Surgical strategy to prevent cardiac injury during reoperation in infants

INTRODUCTION: Simplified Aortic Cannulation (SAC), wherein the innominate artery is used as the arterial inflow site rather than the ascending aorta, has proved to be a useful technique for arterial cannulation especially for small neonates undergoing complex cardiac operations. Since few technical options are available for re-entry cardiac injuries in small infants, we postulate that this technique may be equally helpful in those situations. CASE PRESENTATION: We employed SAC in 4 infants undergoing reoperative cardiac surgery (prior Norwood, n = 2; prior arterial switch operation with suprasystemic pulmonary artery pressures after a Le Compte maneuver, n = 1; prior Ebstein's anomaly, n = 1). In all cases the innominate artery was exposed at the level of the supra-sternal notch, and a 3.5 mm expanded polytetrafluoroethylene (ePTFE) graft was anastomosed to the innominate artery (n = 3), and a 10 French cannula inserted into the graft for whole-body perfusion. Right atrial cannulation was obtained by dividing the anterior aspect of the diaphragm at the level of the xiphisternum, gaining easy access to the right atrial-inferior vena cava junction, without separating the sternal edges. DISCUSSION AND EVALUATION: All four infants successfully underwent their operations using SAC. In one case (2(nd )stage palliation for hypoplastic left heart syndrome) a cardiac injury occurred upon sternal reentry, but utilizing SAC, this was repaired without consequence. CONCLUSION: Simplified aortic cannulation and direct right atrial cannulation may be obtained without dividing the sternum in complex reoperative infant surgeries, without making additional incisions. This may be life-saving in reoperative cardiac injuries in small infants.