6 2 6 Brief communications
`
`plete homograft replacement of the heart and both lungs.
`Surgery 50:842-845, 1961
`5 Reitz BA, Burton NA, Jamieson SW, Bi~ber CP, Pennock
`JL, Stinson EB, Shumway NE: Heart and lung transplan(cid:173)
`tation. Autotransplantation and allotransplantation in pri(cid:173)
`mates witq extended survival. J THORAC CARDIOVASC SURG
`80:360-372, 1980
`6 Scott WC, Haverich A, Billingham ME, Dawkins KD,
`Jamieson SW: Lethal lung rejection without significant
`cardiac rejection in primate heart-lung allotransplants.
`Heart Transplant (in press)
`7 Craighead J: Cytomegalovirus pulmonary disease. Patho(cid:173)
`biol Annu 5:197-220, 1975
`8 Esterley JA: Pneumocystis carinii in lungs of adults at
`autopsy. Am Rev Respir Dis 97:935-937, 1968
`
`New cannulation technique for the severely
`calcified ascending aorta
`
`Leonard A. R. Golding, M.D., Cleveland, Ohio
`
`From the Cleveland Clinic Foundation, Cleveland, Ohio.
`
`Severe calcific atherosclerosis involving the femoral arteries,
`ascending aorta, right subclavian artery, and aortic arch
`precluded standard cannulation techniques for a patient requir(cid:173)
`ing emergency revascularization. A cannula was passed from
`the apex of the left ventricle across the aortic valve to lle in the
`proximal ascending aorta, and successful cardiopulmonary
`bypass was achieved to allow revascularization.
`.
`
` Severe diffuse atherosclerosis can produce difficulties
`in cannulation for cardiopulmonary bypass. In almost all
`cases, however, vascular access can be obtained to allow
`completion of the circuit for cardiopulmonary bypass. In
`this case the severity of the atherosclerotic process
`resulted in inability to use any of the standard tech(cid:173)
`niques for cannulation because the vessels felt essentially
`like solid tubes.
`
`Case report. A 68-year-old woman was referred for
`coronary revascularization with Functional Class IV angina
`pectoris. Coronary arteriography showed an 80% left ostia!
`obstruction with 80% obstruction in the dominant right
`coronary artery. Ventriculography showed normal ventricular
`functiori, but severe calcification was also noted throughout
`the whole ascending aorta extending into the arch. At
`operation this calcification involved the ascending aorta and
`continued into the arch with no evidence of any "soft spots."
`The calcification also extended into the right subclavian and
`carotid arteries. Exploration of both groins revealed severe
`diffuse atherosclerosis extending throughout the femarais and
`
`Address far reprints: Leonard A. R. Golding, M.D., The Cleveland
`Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44106.
`
`The Journal of
`Thoracic and Cardiovascular
`Surgery
`
`Fig. l. Transapical aortic cannulation.
`
`into the iliac arteries. Because of inability to construct the
`proximal end of a vein graft anastomosis to the ascending
`aorta, both interna! mammary arteries were dissected from the
`chest wall, the patient was given heparin, and a two-stage
`venous cannula was inserted through the right atrial append(cid:173)
`age. Aortic cannulation was achieved by passing a 20 Fr.
`end-hole armored venous cannula through the apex of the left
`ventricle and antegrade through the aortic valve to lie in the
`proximal portion of the ascending aorta. A small left ventric(cid:173)
`ular vent was also positioned in the apex of the left ventricle to
`decompress this chamber (Fig. 1). Before the institution of
`cardiopulmonary bypass, no aortic regurgitation was noted on
`the arterial pressure record. The patient was placed on
`cardiopulmonary bypass and cooled systemically to 18º C.
`Bypass flows of 2.2 L/min/m2 were achieved and the amount
`of draipage through the left ventricular vent did not exceed
`300 rnl/min. The left interna! mammary artery was anasto(cid:173)
`mosed to the left anterior descending coronary artery and the
`right interna! mammary to the right coronary artery. The
`anastomoses were done with local occlusion only. The patient
`was rewarmed systemically to normothermia and then easily
`weaned from cardiopulmonary bypass. The postoperative
`course was uneventful with no alteration in the electrocardio(cid:173)
`gram or cardiac enzymes suggestive of myocardial infarc(cid:173)
`tion.
`Discussion. In almost all cases cardiopulmonary
`bypass can be achieved with cannulation of the ascend(cid:173)
`ing aorta, femoral arteries, · right subclavian artery, or
`the aortic arch. On arare occasion the diffuse nature of
`atherosclerosis can preclude such techniques.
`
`Edwards Exhibit 1012, pg. 1
`
`

`
`Volume 90
`Number 4
`october, 1985
`
`Brief communications 6 2 7
`
`Retrograde passage of a cannula across the aortic
`valve was originally described by Zwart and associates 1
`as part of a left ventricular support system. W e ha ve also
`used this technique clinically and have demonstrated by
`echocardiography that the normal aortic leaflets mold
`around the cannúla across the aortic valve, giving no
`evidence of aortic regurgitation. 2
`3 The antegrade pas(cid:173)
`•
`sage of the cannula allows for easy passage across the
`aortic valve. Obviously, such a technique is not practical
`for patients with calcific aortic stenosis, in whom the
`cannula could then completely occlude the aortic orífice,
`or in the presence of significant aortic regurgitation.
`
`REFERENCES
`Zwart HHJ, Kralios A, Kwan-Gett CS, Backman DK,
`Foote JL, Andrade JD, Calton FM, Schoonmaker F, Kolff
`WJ: First clinical application of transarterial closed-chest
`left ventricular bypass. Trans Am Soc Artif Intern Organs
`16:386-391, 1970
`2 Golding L: A simplified blood access method for a tempo(cid:173)
`rary left ventricular assist system in humans. Artif Organs
`2:317-318, 1978
`3 Golding LR, Groves LK, Peter M, Jacobs G, Sukalac R,
`Nosé Y, Loop FD: Initial clinical experience with a new
`temporary left ventricular assist device. Ann Thorac Surg
`29:66-69, 1980
`
`Unusual interatrial communication after the
`Fontan procedure
`
`G. R. Westerman, M.D., R. I. Readinger, M.D.,
`and S. H. Van Devanter, M.D.,
`Little Rock, Ark.
`
`From the Departments of Surgery and Pediatrics, Arkansas Chil(cid:173)
`dren's Hospital, and University of Arkansas for Medica! Sciences,
`Little Rock, Ark.
`
`Two patients are presented who illustrate unusual venous
`anatomy allowing right-to-left shunting at the atrial level after
`Fontan repair.
`
`Arterial desaturation after a modified Fontan repair
`-12 It
`of tricuspid atresia or single ventricle is not unusuaI. 1
`may result from a variety of causes after repair in
`patients with or without previously performed Glenn
`shunts. We have encountered two patients in whom,
`after Fontan's procedure, a right-to-left shunt at the
`atrial level was vía unusual coronary venous anatomy.
`
`Address for reprints: G. R. Westerman, M.D., Arkansas Children's
`Hospital, Division of Cardiovascular Surgery, 804 Wolfe St.,
`Little Rock, Ark. 72202.
`
`Fig. 1. Case l. Right atrial injection; venous communication
`(arrow) between right atrium and coronary sinus located in left
`atrium.
`
`The shunt was clinically insignificant in one patient but
`necessitated two reoperations in another.
`
`Case reports.
`CASE l. A 51/2-year-old boy was catheterized on April 30,
`1982, with a diagnosis of single ventricle {S,L,L} and pulmo(cid:173)
`nary valvular stenosis. Pulmonary artery pressure was 12 mm
`Hg (mean) and no gradient was measured across the bulbo(cid:173)
`ventricular foramen. The left atrium was fully saturated and
`systemic saturation was 89%.
`On Sept. 14, 1982, he underwent a Fontan procedure with
`excision of the septum primum and patch diversion of the
`pulmonary venous return to both the left and right atrioven(cid:173)
`tricular valves. The coronary sinus was diverted to the left side
`of the circulation. A direct communication was then estab(cid:173)
`lished between the right atrium and pulmonary artery.
`He underwent routine recatheterization on Aug. 3, 1983.
`The right atrial and pulmonary arterial pressures were 9 and 8
`mm Hg, respectively. Left ventricular and aortic pressures
`were 105/15 and 105/72 mm Hg, respectively. Systemic
`arterial saturation was 97%. Contrast injection in the right
`atrium revealed a coronary vein that entered the left atrium
`via the coronary sinus but caused no significant desaturation
`(Fig. 1). He continues to do well on no medication with normal
`exercise tolerance.
`CASE 2. A 2-day-old cyanotic infant was catheterized on
`June 28, 1981, the study confirming the echocardiographic
`diagnosis of tricuspid atresia type IA. A balloon septostomy
`
`Edwards Exhibit 1012, pg. 2