NOTES. Left-Sided Cannulation of the Right. Atrium for Mitral Surgery. Ronald P. Grunwald, M.D., A. Attai-Lari, M.D., and George Robinson, M.D.

Transcription

1 NOTES Left-Sided Cannulation of the Right Atrium for Mitral Surgery Ronald P. Grunwald, M.D., A. Attai-Lari, M.D., and George Robinson, M.D. T here are several approaches to the mitral valve which yield satisfactory results. These include: right thoracotomy with single venous cannulation of the right atrium [9, 101 or double vena caval cannulation [5, 8, 11, 121; left thoracotomy with cannulation of the pulmonary artery [17], right ventricular outflow tract [14, 151, or combined right atrium and femoral vein cannulation [3, 181; median sternotomy with double vena caval or single right atrial cannulation [7, 131 ; and bilateral anterior thoracotomies with various venous cannulations [Z, 6, 161, Our experience with the method to be described for single cannulation of the right atrium through the left chest warrants presentation, as it offers several real and theoretical advantages. While no claim is made for originality of this or similar technique [3, 41, review of the literature fails to disclose a previous detailed description of this exact method or a report of a series using it in the human patient. We have used the left thoracic approach with single catheter cannulation of the right atrium in 35 cases and have found it eminently satisfactory. In only one case did massive enlargement of the right ventricle require us to use other than the technique described below. CANNULATION TECHNIQUE The patient is positioned in the full right lateral decubitus position with the left hip rotated posteriorly. The left iliac artery is exposed From the Cardiothoracic Surgical Service, Department of Surgery, Montefiore Hospital and Medical Center, Bronx, N.Y. Accepted for publication Mar. 14, VOL. 2, NO. 4, JULY,

2 GRUNWALD, ATTAI-LARI, AND ROBINSON extraperitoneally through a muscle-splitting incision. The femoral artery may be used easily in thin patients. The left thorax is entered through a full posterolateral incision in the fourth or fifth intercostal space extending from the sternum to the sacrospinalis muscles. The sternum is not transected. The lung is retracted posteriorly, and the pericardium is incised vertically, anterior to the phrenic nerve, from the diaphragm to its reflection on the pulmonary artery. Additional exposure is afforded by an anterior extension of the pericardiotomy, posterior to the sternum. The phrenic nerve is elevated from the pericardium and a second extension is carried beneath the nerve to the pericardial reflection on the left pulmonary veins (Fig. 1). Traction sutures of 2-0 silk are placed in the pericardium. The operating table is rotated approximately 20 degrees to the left, and the anterior pericardium is grasped with clamps and elevated toward the left with firm traction. The operator s left hand manually displaces the heart posteriorly with a small moist pad unrolled over the outflow tract of the right ventricle. A purse-string suture of size 0 silk is placed well down on the right atrial appendage and incorporated in a rubber tube to form a tourniquet. The heart is allowed to return to its., \,/ \. \ /# i, 9bHg FIG. 1. The opened pericardium as seen from the left side, demonstrating the anterior and posterior extensions and the visualization of the right atrial appendage when traction is exerted on the anterior Paps. 602 THE ANNALS OF THORACIC SURGERY

3 NOTE: Atrial Cannulation normal position while heparin is administered, and the iliac or femoral artery previously exposed is cannulated. Appropriate connections are made to the pump oxygenator. The heart is retracted as before; the right atrial appendage is grasped with either a curved De Bakey or a Swan aortic clamp and is opened on its anterior surface. Trabeculae are divided over a right-angle clamp. A No. 38 plastic catheter with rubber stop and extra side holes is fitted with an occlusive obturator which extends beyond the tip for 1 cm. The obturator eases introduction of the catheter and is an essential feature of this technique. With the first assistant grasping the edges of the atriotomy between forceps, the operator retracts the heart with his left hand and inserts the cannula with his right hand as the second assistant removes the clamp and tightens the purse-string tourniquet after the catheter has been introduced. Virtually no blood is lost in the maneuver. The cannula is now secured with a size 0 silk ligature on the appendage. This ligature is then retied around the catheter above the rubber stop and also around the rubber tourniquet. Migration of the cannula is thus avoided (Fig. 2). \I FIG. 2. The heart exposed, the right atrial appendage opened, the right ventricle retracted, and the atrium about to be cannulated. Note the design of the obturated catheter. VOL. 2, NO. 4, JULY,

4 GRUNWALD, ATTAI-LARI, AND ROBINSON Perfusion is now instituted; the apex of the heart is elevated, and a size 0 silk purse-string suture is placed at the left ventricular apex. A stab wound is made, dilated with Hegar dilators, and a No. 26 obturated catheter is inserted into the left ventricle. This ventricular vent is then connected to the coronary suction lines. Complete bypass is insured by placing a seraphin clamp across the pulmonary artery. Mitral valve surgery is then performed through a left atriotomy. At the end of the procedure, following closure of the left atrium, the pulmonary artery clamp is removed. The apex of the heart is elevated to allow air to escape from the left ventricle through the vent. The vent is then clamped. Supportive perfusion is maintained until there is good cardiac action, at which time the apical vent is removed and perfusion terminated. Following perfusion the right atrial cannula is used to monitor right atrial pressure and guide transfusion from the pump oxygenator until a transsaphenous central venous pressure catheter is inserted. When indicated, left atrial pressure is monitored while performing these transfusions. Exit from the right atrium is easily accomplished in essentially reverse order from the cannulation, i.e., the cannula is withdrawn as the clamp is reapplied and the purse-string tourniquet tightened. The purse-string tourniquet is then tied and the closure reinforced by oversewing or religating with a second size 0 silk ligature. DISCUSSION Blanco [ 11 firmly established single catheter drainage of the right heart in 1959, demonstrating that total cardiac bypass can be achieved by this method. Cardiac surgeons operating upon the mitral valve through the right thorax or through a median sternotomy frequently use single catheter drainage of the right atrium. Catheter drainage of the pulmonary artery, right ventricular outflow tract, or femoral vein and right atrium is not required simply because the left thoracic approach has been selected. Single right atrial cannulation with the pulmonary artery clamped provides total bypass. With the pulmonary artery occlusion released, supportive perfusion is possible. There has been no difficulty attributable to the technique. Effective siphonage by the gravity venous return system totally decompresses the right heart. Right ventriculotomy with its potential functional impairment is avoided. The technical problems of dealing with an incision in a hypertensive attenuated pulmonary artery are also obviated by the described technique. Aortic insufficiency that is clinically insignificant but annoying while on perfusion has been managed by the apical left ventricular vent. This vent is easily placed when using a left thoracotomy. On extremely rare occasions intermittent aortic cross clamping has been required. 604 THE ANNALS OF THORACIC SURGERY

5 NOTE: Atrial Cannulation There have been no technical problems with introduction or removal of the right atrial cannula. The technique enables us to use the left thoracic approach which we feel is superior, as it allows the surgeon to evaluate the pathological anatomy adequately and to select the best procedure for correction of the lesion. It is ideally suited for open or closed valvotomy, valvuloplasty, annuloplasty, or prosthetic replacement. We have elected to use the left thoracotomy as the approach of choice in all primary operations on the mitral valve. It is not employed in those patients who have had a previous left thoracic procedure or those in whom aortic or tricuspid valve surgery is contemplated. Thus when properly selected, it offers many advantages and no serious disadvantages. SUMMARY A safe technique for right atrial cannulation through a left thoracotomy incision is presented. This technique has been satisfactorily used without complication in 55 open-heart procedures on the mitral valve. Its simplicity and theoretical advantages make it a useful and recommended technique. REFERENCES 1. Blanco, G., Oca, C., Rey-Baltar, E., Nichols, H. T., and Bailey, C. P. Single catheter drainage of the right atrium or ventricle during total cardiac by-pass. Dis. Chest 35:554, Braunwald, N. S., Cooper, T., and Morrow, A. G. Complete replacement of the mitral valve. J. Thorac. Cardiov. Surg. 40:1, Clowes, G. H. A., Jr., Traks, E., Lim, K., Barensky, J., and Del Quarcio, L. R. M. Results of open surgical correction of mitral valve insufficiency and description of technique for approach from the left side. Surgery 51: 138, Cross, F. S., and Thomas, 0. J. Evaluation of surgical approaches to the mitral valve. A.M.A. Arch. Surg. 77:875, Effler, D. B., Groves, L. K., Martinez, W. V., and Koeff, W. J. Open heart surgery for mitral insufficiency. J. Thorac. Surg. 36:665, Ellis, F. H., Jr., Brandenburg, R. O., Callahan, J. A., and Marshall, H. W. Open heart surgery for acquired mitral insufficiency. A.M.A. Arch. Surg. 79: 222, Ellis, F. H., Jr., Callahan, J. A., McGoon, D. C., and Kirklin, J. W. Results of open operations for acquired mitral valve disease. New Eng. J. Med. 272: 869, Gerbode, F., Kerth, W. J., Osborn, J. J., and Selzer, A. Correction of mitral insufficiency by open operation. Ann. Surg. 155:846, Kay, E. B., Noqueira, C., Head, T. R., Coenen, J. P., and Zimmerman, H. A. Surgical treatment of mitral insufficiency. J. Thorac. Surg. 36:677, Kay, E. B., Noqueira, C., and Zimmerman, H. A. Correction of mitral insufficiency under direct vision. Circulation 21 :568, Lillehei, C. W., Gott, V. L., DeWall, R. A., and Varco, R. L. The surgical treatment of stenotic or regurgitant lesions of the mitral and aortic valves by direct vision. J. Thorac. Surg , VOL. 2, NO. 4, JULY,

6 GRUNWALD, ATTAI-LARI, AND ROBINSON 12. Merindino, K. A., Thomas, G. I., Jessiph, J. E., Herron, P. W., Winterscheid, L. C., and Velto, R. R. The open correction of rheumatic mitral regurgitation and/or stenosis. Ann. Surg. 150:5, Meyer, B. W., Verska, J. J., Lindesmith, G. G., and Jones, J. C. Open repair of mitral valve lesions. Ann. Thoruc. Surg. 1:453, Morrow, A., Clark, D., Harrison, D. C., and Braunwald, E. Prosthetic replacement of the mitral valve: Operative methods and the results of preoperative and postoperative hemodynaniic assessments. Circulation 29 (Suppl. 1): 4, Nichols, H. T., Blanco, G., Ureschis, J. F., and Lekoff, W. Open-heart surgery for mitral regurgitation and stenosis. A.M.A. Arch. Surg. 82: 128, Scott, H. W., Daniel, R. A., Adams, J. E., and Scholl, L. G. Surgical correction of mitral insufficiency under direct vision. Ann. Surg. 147:625, Shaw, R. S. Discussion of: Results of open surgical correction of mitral valve insufficiency and description of technique for approach from the left side. Surgery 51:153, See reference Thomas, G. I., Edmark, K. W., and Jones, T. W. Bivensus diversion for approach to mitral valve lesions from the left side. Surg. Gynec. Obstet. 120: 1061, THE ANNALS OF THORACIC SURGERY