Left-to-right shunts in control of bleeding following surgery for aneurysms of the ascending aorta.

Surgical repair of complex thoracic aneurysms requiring aortic valve replacement and coronary revascularization is occasionally complicated by significant bleeding despite the experience of the surgeon. While bleeding from the mediastinal tissues and the anterior suture line is usually easily controlled, posterior bleeding may require dismantling the repair and a second bypass run. The synergism of a second bypass run and continued bleeding may result in increased mortality and/or morbidity. We recently encountered bleeding in a patient who developed ventricular dysfunction after bypass and opted to interpose a Gore-tex graft between the aneurysm wall and the right atrium with immediate hemostasis and a benign course. Subsequently we used four different shunts successfully in 9 of 33 patients. The average bleeding rate 30 minutes after protamine was 221 +/- 60 ml/minute with a range of 190 to 350 ml/minute. The initial two hour chest tube drainage averaged 880 +/- 285 ml with a range of 490 to 1300 ml. There were no re-explorations for bleeding. The shunt in the first patient has remained open without cardiac decompensation. The last patient developed heart failure and required elective repair of a leak at the descending end of an arch replacement. Our experience suggests that these shunts can be effective, particularly if posterior suture line bleeding is encountered.