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Cardiopulmonary bypass for adults with congenital heart disease: pitfalls for perfusionists
Michael L Schmitz1, Sherry C Faulkner, Charles E Johnson
1Division of Pediatric Cardiovascular Anesthesiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock 72202-3591, USA. schmitzmichaell@uams.edu
Insights
Adults with congenital heart disease (CHD) face unique surgical challenges due to complex anatomy and potential shunts. Specialized monitoring is crucial for managing these patients during cardiac surgery.
Area of Science:
- Cardiology
- Cardiac Surgery
- Perfusion Science
Background:
- Increasing survival rates for congenital heart defects (CHD) lead to a growing adult population with complex cardiac histories.
- Adults with CHD will soon outnumber pediatric patients, necessitating cardiac surgical interventions for disease progression or age-related conditions.
- These patients often present with unique anatomical variations and physiological challenges requiring specialized surgical approaches.
Purpose of the Study:
- To highlight the specific challenges encountered during cardiopulmonary bypass in adult congenital heart disease patients.
- To emphasize the need for awareness of congenital anomalies during cardiac surgery in this population.
- To discuss alternative monitoring strategies for improved patient management.
Main Methods:
- Review of anatomical and physiological considerations in adult CHD patients undergoing cardiac surgery.
- Discussion of potential complications related to shunts, cannulation, and aberrant anatomy.
- Evaluation of conventional versus advanced monitoring techniques in the context of adult CHD.
Main Results:
- Anatomical shunts (left-to-right and right-to-left) can significantly impact systemic blood flow and pulmonary circulation.
- Complex aortic reconstructions and aberrant coronary anatomy pose challenges for cannulation and myocardial protection.
- Conventional monitoring may be unreliable, necessitating advanced methods like serial lactate, NIRS, and TCD.
Conclusions:
- Adult congenital heart disease patients require meticulous surgical planning and intraoperative management due to unique anatomical and physiological factors.
- Perfusionists must be vigilant for unexpected congenital anomalies during cardiac surgery in this population.
- Advanced monitoring techniques offer superior insights compared to conventional methods for optimizing outcomes in adult CHD surgery.
Abstract:
The fixed incidence of congenital heart defects and improved survival have resulted in increasing numbers of adults with congenital heart disease (CHD) who have undergone complex repairs and/or palliations. Eventually, there will be more adults with CHD than children. They will require cardiac surgical interventions associated with progression of their CHD or for age-related disease, such as coronary revascularization. During bypass, anatomical shunts may exist within or without the heart. Left-to-right shunts can result in dramatically lower systemic blood flow than pump flow due to 'steal', while pulmonary edema ensues due to excessive pulmonary flow. Right-to-left shunts carry risks of massive air embolism and double or triple venous cannulation may be necessary. Cannulation of composite reconstructed aortas may be difficult, risking dissection or aortic obstruction, and double arterial cannulation may be indicated. Aberrant coronary arterial and venous anatomy may .preclude adequate myocardial preservation with common techniques and can be complicated by aortic insufficiency. Valves and conduits may exhibit failure. Conventional monitoring, such as central venous oximetry, may be misleading. Monitoring, such as serial lactate measurement, near-infrared spectroscopy and transcranial Doppler blood velocity, offer advantages for such patients. The perfusionist needs to be aware of such conditions as much congenital aberrancy may present unexpectedly during cardiac surgery.
