variety of complex cyanotic congenital heart defects. Age ranged from four months to six years and the median weight was 11.17 kg (range 4.3 - 18). After systemic heparinization, the procedure was done by creating a temporary shunt between the innominate vein and the right atrium connected across a three way connector for de-airing. Fifty one patients had bilateral cavae. All cases underwent complete clinical neurological examination. RESULTS: No case required conversion onto cardiopulmonary bypass. Four patients (2.14%) died in the immediate postoperative period. The mean internal jugular venous pressure on clamping the decompressed superior vena cava was 24.69 +/- 1.81 mm Hg. There was no intra-operative hemodynamic instability and oxygen saturation was maintained at more than 70% throughout. Post Glenn shunt, the saturations improved to mid 80s. Seventy four cases had documented forward flow across the pulmonary valve. The mean duration of ventilation was 10.17 +/- 8.96 hours and there were no neurological complications. Six patients (3.22%) developed pleural effusions, 4 patients (2.15%) had nodal rhythm and 9 patients (4.83%) had superficial sternal wound infection. CONCLUSIONS: Our results show that off-pump bidirectional Glenn shunt can be done safely in patients not requiring associated intra-cardiac correction. It avoids cardiopulmonary bypass and its related complications, is economical and associated with excellent results. In our opinion, this is the largest series of off-pump bidirectional Glenn shunt in the literature.

Off-pump Kawashima operation.

We describe the technique of Kawashima repair without using cardiopulmonary bypass in 6 consecutive patients of single ventricle morphology with interrupted inferior vena cava and pulmonary stenosis. No patient had central nervous system disorder or chylothorax. The off-pump technique is feasible in Kawashima repair. This technique avoids use of cardiopulmonary bypass, thereby preventing its deleterious effects, which is also economical.

Sternotomy approach for modified Blalock-Taussig shunt: is it a safe option?

Central aorta-pulmonary artery shunts have fallen into disfavor because of shunt thrombosis and congestive heart failure, and a modified Blalock-Taussig shunt via thoracotomy can lead to pulmonary artery hypoplasia and distortion. We reviewed the outcomes of a modified Blalock-Taussig shunt by a sternotomy approach in 20 infants from July 2007 to October 2009. Their mean age was 5.79 months, and median weight was 5.4 kg. A 4-mm graft was placed in 11 patients, a 5-mm graft in 8, and a 3.5-mm graft in 1. There was no incidence of sepsis, seroma, or phrenic nerve palsy. There was one hospital death. The mean hospital stay was 10.4 +/- 4.3 days (range, 8-15 days). The mean oxygen saturation at discharge was 89% (range, 81%-93%). The sternotomy approach is technically easier to perform, cosmetically preferable, and probably hemodynamically superior. Correction of branch pulmonary stenosis is easily incorporated into this procedure. The theoretical disadvantage of this method is a potential technical difficulty with sternal reentry for subsequent procedures.