Intraoperative fluorescence with indocyanine green in congenital cardiac surgery: Potential applications of a novel technology

Abstract

Background: Achieving successful repair of congenital heart defects requires attention to detail. Careful evaluation of anastomotic site patency, reimplanted coronary arteries, location of epicardial coronaries, and myocardial perfusion may be necessary to ensure safe conduct of the operation and achieve excellent outcomes.Methods: Intraoperative fluorescence angiography (IOFA) was performed using indocyanine green in patients undergoing the following procedures: coronary artery reimplantation, coronary artery unroofing, evaluation of intraoperative coronary anatomy, reoperation requiring ventriculotomy, coarctation/interrupted aortic arch repair, systemic-to-pulmonary artery shunt, Norwood procedure, thoracic duct localization, and vascular rings. Results:The technique was feasible in all patients. No mortality or adverse events related to the dye were encountered. Adequate intraoperative imaging was obtained in 15 patients (20 images), which correlated well with postoperative studies. The imaging quality was superior for assessing shunt patency, myocardial perfusion, and anastomotic patency and determining the location of epicardial coronary arteries but was less so for assessing branch pulmonary arteries.Conclusions: IOFA is a useful and safe technique that can provide a quick on-table assessment of a variety of congenital surgical procedures. This may help answer questions that can minimize postoperative interventions and help ensure a smooth perioperative course and excellent outcomes. (JTCVS Techniques 2021;-:1-12)Right modified Blalock-Taussig shunt as visualized in a patient with double-outlet right ventricle/pulmonary atresia.

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“…There are currently no FDA‐approved agents to facilitate intraoperative NIRF visualization of the ureter. Experimental studies of the dyes methylene blue and indocyanine green, which are approved for use in other indications, 23 , 24 , 25 have revealed deficiencies in optical properties and route of administration and clearance, respectively, that make them unsuitable for such procedures. 12 To address this unmet need, novel NIRF agents are being developed.…”

“…In the remaining participant (8-mg cohort), green urine coloration first appeared in the 2-to 2.5-hour interval. Green urine was observed until 3 to 3.5 hours after dosing in 3 of the 4 participants in the indocyanine green, which are approved for use in other indications, [23][24][25] have revealed deficiencies in optical properties and route of administration and clearance, respectively, that make them unsuitable for such procedures. 12 To address this unmet need, novel NIRF agents are being developed.…”

Commentary: Indocyanine green: The Green Lantern of congenital heart surgery?

“…The unique fluorescent property of indocyanine green (ICG) has been leveraged in imaging technology to allow intraoperative visualization of various vascular structures and assist with surgical planning and assessment of technical results. Said and colleagues 1 demonstrate their experience with the technology in myriad clinical situations. There are several important lessons to be gleaned.…”

“…Said and colleagues 1 provide important details regarding dilution of ICG, dose, and method of delivery, The ICG can be administered into the aortic root in a crossclamped or perfusing heart after institution of cardiopulmonary bypass. The presence of aortic insufficiency may affect the dosing and timing of administration.…”

Commentary: Intraoperative fluorescence with indocyanine green: A potentially useful adjunct modality to enhance intraoperative diagnosis and decision making?

“…In this issue of the Journal , Said and associates 1 provide a nice description of their application of intraoperative fluorescence with indocyanine green (ICG) in congenital heart surgery operations. The value of any technical paper is in providing a sufficiently detailed description so that someone not familiar with a technique could find guidance if contemplating adopting it.…”