Impact of Sternotomy and Pericardial Opening in Patients With Ventricular Septal Defects: Assess Before Sawing!

In Brief

Published ahead of print June 14, 2017.

To the Editor

In their echo rounds, Miles et al¹ discuss an interesting case of perimembranous ventricular septal defect complicated by an aorto-right ventricular fistula. Their patient presented with a severe left-to-right shunt (Qp/Qs ratio 2.3:1) and a mildly dilated right ventricle with preserved systolic function and normal pulmonary artery pressures. In our experience, patients with perimembranous ventricular septal defect and large left-to-right shunt may suffer sudden hemodynamic deterioration after chest or pericardial opening that necessitates rapid institution of cardiopulmonary bypass. Patients anesthetized and mechanically ventilated show increases in pulmonary artery pressure and resistance because of the effects of positive pressure ventilation.² In addition, the closed pericardium constrains the right ventricle and reduces dilation.³ The sudden drop in thoracic pressure after sternal sawing and the lack of constraint on right ventricular filling after pericardial opening may decrease the right ventricular and pulmonary pressures and, as a consequence, increase the shunt fraction throughout the cardiac cycle. In turn, this can precipitate acute right ventricular dilation and failure. Did the patient presented suffer such an experience? Do the authors have echocardiographic images from after sternotomy and after pericardial opening? We applaud the full echocardiographic assessment described and suggest that the findings described serve as advance warning to be prepared to rapidly instituted cardiopulmonary bypass.

Filippo Sanfilippo, MD, PhD
Department of Anesthesia and Intensive Care
Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione
Palermo, Italy
[email protected]

Gabriele Di Gesaro, MD
Cardiology Unit
Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation
Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione
Palermo, Italy

Roberto Serretta, MD
Department of Anesthesia and Intensive Care
Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione
Palermo, Italy

Giuseppe Raffa, MD
Cardiac Surgery and Heart Transplantation Unit
Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione
Palermo, Italy

Francesco Clemenza, MD
Cardiology Unit
Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation
Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione
Palermo, Italy