Do you use right toracotomy or sternotomy? On pump or off pump? Shunt or head elevation? To achieve best results
I always perform the BDG procedure with full median sternotomy never with right thoracotomy, but sometimes on-pump, sometimes off-pump with a shunt. I try off-pump if the anatomy is feasible (easy to reach SVC, if the patient is not a re-do and without a right mBT shunt ...etc) and considerably if the child is a bit of grown and if the patient tolerated RPA clamp well; in brief if I feel I and the child are both comfortable. Otherwise I go on-pump and operation is straightforward. On-pump procedure has its well known own advantages and I don't think CPB is very harmful for the child.
This is I do off-pump: I cannulate SVC high, cannulate the RA, connect both cannula, tell the anesthesia increase the to increase FiO2 to 100%, give some fluid, and start dopamin at a level of 5mcg/kg/min. In case of heart failure I tell them not to hesitate to inject very small doses of adrenalin.
On-pump or off-pump, I guess the results are more or less similar.
Sternotomy has the advantage of full surgical control as well as evaluation of the anatomy. Re-sternotomy for a Fontan is not a big deal.
On the other hand I believe simple SVC clamp and go with head elevation is an extremely risky procedure and may end up sequela of increased cerebral pressure and cerebral ischemia in the post-operative period.
Check out the following short publication:
Superior caval clamping without a cavoatrial shunt during bidirectional Glenn operation.
Ugurlucan M, Cicek S.
Interact Cardiovasc Thorac Surg. 2013 May;16(5):653-4. doi: 10.1093/icvts/ivt134.
PMID: 23606294 [PubMed - indexed for MEDLINE] Free PMC Article
The patients scheduled for BDG shunt construction are cyanotic and generally have their oxygen saturation in a range of 65-85%. In these patients oxygen delivery is maintained by increase in total hemoglobin. Many of these patients have abnormal brain MRI and one or other kind of neurologic deficit. Needless to emphasize, these patients have no room for any further neurologic insult.
The BDG shunt is performed through median sternotomy and usually with the support of cardiopulmonary bypass (CPB). The BDG shunt construction requires clamping of superior vena cava (SVC) and partial clamping of pulmonary artery. For ensuring adequate cerebral perfusion during BDG shunt construction the SVC should be adequately decompressed. During BDG construction on CPB, the SVC is decompressed by cannulating the SVC or the innominate vein using a right angled DLP cannula. During BDG construction without CPB, a shunt from SVC to right atrium is employed to decompress the SVC. In presence of bilateral SVC, BDG can be constructed without CPB; however, before committing for the shunt construction without the support of CPB, it is suggested that on test clamping the surgical SVC the central venous pressure does not rise above 12-15 mmHg;
During on pump (CPB) procedures 100% arterial O2 saturation is ensured, whereas, during off pump BDG construction saturation decreases further as the pulmonary blood flow on the side of BDG construction is shut off because of application of side clamp on the pulmonary artery. Further, during these procedures hemodynamic compromise is common because of manipulation of heart and great vessels. Compromised hemodynamics, decreased oxygen saturation, and possibility of cerebral venous congestion due to inadequate SVC decompression can seriously jeopardize adequacy of cerebral perfusion, cerebral O2 delivery, and the neurologic outcome of the patient.
In our Dept BDG is performed usually on cardiopulmonary by-pass , beating heart, with cannulation of SVc and RA
In particular case we have performed different surgical strategies:
In case of difficulty to direct cannulation of SVC (ie very small infant and bidierectional bilater SVCs) we performed the procedure with vent inside the SVCs without clamping the SVC and or the venous TA
In case of GUCH with a BTMS and unventriculr heart we performed the BDG off by pump with decompressing shunt (SVC - RA) and partial heparinization (2 mg/Kg)
In case of Pulmonary atresia intact ventricular septum and hypo RV with large sinusoids and no definite RV dependent coronary circulation we performed BDG off by pass wondering the inference of CPBP + BTMS on coronary circulation
In the 2 latter cases BT is mandatory and preferentially the left side
Off-pump and median sternotomy. The patients tolerate the procedure extremely well. I have done it on both sides in case of bilateral SVCs and there has been no difficulty in exposure and access.
Dr Anjum have tried through right thoracotomy ?using shunt or head elevation
ECC for BDG procedure is always prefered in our institution. As mantioned above, the majority of children who need the procedure are seriously cyanotic and clamping of the RPA might decrease the saturation level even more. Since for the majority of caseses it is the second operation in the single ventricle physiology path, we prefer the full median re-sternotomy.
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