British Journal of Anaesthesia, 2002, Vol. 88, No. 4 590-592
© 2002 The Board of Management and Trustees of the British Journal of Anaesthesia
Case Reports |
Transoesophageal echocardiographic monitoring of pulmonary venous obstruction induced by sternotomy closure during infant heart transplantation
1Department of Anesthesiology, National Taiwan University, College of Medicine and Hospital,Taipei, Taiwan*Corresponding author: Department of Anesthesiology, National Taiwan University Hospital, Chairman, Veterans General Hospital, Taipei, 7, Chung-Shan S. Rd, Taipei, Taiwan
Accepted for publication: November 16, 2001
 |
Abstract |
|---|
 Top Abstract IntroductionCase reportDiscussionReferences |
|---|
A case of an infant receiving orthotopic heart transplantation with over-sized donor heart was reported. Left lower pulmonary venous obstruction after sternotomy closure was detected by transoesophageal echocardiography (TOE) and the decision to delay sternal closure was made and the clinical outcome was very satisfactory. The usefulness of intraoperative TOE monitoring and postoperative TOE follow-up for infant heart transplantation, especially in those cases of size mismatch, was well demonstrated.
Br J Anaesth 2002; 88: 590–2
Keywords: heart, orthotopic heart transplantation; complications, pulmonary venous obstruction; monitoring, transoesophageal echocardiography
|
Introduction |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
Intraoperative transoesophageal echocardiography (TOE) is a useful tool for the immediate evaluation of pulmonary venous anastomoses and allows immediate surgical correction during lung transplantation.1–4 We would like to report a case of an infant receiving orthotopic heart transplantation, in whom left lower pulmonary venous obstruction after sternotomy closure was detected by TOE and the decision to delay sternotomy closure was made. The sternotomy was closed safely on the fourth postoperative day. The usefulness of TOE during size mismatch infant heart transplantation is well demonstrated.
|
Case report |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
A 6-month-old, 4 kg boy with hypertrophic cardiomyopathy had been diagnosed immediately after birth with left ventricular outflow tract obstruction and right ventricular outflow tract obstruction complicated by refractory congestive heart failure. Despite medical control, his condition deteriorated and he was put on the waiting list for heart transplantation at 3 months of age.
This patient received standard orthotopic heart transplantation with a donor heart from a 13-month-old, 11 kg girl who had died as the result of an astrocytoma of the brain. Anaesthesia was induced with i.v. ketamine 2 mg kg–1, and maintained with fentanyl 10 µg kg–1 h–1 infusion. Pancuronium was used for neuromuscular block. CVP and arterial pressure monitors were placed smoothly after induction of anaesthesia.
TOE was performed by a cardiac anaesthesiologist trained in the use of TOE. A specially designed TOE probe for newborns and infants (GE Vingmed Ultrasound) was used. This probe is 6.5 mm in external diameter and 50 cm in length, with a 7.5 MHz, monoplane and colour flow Doppler transducer. For insertion of the TOE probe the patient was placed supine with his head in the midline position. The transducer tip covered with sterile Surgilube was introduced gently into the oesophagus. Before surgery, the TOE image showed all four chambers to be severely dilated with poor contractility. After skin incision, a short run of ventricular tachycardia with hypotension was controlled with medication and the patient was put on cardiopulmonary bypass immediately. The recipient’s heart was removed by transecting the atrio-ventricular grooves, posterior to both atrial appendages. The aorta and pulmonary artery were transected at the level of the commissures of the semilunar valves. Implantation of the donor heart was started by anastomosis of the left atrium with a continuous suture, followed by anastomosis of the right atrium and pulmonary arteries. The aortic anastomosis was carried out last. The total ischaemic time was 180 min.
After weaning from cardiopulmonary bypass, infusion of nitroglycerin (0.5 µg kg–1 min–1) and dopamine (8 µg kg–1 min–1) were started. TOE showed no obvious regional wall motion abnormality, valvular stenosis, or regurgitation. Unfortunately, when the surgeon approximated the sternotomy, the patient’s oxygen saturation (SpO2) fell gradually from 99 to 92–95%. The problem was not resolved by careful suction of the trachea or adjustment of the ventilator settings. No significant fall in arterial pressure was noted. Left lower pulmonary venous obstruction was detected as a mosaic pattern of colour flow Doppler image on TOE with a peak flow velocity of 1.5 m s–1 (Fig. 1). The surgeon opened the sternotomy to check the anastomoses and no obvious anatomic problem was found. The TOE showed that the peak flow velocity of the left lower pulmonary vein had decreased to 1.0 m s–1. The patient’s SpO2 increased gradually back to 99%. We concluded that pulmonary venous obstruction was a result of an oversized donor heart being placed in the relatively small pericardial cavity. We decided to keep the sternotomy open, separating the sternal edges with a 1 cc syringe and the wound was covered with a surgical membrane.
|
After transfer to the surgical intensive care unit, the patient’s condition stabilized and inotropic agents were tapered gradually. After discontinuing the infusions, hypertension was controlled with propranolol and captopril. A TOE examination on the fourth postoperative day showed no more pulmonary venous obstruction and the sternotomy was closed. The patient made an uneventful recovery and was discharged on the 28th postoperative day.
|
Discussion |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
Orthotopic heart transplantation is a widely accepted therapeutic measure for adult patients with end-stage heart disease. Although cardiac transplantation is currently an accepted treatment for infants and children with end-stage heart failure, and inoperable complex congenital defects,5 6 it is under-used in newborns and infants because of a shortage of donor organs. Most authors consider that large donor-sized size mismatches can be well tolerated in infant and paediatric heart transplantation.7 Some authors even believe that the use of an oversized donor heart might be beneficial, particularly in those with pre-transplantation pulmonary hypertension. However, a high incidence of transient lobar or complete lung collapse in transplants with a high donor-to-recipient weight ratio has been reported.7 Tweddell and colleagues predicted the need for prolonged ventilator support when a donor-to-recipient weight ratio is greater than 2.8 On the contrary, use of undersized donor hearts is associated with poor results and should be strongly discouraged.9
In our case with a donor-to-recipient ratio of 2.75, problems of donor–recipient size mismatch were anticipated. Under TOE monitoring, we found marked left lower pulmonary venous obstruction detected as a mosaic flow pattern of the colour flow Doppler image. This finding changed the surgical management. The delay of sternal closure relieved the pulmonary venous obstruction and may have contributed to the prevention of lung complications such as lobar collapse or lung congestion. After several days of donor heart remodelling,10 11 the sternotomy was closed successfully and bedside TOE confirmed that pulmonary venous obstruction did not recur.
A possible alternative cause of the pulmonary venous obstruction was compression of the left atrium by the TOE probe placed in the oesophagus, we think this unlikely because of the clear association between the obstruction and sternal closure.
In summary, we report a case of an infant receiving orthotopic heart transplantation, in whom left lower pulmonary venous obstruction after sternotomy closure was detected by TOE and the decision to delay sternal closure was made with a good clinical outcome. The usefulness of intraoperative TOE monitoring and postoperative TOE follow-up for infant heart transplantation, especially in those cases of size mismatch, was well demonstrated.
|
References |
|---|
|
TopAbstractIntroductionCase reportDiscussionReferences |
|---|
1 Suriani RJ. Transesophageal echocardiography during organ transplantation. J Cardiothorac Vasc Anesth 1998; 12: 686–94[ISI][Medline]
2
Michel-Cherqui M, Brusset A, Liu N, et al. Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. A report on 18 cases. Chest 1997; 111: 1229–35
3 Leibowitz DW, Smith CR, Michler RE, et al. Incidence of pulmonary vein complications after lung transplantation: a prospective transesophageal echocardiographic study. J Am Coll Cardiol 1994; 24: 671–5[Abstract]
4
Huang Y-C, Lin Y-H, Cheng Y-J, et al. Graft failure due to pulmonary venous obstruction diagnosed by intraoperative transesophageal echocardiography in lung transplantation. Anesth Analg 2000; 91: 558–60
5
Kanter KR, Tam VK, Vincent RN, et al. Current results with pediatric heart transplantation. Ann Thorac Surg 1999; 68: 527–30
6
Dapper F, Bauer J, Kroll J, et al. Clinical experience with heart transplantation in infants. Eur J Cardiothorac Surg 1998; 14: 1–6
7 Fullerton DA, Gundry SR, Alonso de Begona J, et al. The effects of donor–recipient size disparity in infant and pediatric heart transplantation. J Thorac Cardiovasc Surg 1992; 104: 1314–9[Abstract]
8 Tweddell JS, Canter CE, Bridges ND, et al. Predictors of operative mortality and morbidity after infant heart transplantation. Ann Thorac Surg 1994; 58: 972–7[Abstract]
9 Tamisier D, Vouhe P, Le Bidois J, et al. Donor–recipient size matching in pediatric heart transplantation: a word of caution about small grafts. J Heart Lung Transplant 1996; 15: 190–5[ISI][Medline]
10
Fukushima N, Gundry SR, Razzouk AJ, Bailey LL. Growth of oversized grafts in neonatal heart transplantation. Ann Thorac Surg 1995; 60: 1659–64
11 Shirali GS, Lombano F, Beeson WL, et al. Ventricular remodeling following infant-pediatric cardiac transplantation. Does age at transplantation or size disparity matter? Transplantation 1995; 60: 1467–72[ISI][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||