Table Of ContentJ. Stark and A.D. Pacifico (Eds.)
Illustrations by M. Courtney
Reoperations in
Cardiac Surgery
Foreword by David C. Sabiston, Jr
With 388 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
Jaroslav Stark, MD, FRCS, FACS
Consultant Cardiothoracic Surgeon, The Hospital for Sick Children, Great
Ormond Street, London WCIN 3JH, UK.
Albert D. Pacifico, MD
Professor and Director, Division of Cardiothoracic Surgery, University of
Alabama at Birmingham, University Station, Birmingham, Alabama 35294,
USA.
ISBN-13:978-1-4471-1690-5 e-ISBN-13:978-1-4471-1688-2
DOl: 10.1007/978-1-4471-1688-2
British Library Cataloguing in Publication Data
Reoperations in cardiac surgery.
I. Man. Heart. Surgery
I. Stark, J. (Jaroslav), 1934-
II. Pacifico, A.D.(Albert D.)
617'.412
ISBN-13:978-1-4471-1690-5
Library of Congress Cataloging-in-Publication Data
Stark,·J. (Jaroslav)
Reoperations in cardiac surgery / J. Stark and A.D. Pacifico
(eds.) ; foreword by D. Sabiston
p. cm.
Includes bibliographies and index.
ISBN 0-387-19552-1
1. Heart-Reoperation. 2. Congenital heart disease-Reoperation.
I. Pacifico, Albert D. II. Title.
[DNLM: I. Heart Surgery. 2. Surgery. Operative. WG 169 S795r)
RD598.35.R46S73 1989
617' .4 12 --dc19
DNLMIDLC 89-6080
for Library of Congress CIP
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Foreword
Nearly a century has passed since Rehn performed the first successful cardiac
operation by closing a right ventricular stab wound in a gravely ill patient.
Moreover, it has been more than fifty years since Gross successfully corrected the
first congenital cardiac malformation in 1938 by suture ligation of a patent ductus
arteriosus. The introduction of the Blalock operation for tetralogy of Fallot by
Blalock in 1944 greatly advanced the management and prognosis of a critically ill
group of cardiac patients, and the success of this procedure further stimulated the
development of concepts and techniques for the surgical management of other
severe congenital cardiac defects. Until the successful use of extracorporeal
circulation by Gibbon in 1953, it was often necessary to perform cardiac operations
which were palliative rather than curative procedures. With the advent of additional
new and improved techniques, correction of many hitherto incurable cardiac
disorders became possible and reoperation under these circumstances became
frequent.
Cardiac surgery is very fortunate in having two master surgeons, whose distinctive
contributions and clinical proficiency are recognized worldwide, to edit this
extraordinary and unique text. They have placed emphasis on a number of specific
complications of primary cardiac procedures which lead to the necessity for
reoperation. Problems associated with postoperative infections, thrombotic dis
orders, stenoses of suture lines, deterioration of prosthetic materials and mechanical
valves, rejection of transplanted organs and tissues, and a host of additional
complications are described together with their appropriate surgical management.
The ·Editors have selected 14 other authorities in both acquired and congenital
disease to record their experiences and solutions to these vexing problems.
The initial chapters concern the necessity to obtain preoperatively as much
information as possible on the cardiac lesions requiring correction. Specific attention
is given to the roles of angiocardiography, digital subtraction angiography, cardiac
catheterization, echocardiography, chest roentgenography, computed transaxial
tomographic scanning (CT), magnetic resonance imaging, electrocardiography, and
other appropriate techniques. The authors deserve special commendation for the
thoroughness found in each section as well as the excellence of the illustrations
which depict the stepwise correction of the various problems. Similarly, examples
of the diagnostic studies are beautifully reproduced with their significant features
being made obvious to the reader. Each subject is carefully referenced with a
select and up-to-date bibliography. It is apparent that the authors have given each
subject maximal thought and attention in the preparation of this very laudable
text. Each of the common cardiac procedures is included as are a number of less
frequently encountered but nevertheless very significant problems requiring
vi
Foreword
reoperation. The reader is particularly struck with the obvious familiarity of each
contributor with the subject presented, which provides gratifying confidence to
those undertaking these reoperations.
In summary, Reoperations in Cardiac Surgery is a very timely contribution edited
by two of the most renowned contemporary cardiac surgeons with additional
contributors of similar stature. Of maximal current significance, this masterwork
will predictably become a widely used and frequently cited reference as well as an
essential part of the library of all cardiac surgeons.
May 1989 David C. Sabiston, Jr
Preface
More cardiac operations are performed each year. The incidence of reoperations
is also increasing. There are several reasons for this increase: failure of mechanical
and biological valve substitutes, conduits and coronary bypass grafts, erroneous
diagnosis, incomplete repair and infection. In surgery of congenital heart defects
replacement of the original prosthetic valve is required if the child outgrows the
prosthesis. Reoperation may also be part of a staged repair for a complex lesion
or may be required for residual or recurring defects.
The purpose of this book is to provide information about the diagnosis of early
and late complications, the indications for reoperation and the optimal timing of
reoperation. The main emphasis is on the description of safe surgical techniq"ues.
The book is divided into three sections. The general part includes chapters on
diagnosis, anaesthesia, surgical approaches to the heart and great vessels,
reoperations in the presence of infection, postoperative mediastinitis, pacemakers,
and heart and heart-lung transplantation. The second section describes surgical
techniques used for reoperations of congenital heart defects. All common defects
are included. To avoid repetition and too lengthy text some combinations of lesions
are not discussed separately. They are described either in the congenital or the
acquired heart defect section although they can have both aetiologies. The third
section on acquired heart disease includes chapters on. coronary arteries, mitral
and tricuspid valves, arrhythmia and thoraco-abdominal aneurysms.
The authors describe the techniques which gave them, over the years, the best
results. Some alternatives are mentioned without an attempt to cover all published
techniques. The text relies on Michael Courtney's illustrations. He worked very
closely with the Editors and was able to transform sketches made by individual
authors into instructive three-dimensional illustrations. With a few exceptions all
drawings are oriented as the heart is seen by the operating surgeon.
This book should provide information to a young surgeon who does not have a
large experience with reoperations. We hope that it will also be useful to established
surgeons, especially in the chapters on the less common lesions or complications.
It may also be of interest to cardiologists, cardiac anaesthetists, radiologists,
intensive care personnel and nurses. We believe that a well-performed original
operation will lead to a minimal number of complications. However, when residual
or recurring defects cause haemodynamic problems, correctly timed and expertly
performed reoperations may return the patient to normal health and an active life.
We hope that the book will contribute to this goal.
J. Stark, MD, FRCS, FACS A.D. Pacifico, MD
Consultant Cardiothoracic Surgeon Director, Division of Cardiothoracic Surgery
Acknowled2ements
We would like to express our thanks to Dr. G.R. Graham, former Clinical
Physiologist at The Hospital for Sick Children, Great Ormond Street, for his
suggestion to write this book. Our thanks are due to all the contributors for
preparing the text, for allowing considerable e~itorial changes to achieve uniformity
and for their co-operation in working with one artist.
Michael Courtney made a great contribution to this book. His clear understanding
of the points we wanted to illustrate and his ability to transfer them into high
quality illustrations will, we hope, be appreciated by the readers.
Our thanks are due to our secretaries, Miss. V. Parkhouse, Miss. P. Hunter,
and especially Mrs. S. Croot, Research Secretary in the Cardiothoracic Unit at
The Hospital for Sick Children, Great Ormond Street, who has helped with the
collection of the material, researched literature, and edited and transcribed all the
manuscripts.
March 1989 J. Stark, MD, FRCS, FACS
Consultant Cardiothoracic Surgeon
A.D. Pacifico, MD
Director, Division of Cardiothoracic Surgery
Contents
Contributors. .. . .. . . .. . .. . .. .. . . .. . . . . .. .. . . .. . . . .. . . . . . . . . .. . . . .. . . . .. . . . . . . . ... .. . . . . . . . . . ... . . .. xix
Abbreviations .....................................................................................x xiii
Section I: General
1 Investigation Before Reoperations for Congenital Heart Disease
1. F. N. Taylor............................................................................... 3
Introduction.. .. ... . . . .. .. . . .. . .. . .. .. . . . . .. .. .. .. . . .. . . . . .. .. . . . ... . .. . .. . . . . . .. . . . .. .. .. . .. 3
Staged Procedures......................................................................... 4
Residual Lesions........................................................................... 5
Clinical Considerations............................................................... 5
Non-~nvasive I~ves.tigation .......................................................... 8
Invasive Investigation..................................... ................... ......... 10
Recurrent Lesions......................................................................... 13
Changes Resulting from Growth, and Deterioration in Prosthetic
Function............................................ .... ........ .............................. 14
Prognosis After Completion of Intended Management........................ 15
Conclusion ........ :.......................................................................... 16
2 Investigations Before Reoperation for Acquired Heart Disease
Celia M. Oakley........................................................................... 17
Introduction.. . . . ... . . .. .. .. .. . .. . .. .. .. . . .. ... . . . . . . . .. .. . . . . .. . .. . . . . . . . . . . . . . . . . . . . .. . .. . . 17
Methods of Investigation................................................................ 17
Non-invasive Investigation ................ .......................................... 17
Invasive Investigation................................................................. 18
Reasons for Failure of Previous Operations....................................... 19
Wrong Indication or Wrong Operation.... ........................ .............. 19
Valve Disease........................................................................... 19
After Pericardiectomy................................................................ 25
Special Problems ...................................................., . ................ ;.... 26
The Myocardium....................................................................... 26
Marfan's Syndrome.................................................................... 27
Myxoma and Other Cardiac Tumours........................................... 27
Pregnancy ................................................................................ 28
Traumatic Heart Disease............................................................ 29
Emergencies ................................................................................ 29
x Contents
Mechanical Disasters.................................................................. 29
Prosthetic Valve Thrombosis "Encapsulation" ................................ 30
Infective Endocarditis ........ ..... .............................. ..................... 31
Reoperation After Previous Coronary Bypass Surgery......................... 33
Pericardial Syndromes ................................................................... 35
Postoperative Pericardial Collection.............................................. 35
Conclusion ......................................................... , ......................... 35
3 Anaesthesia for Cardiac Reoperations
M. Scallan................................................................................... 39
Introduction. . .. . . . . . . . . .. .. .. ... . . . . . . . . .. . . . . . . .. . . .. .. ... . . . . . .. . .. . . . . . . . . .. . .. . . . .. .. . . . 39
Preoperative Assessment................................................................ 39
Anaesthesia. .. . . ... .. .. ... . . . .. . .. . . .. . . . . . . . .. ... ... . . . ... .... . ... . . . .. ... . . .. . . .. . . . .. . . .. . 40
Monitoring .................................................................................. 40
Specific Conditions........................................................................ 41
Reoperation for Coronary Artery Bypass Grafts............................. 41
Valvar Heart Disease ................................................................. 41
Congenital Heart Disease........................................................... 42
Postoperative Complications........................................................... 42
Conclusion................................................................................... 42
4 Approaches to the Heart and Great Vessels at Reoperation
J. Stark ....................................................................................... 43
Introduction. .. . . .. . . . .. ... . . ... . .. . . ... .. . . . . .. .. . . . . .. .. . . . . .. ... . . . . . .. . . . . . .. . . . . . .. . .. . . 43
Sternal Re-entry........................................................................... 44
Prevention ................................................................................ 44
Operative Technique................................ ........................ .......... 45
Results .................................................................................... 51
Re-thoracotomy ........................ ................ ........ .................... ........ 51
Conclusion................................................................................... 52
5 Reoperations in the Presence of Infection
L. H. Cohn............................................................ ..... .... .............. 55
Introduction. . .. . .. . . . . . .. .. .. . .. . .. . . .. . .. . . . . . . . . . . . . . . .. . .. . . . ... .. .. . .. . . . . . . . . . . . .. . . . . . 55
General Considerations.................................................................. 55
Indications for Surgery.................................................................. 56
Prosthetic Valve Endocarditis...................................................... 56
Infected Aortocoronary Bypass.... ................................................ 57
Infected Cardiac Suture Line................................ ....................... 57
Surgical Technique........................................................................ 58
Reoperation in the Presence of Infected Prosthetic or Bioprosthetic
Valves ..................................................................................... 58
Surgical Technique for the Infected Cardiac Suture Line.................. 64
Surgical Treatment of Infected Coronary Bypass Graft.................... 64
Results ........................................................................................ 65
Conclusions and Summary.............................................................. 66
6 Pacing: Indications, Technique of Insertion and Replacement of Leads
and Generators
P. G. Rees.................................................................................... 67
Introduction .......................................' .. ... . . . .. . .. . . . . . . .. . . . .. . . ... .. . . ... .. . . . 67
Description of Generators ............ 1.............................................. 67
Contents xi
Indications for Permanent Pacemaker Insertion.................................. 68
Choice of Pacing Systems............................................................... 69
Generator ...................... , ......... '" .. ... . .. .. . . .. .. ... .. .. . .. ... . .... .. . . ... ... . 69
Wire ....................................................................................... 70
Pacing ......................................................................................... 71
Temporary.. ... .. .. . ... ... ... . . .. . .. . . . .. . ... .. .. .. .. . . .. . . .. ... .. .. .. . .. .. .. . .. . ... .. ... 71
Permanent ............................................................................... 71
Generator Implantation .............. "................................................... 75
Pectoral/Axillary Approach......................................................... 76
Subxiphoid Approach................................................................. 76
Suprarenal Approach................................................................. 76
Reoperation. .. . . .. . . .. .... .. ... . .. .. ... . .. .. . . .. . . . . .. . . .. . . .. .. ... .. . . . . .. .. ... .. . . . .. . ... . 77
Pulse Generator Replacement ..................................................... 77
Pacemaker Lead Problems.......................................................... 78
Pacemaker System Replacement for Infection................................ 78
Follow-up.................................................................................... 78
Restrictions .......................................................................... ,. .. 79
Conclusion................................................................................... 80
7 Postoperative Mediastinitis
P.F. Sauer and L.O. Vasconez ........................................................ 81
Introduction................................................................................. 81
Aetiology.................................................................................... 81
Bacteriology............ ................ ............ ............. ... ..................... .... 81
History of Management Options...................................................... 82
Sternal Blood Supply ......................................................" ............... 82
Reconstructive Options.................................................................. 83
Omentum ................................................................................ 83
Pectoralis Major........................................................................ 85
Rectus Abdominis..................................................................... 86
Complications .............................................................................. 88
Mediastinitis in Infants and Children...... ....................................... ... 90
Conclusions............................ ..................................................... 90
8 Heart and Lung Retransplantation
M.R. Mill and E.B. Stinson ............................................................ 93
Cardiac Retransplantation ............................................................. 93
Introduction ......................................... , ... " ............ , ... .. . . ... . . .. .. .. .. . 93
Indications for Retransplantation..................................................... 93
Technique of Retransplantation....................................................... 93
Postoperative Care........................................................................ 98
Results at Stanford University Hospital ..................................... ;...... 98
Summary ..................................................................................... 99
Heart-Lung Retransplantation ........................................................ 100
Introduction ................................................................................. 100
Indications for Retransplantation ..................................................... 100
Technique of Retransplantation ....................................................... 100
Postoperative Care ........................................................................ 102
Results ........................................................................................ 102
Summary ..................................................................................... 103
