Perfusion for Congenital Heart Surgery. Notes on Cardiopulmonary Bypass for a Complex Patient Population

Description

• Confidently devise a safe and successful ‘plan for the pump run’ for patients undergoing surgery for congenital heart disease. This practical guide for perfusionists and other members of the cardiac surgical team provides information on the devices, technology and techniques required for successful bypass of patients with congenital heart defects
• A practical, spiral-bound, go-to reference designed to answer the most frequently-posed questions about bypass for CHD, the surgical treatment of which is often complicated
• Focuses on the latest technology and techniques and provides clear, matter-of-fact guidance based on specific diagnoses
• Written by a seasoned perfusionist who is co-chief and educator at one of the world’s leading children’s hospitals
• Spiral binding allows the book to be laid flat for easy referral in the operating room
• A notes section following each diagnosis enables readers to add institution and/or surgeon-specific information to tailor a bypass plan for each CHD lesion

Table of Contents

Foreword
Preface
Acknowledgments

1 Equipment for bypass 1

• Oxygenators 1
• Arterial line filters 12
• Tubing packs 13
• Cardioplegia systems 16
• The heart–lung machine 17
• The heater-cooler system 19
• Cannulae 20

2 Priming the bypass circuit 27

• Prime constituents 27
• Steps for priming 28

3 The bypass plan 33

• Communication agreement for case 33
• Anticoagulation management 35
• Blood gas management 40
• Carbon dioxide management 40
• Oxygenation strategy 42
• Hematocrit management 45
• Blood pressure management 47
• Temperature management 49
• Flow rates regional perfusion and hypothermic circulatory arrest 52
• Methods of ultrafiltration 55
• Before bypass 55
• On bypass 55
• After bypass 56
• SMUF specifications 59
• Standard and augmented venous return 60
• Standard venous return with gravity siphon drainage 60
• Augmented venous return 60
• The prebypass checklist 63
• The surgical safety checklist for congenital heart surgery 65

4 Typical phases of cardiopulmonary bypass 72

• Commencement of bypass 72
• Standard support phase of bypass 74
• Termination of bypass 76
• Post bypass 78

5 Additional notes based on bypass tasks 79

• Prebypass 79
• Heart–lung machine (HLM) 79
• Reoperations 79
• Cannulation 79
• Transfusion during cannulation 80
• On bypass 80
• Verification of adequate drainage when caval tapes are used 80
• Blood gas management 80
• Cardioplegia delivery 81
• Planned circulatory arrest 81
• Induced ventricular fibrillation 82
• Administration of blood products 82
• Atrial line placement 82
• LV vent placement 83
• Bed rotation during bypass 83

6 Bypass considerations based on diagnosis 85

• Anomalous coronary arteries 86
• Aortic regurgitation/insufficiency 89
• Aortic stenosis 91
• Aortopulmonary collaterals 93
• Aortopulmonary window 95
• Atrial septal defect 96
• Cardiomyopathy requiring orthotopic heart transplantation 99
• Coarctation of the aorta 100
• Common atrioventricular canal defect 102
• Cor triatriatum 104
• Corrected transposition of the great arteries (L-TGA Levo-TGA or C-TGA) or congenitally corrected TGA 105
• Critical aortic stenosis 107
• Double chambered right ventricle 109
• Double inlet left ventricle 110
• Double outlet left ventricle 111
• Double outlet right ventricle 112
• Ebstein’s anomaly 113
• Hypoplastic left heart syndrome 114
• Stage 1 (Norwood) procedure 115
• Hybrid stage 1 palliation 117
• Stage 2 or bidirectional Glenn shunt 117
• Fontan procedure (total cavopulmonary anastomosis) 119
• Interrupted aortic arch 121
• Left superior vena cava 123
• Lung transplantation 124
• Mitral regurgitation/insufficiency 125
• Mitral stenosis 126
• Patent ductus arteriosus 127
• Pulmonary artery abnormalities 128
• Pulmonary atresia 129
• Pulmonary atresia with an intact ventricular septum 129
• Pulmonary atresia with ventricular septal defect 130
• Pulmonary regurgitation/insufficiency 132
• Pulmonary stenosis 133
• Pulmonary vein stenosis or pulmonary venous obstruction 134
• Tetralogy of Fallot 136
• Total anomalous pulmonary venous return and partial anomalous pulmonary venous return 138
• d-Transposition of the great arteries 140
• Tricuspid atresia 142
• Tricuspid regurgitation/insufficiency 143
• Truncus arteriosus 144
• Ventricular septal defect 146

7 Notes on select issues during bypass 148

• Blood pressure higher than expected 148
• Blood pressure lower than expected 149
• Bypass circuit pressure higher than expected 151
• Bypass circuit pressure lower than expected 152
• Central venous pressure elevated 153
• Heat exchange issue (slow cooling or warming) 154
• NIRS values lower than expected 155
• PaCO2 higher than expected 157
• PaCO2 lower than expected 159
• PaO2 lower than expected 160
• Reservoir volume acutely low 161

8 Notes on select emergency procedures during bypass 163

• Arterial pump failure (roller head) 164
• Failure to oxygenate 165
• Massive air embolization 166
• Acute aortic dissection at the initiation of bypass 168
• Venous air lock 169
• Inadvertent arterial decannulation 170
• Inadvertent venous decannulation 171

9 Brief overview of named procedures and terms 172

• Alfieri stitch 172
• Batista procedure 172
• Bentall procedure 172
• Bidirectional Glenn shunt 172
• Blalock–Hanlon procedure 172
• Blalock–Taussig shunt (BTS) 173
• Brock procedure 173
• Central shunt 173
• Cone procedure 173
• Cox maze procedure 173
• Damus–Kaye–Stansel anastomosis 173
• Double switch procedure 173
• Fontan procedure 174
• Gott shunt 174
• Hemi–Fontan procedure 174
• Holmes heart 174
• Jatene operation 174
• Kawasaki disease 174
• Kawashima procedure 175
• (Diverticulum of) Kommerell 175
• Konno procedure 175
• LeCompte maneuver 175
• LeCompte procedure 175
• Manougian procedure 175
• Marfan’s syndrome 175
• Maze procedure 175
• Mustard procedure 176
• Nicks procedure 176
• Nikaidoh procedure 176
• Noonan syndrome 176
• Norwood operation 176
• Pannus 176
• Pentalogy of Cantrell 176
• Potts shunt 177
• Rashkind procedure 177
• Rastelli operation 177
• Ross procedure 177
• Sano shunt 177
• Scimitar syndrome 177
• Senning operation 177
• Shone’s complex 178
• Takeuchi procedure 178
• Taussig–Bing anomaly 178
• Trusler repair 178
• Van Praagh classification 178
• Warden procedure 178
• Waterston shunt 178
• Williams syndrome 178
• Yasui procedure 179

10 Abbreviations for congenital heart surgery 180

11 Recommended reference books 186

12 Comprehensive experience-based equipment selection chart select medications administered during bypass 187

Index 190

Author

Gregory S. Matte
Perfusion Clinical Coordinator (Co-Chief)
Boston Children’s Hospital
Boston, MA

In addition to coordinating perfusion at Boston Children’s, an internationally-recognized children’s hospital, Mr. Matte has extensive experience training clinicians and has written extensively in leading journals in the field.