Is the liberal use of preoperative 3-dimensional imaging and presternotomy femoral cutdown beneficial in reoperative adult congenital heart surgery?

Objective: Patients with congenital heart disease frequently survive into adulthood, and many of them will require repeat surgery. Often, the unique anatomy can make reoperative sternotomy and the conduct of cardiopulmonary bypass challenging. We evaluated the utility of preoperative 3-dimensional imaging and presternotomy femoral cutdown in reoperative adult congenital heart disease surgery.
Methods: We retrospectively studied 205 adult patients, who had undergone reoperative cardiac surgery for congenital heart disease from 2006 to 2011. Using the operative history and 3-dimensional preoperative imaging findings, an algorithm was created to determine whether femoral cutdown or cannulation should be performed before sternal reentry. Analyses were performed to determine the benefits of this strategy. In addition, analyses were performed to identify adverse outcomes related to this strategy.
Results: Presternotomy femoral intervention was performed in 112 of 205 patients (55%)-femoral cutdown alone in 69 (34%) and femoral cutdown, cannulation, and institution of cardiopulmonary bypass in 43 (21%). Of the 19 patients (9%) with a cardiac injury, femoral cutdown had already been performed in 17, of whom 10 had also undergone cannulation. Only 2 patients required urgent femoral cutdown or cannulation. A strong correlation was found between the site of injury predicted by the preoperative algorithm and the actual site of cardiac injury (88%). In both univariate and multivariate models, the risk factors for cardiac injury included a history of cardiac injury during sternal reentry (18% vs 1%, P = .0001), proximity of the right ventricular outflow tract to the posterior chest wall (35% vs 14%, P = .04), and increased reoperative sternotomy incidence (P = .01). In 31 patients, despite safe reentry, the femoral vessels were used as a preferential site of venous (n = 6), arterial (n = 9), or venous and arterial cannulation (n = 16) because of anatomic constraints within the chest cavity. Three patients experienced groin complications (pseudoaneurysm, abscess, ischemia) requiring surgery.
Conclusions: Cardiac injury during reoperative surgery in adults with congenital heart disease is not uncommon. The preoperative history and imaging findings could be predictive of certain cardiac injury patterns. Using the preoperative history and 3-dimensional imaging findings, a more selective algorithm for presternotomy femoral intervention might be warranted.
(Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)