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
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Abstract |
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Br J Anaesth 2002; 88: 5902
Keywords: heart, orthotopic heart transplantation; complications, pulmonary venous obstruction; monitoring, transoesophageal echocardiography
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Introduction |
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Case report |
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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 kg1, and maintained with fentanyl 10 µg kg1 h1 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 recipients 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 kg1 min1) and dopamine (8 µg kg1 min1) were started. TOE showed no obvious regional wall motion abnormality, valvular stenosis, or regurgitation. Unfortunately, when the surgeon approximated the sternotomy, the patients oxygen saturation (SpO2) fell gradually from 99 to 9295%. 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 s1 (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 s1. The patients 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.
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Discussion |
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In our case with a donor-to-recipient ratio of 2.75, problems of donorrecipient 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.
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References |
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