Strategies for the High Risk Redo in CHD

Strategies for the High Risk Redo in CHD Joseph A. Dearani, MD AATS, Minneapolis 2013

No Disclosures 2011 MFMER slide-3

The most significant predictor of early mortality in a 23-year old man with CHD undergoing fourth reoperation? 1.Bypass time 2.XC time 3.Single ventricle diagnosis 4.Age 2011 MFMER slide-4

Reoperation Outline Plan for the big picture Patient selection Preop imaging Intraop strategies Avoiding cardiac injury Transfusion protocols ICU care 2011 MFMER slide-5

CHD - The Issues Present operation & long term outlook Valve problems most common Reduced survival with multiple operations Resternotomy low/no risk children Morales, et al. ATS 2008 Resternotomy increased risk adult Holst, et al. ATS 2011 Launcelott, et al. ATS 2012 Park, et al. JTCVS 2010 2011 MFMER slide-6

What s important EF determines risk of operation EF determines late survival EF Assessment LV echo RV MRI & echo Occasionally LV, RV gram 2011 MFMER slide-7

The ventricles RV and LV Dilatation systolic dysfunction Regurgitant lesions (acute vs chronic) Hypertrophy diastolic dysfunction Obstructive lesions LVEDP, LAP, PAP s 2011 MFMER slide-8

Ventricular Dysfunction Global vs Regional dysfunction LV or RV vs bivent dysfunction? Coronary disease or anomaly? Pericardial disease tamponade, constriction, 2011 MFMER slide-9

Patient Selection What s the starting point? EF -? improvement after surgery Systolic & diastolic function LVOTO, AS, RVOTO, PS usually Complete revascularization (CABG) usually AR, MR, PR, TR not immediately CPB, XC times long or short? IABP, VAD, ECMO 2011 MFMER slide-10

Patient Selection What else is important? Pulm function, pulm hypertension Hepatic function Renal function Class IV heart failure # prior sternotomies Calcified aorta; peripheral vessel patency Coronary artery disease, CABG conduits 2011 MFMER slide-11

Preop Imaging - CT CT beneficial in planning redo Aviram, et al. ATS 2005 CT lower risk of stroke with redo Lapar, et al. ICTS 2011 Who should get a preop CT? dilated aorta, extracardiac conduits, prior root surgery, prior CABG;? every CHD pt 2011 MFMER slide-12

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Coronary Artery Issues Coronary angio vs CT angio Ostial abnormalities eg, high takeoff - truncus Distribution and path eg, LAD off RCA - TOF Coronary artery disease LIMA, hybrid approach 2011 MFMER slide-15

TOF Anomalous LAD 2011 MFMER slide-16

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The Redo Sternotomy Rule # 1 - Every Patient is at Risk

Rule #2 Checklist to Prevent Death Aortic injury Graft injury (CABG) graft dependent RV injury with bad RV Right-sided injury with intracardiac shunt Unrecognized LV distention All single ventricle patients 2011 MFMER slide-19

Rule # 3 use TEE New finding ~5% Assessment post-cpb 5-10% require revision aortic & atrioventricular valve repairs complex outflow tract reconstructions Assessment of AIR Randolph, et al. 1996 2011 MFMER slide-20

Role of Right Anterior Thoracotomy Tricuspid > mitral Maze, atrial shunt Limitations Control of aorta (cross clamp) Aortic tack vent and de-airing Prior right thoracotomy Body habitus 2011 MFMER slide-21

What is at risk? Innominate vein - everyone Aorta TOF, PA-VSD, prior Ross Conduit TGA, Truncus RA Ebstein, TGA atrial switch, Fontan RV Ebstein, TOF Patent bypass grafts, RCA 2011 MFMER slide-22

Early Results (n=1,040) Sternotomy # 2 3 4 5+ N= 630 298 78 34 Mortality (%) 2 5 8 0 Resp failure (%) 5 6 6 15 Pacemaker (%) 4 4 4 0 Stroke (%) 1 2 3 0 Renal failure (%) 3 3 5 3 Sternal infect (%) 2 1 6 3 Note 75% operations valve-related; 25% multivalve 2011 MFMER slide-23

Cardiac Injury in CHD Cardiac chamber or vascular structure During or after resternotomy Expected or unexpected Sternotomy # 2 3 4 5+ N= 630 298 78 34 Major (%) 4 7 13 15 Holst et al. 2011 2011 MFMER slide-24

Multivariate Predictors of Cardiac Injury (congenital) OR P Diabetes 2.6 0.007 History Stroke 2.0 0.018 # sternotomies 1.4 0.008 Holst et al. 2011 2011 MFMER slide-25

Multivariate Predictors of Cardiac Injury (acquired) OR Radiotherapy 4.9 Increased # sternotomies 1.7 Patent IMA 1.8 Park et al. 2011 2011 MFMER slide-26

Predictors for Early Mortality at Resternotomy (acquired) OR Cardiac injury 2.6 Prior AV operation 1.9 Current AV operation 1.6 NYHA III/IV 3.3 Preop renal failure 1.9 Prior CABG 1.9 Park et al. 2011 2011 MFMER slide-27

Multivariate Predictors of Early Mortality (congenital) OR P Urgent operation 7.7 <0.001 Single ventricle 6.9 <0.001 Bypass time 1.1 <0.001 Holst et al. 2011 2011 MFMER slide-28

Bypass time matters, but what about XC time?? LV function usually normal in CHD RV function often abnormal in CHD Less need for XC with R-sided procedures (eliminate intracardiac shunts) Coronary artery disease uncommon 2011 MFMER slide-29

Multivalve Surgery in ACHD Holst et al. 2013

Cross clamp time probably not as important as bypass time, but be efficient and pay attention to myocardial protection 2011 MFMER slide-32

Multivariate Predictors of Late Survival Multivalve CHD OR P Mech vent >5d 4.9 0.002 Coronary disease 4.0 0.005 Cardiac injury 2.5 0.018 Holst et al. 2012 2011 MFMER slide-33

Survival (%) When CABG needed Survival by LIMA Graft in ACHD 100 80 Yes 60 No 40 20 0 p=0.006 0 5 10 Follow-up time (year) Stulak et al. 2010 2011 MFMER slide-34

Late Survival since Last Sternotomy Survival (%) Sternotomy (no.) 2 3 4 5+ P=0.010 Years #2 583 415 311 218 139 80 #3 268 208 152 108 71 36 #4 67 47 31 25 16 7 5+ 31 19 14 8 6 3 2011 MFMER slide-35

Remember multiple reoperations usually valve-related Valve repair and re-repair preferred, but Be realistic about durability Be thoughtful about when to jump to valve replacement Goal fewer operations over lifetime 2011 MFMER slide-36

Multivariate Predictors of Late Mortality OR P Sternotomy 5+ 3.4 0.002 Respiratory failure 3.4 <0.001 Diabetes 2.2 0.025 Transfusion 1.9 0.014 Older age 1.4 <0.001 Ejection fraction 0.76 0.002 2011 MFMER slide-37

Survival and Postop Transfusion 2011 MFMER slide-38

Operating Room Transfusion Algorithm 2011 MFMER slide-39

ICU Transfusion Algorithm 2011 MFMER slide-40

Reducing Transfusion Transfusion algorithm Intraop whole blood autologous tx Antifibrinolytic agents Smaller CPB tubing and primes Preop JW protocol elective cases 2011 MFMER slide-41

Annual Transfusion for CV Surgery

Peripheral Cannulation Femoral or axillary artery chimney (cutdown) Right IJ and femoral vein Options expose vs cannulate vs CPB to open 2011 MFMER slide-43

Bypass Time & Hazardous Re-entry Your Options 1. Bypass to open 2. Separate from bypass & dissection 3. Resume bypass 4. Planned procedure vs Bypass from resternotomy to end 2011 MFMER slide-44

Avoiding Compartment Syndrome Smaller cannulae when feasible Antegrade leg perfusion with adequate venous outflow Consider opposite groins for art and ven Avoid long ischemic time to leg Avoid antegrade leg perfusion with ipsilateral femoral venous obstruction Switch to central cannulation when feasible 2011 MFMER slide-45

CPB - Assisted Venous Drainage Centrifugal pump Cardiac decompression Axillary or femoral artery Femoral and right IJ vein Smaller cannulae Smaller prime Caution with intracardiac shunts Nyawo et al. HSF 2008 2011 MFMER slide-46

Intracardiac shunts general rules PFO (beyond infancy) close Residual ASD, VSD close Do bubble study intraop Always be looking for it Intraop cardiac injury continuous TEE 2011 MFMER slide-47

Air Embolism Aortic laceration + Beating heart + Opening the sternum + Diastole Deep hypothermic CPB Right heart injury + Negative venous pressure + Intracardiac shunt (ASD, VSD) CPB with positive CVP 2011 MFMER slide-48

Aortic Tack Vent Right-sided cardiotomy ( simple PVR ) Trendelenberg, CO 2 line 2011 MFMER slide-49

Postop Pearls Right-sided lesions (regurg>stenosis) epi + mil + vaso (methylene blue), wean slowly faster HR; relative lower RA or PAP RVAD vs ECMO Left-sided lesions (stenosis, regurg) Epi + mil Slower HR; higher RA or PAP IABP vs LVAD vs ECMO Rhythm sinus or AV synchrony 2011 MFMER slide-50

Resternotomy Summary Plan for the big picture Patient selection Preop imaging Intraop strategies Avoiding cardiac injury Transfusion protocols ICU care 2011 MFMER slide-51

The most significant predictor of early mortality in a 23-year old man with CHD undergoing fourth reoperation? 1.Bypass time 2.XC time 3.Single ventricle diagnosis 4.Age 2011 MFMER slide-52

Questions & Discussion