SPY ing on Coronaries: The Use Of Intraoperative Imaging to Avoid Coronary Artery Injury During Redo Congenital Cardiac Surgery

Transcription

1 SPY ing on Coronaries: The Use Of Intraoperative Imaging to Avoid Coronary Artery Injury During Redo Congenital Cardiac Surgery Avianne P. Bunnell, B.S. Kamal K. Pourmoghadam, M.D. William M. DeCampli, M.D., Ph.D Division of Pediatric Cardiac Surgery at Arnold Palmer Hospital for Children, University of Central Florida College of Medicine

2 The Authors Do Not Have Any Relationships Or Financial Disclosures To Declare

3 Novadaq Spy Intraoperative Imaging System (SPY)... Indocyanine green (ICG) dye fluorescence with The Novadaq Spy Intraoperative Imaging System (Novadaq Technologies Inc, Toronto, Canada) Used in human subjects for >40 years Various initial uses More popularized in the last 10 years in Adult cardiac surgery Transplant Plastic surgery Neurosurgery

4 ICG Advantages Excellent safety profile Water soluble albumin-bound iodide Short half-life Bile excretion Negligible parenchymal uptake Imaging without ionizing radiation Repeat use Real-time visual assessment Guides surgical decision making

5 Limitations... Contraindication to ICG use: Iodide Allergy Necessitates the injection of an exogenous media

6 How it Works... ICG itself illuminates with 806-nm light With SPY filter, fluoresces and emits at 830 nm Captured by videocamera Real-time images displayed on computer screen as dye passes through field of view Recordable event Can be visible to naked eye NOVADAQ Imaging Illuminated (2013) SPY Elite [photograph] NOVADAQ Headquarters Bonita Springs, Florida

7 Our Aims... Use SPY intraoperative imaging modality during redo congenital cardiac operations to prevent coronary artery injury Preoperative echocardiography and angiography Intraoperative SPY imaging Real-time imaging data Mapping the course of specific coronaries Impacting the plan for reconstructive surgery.

8 Case year-old young lady born with tetralogy of Fallot (TOF). Repair as an infant (4 months old) Anomalous origin of the right main coronary artery Flap of anterior main and left pulmonary artery reflected Remained with wide open pulmonary insufficiency RV dilatation & dysfunction Presented for implantation of pulmonary valve and relief of severe LPA stenosis SPY intraoperative imaging was used to identify coronary anomaly in real time

9 Left Clip Patch Superior Inferior RCA Once the course of the coronary Right is identified, its location is marked by Liga clips

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11 Outcome... Underwent implantation of a 23mm bioprosthetic pulmonary valve and LPA arterioplasty Postoperative course unremarkable Extubated in ICU post-op day 1 Discharged on post-op day four no anticoagulation therapy

12 Case year old man born with TOF, repaired at 8 months old Non-transannular patch technique No follow-up Presented to ED after MVA due to syncope Wide-open pulmonary insufficiency & severely dilated, poorly functioning RV Ventricular Tachycardia, possible etiology of syncope Preoperative Doppler Echocardiogram Large conus branch arising from RCA &traversing between RVOT and right AV groove SPY technique employed to identify conus branch & adjust cryoablation

13 Pre-ICG infusion Small branch off Conus Post ICG infusion Large Conus Branch From RCA

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15 Cryoablation...

16 Cryoablation... MPA AO

17 Cryoablation... Jump Site

18 Outcome... Implantation of a bioprosthetic 25mm pulmonary valve and surgical and epicardial CryoMaze Ablation for ventricular tachycardia. Extubated post-op night Discharged to home post-op day eight on atenolol Normal sinus rhythm with no ventricular ectopies

19 SPY in Congenital Cardiac Surgery ICG utilized safely in human subjects for over 40 years More recently numerous publications have documented its efficacy in a diverse range of surgical subspecialties Provides real time data for assessment of vascular anatomy/competence Nevertheless, the benefit of SPY intraoperative imaging technique remains relatively unrecognized in congenital cardiac surgery

20 SPY in Congenital Cardiac Surgery In congenital cardiac surgery, numerous reconstructive procedures are performed in patients who have had prior surgeries Epicardial coronary artery anatomy difficult to ascertain In this presentation, novel utilization of SPY was shown in a select group of patients with anatomical variance Benefited from acquiring real time data altered course of operation, ensuring successful outcome. Technique remains very helpful as an adjunct to preoperative echocardiographic and angiographic data

21 Conclusion... Once an anatomical variance in coronary anatomy is recognized, SPY modality provides safe, quick, and reliable real time data to identify and perhaps adjust surgical plans, thus ensuring patient safety.