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J Thorac Cardiovasc Surg 1998;116:914-923
© 1998 Mosby, Inc.

SURGERY FOR CONGENITAL HEART DISEASE

TOTAL REPAIR OF PULMONARY ATRESIA WITH VENTRICULAR SEPTAL DEFECT AND MAJOR AORTOPULMONARY COLLATERALS: AN INTEGRATED APPROACH

From the Divisions of Pediatric Cardiac Surgery,^a Pediatric Cardiology,^b and Pediatric Cardiac Anesthesia,^c Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesł Hospital, Rome, Italy.

Read at the Seventy-eighth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 3-6, 1998.

Received for publication May 8, 1998. Revisions requested July 16, 1998; revisions received Aug 4, 1998. Accepted for publication Aug 6, 1998. Address for reprints: Adriano Carotti, MD, Department of Pediatric Cardiology and Cardiac Surgery, Ospedale Bambino Gesú, Piazza S Onofrio, 4, 00165 Rome, Italy.

Background: Predicting postrepair right ventricular/left ventricular pressure ratio has prognostic relevance for patients undergoing total repair of pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries. To this purpose, we currently rely on 2 novel parameters: (1) preoperative total neopulmonary arterial index and (2) mean pulmonary artery pressure changes during an intraoperative flow study.
Methods: Since January 1994, 15 consecutive patients (aged 64 ± 54 months) with pulmonary atresia, ventricular septal defect, and major aortopulmonary collaterals were managed according to total neopulmonary arterial index. Seven patients with hypoplastic pulmonary arteries and a total neopulmonary arterial index less than 150 mm²/m² underwent palliative right ventricular outflow tract reconstruction followed by secondary 1-stage unifocalization and ventricular septal defect closure. The other 8 patients with a preoperative index of more than 150 mm²/m² underwent primary single-stage unifocalization and repair. The ventricular septal defect was closed in all cases (reopened in 1). In 9, such decision was based on an intraoperative flow study.
Results: Patients treated by right ventricular outflow tract reconstruction had a significant increase of pulmonary artery index (P = .006) within 22 ± 6 months. Repair was successful in 14 cases (postrepair right ventricular/left ventricular pressure ratio = 0.47 ± 0.1). One hospital death occurred as a result of pulmonary vascular obstructive disease, despite a reassuring intraoperative flow study. Accuracy of this test in predicting the postrepair mean pulmonary artery pressure was 89% (95% CI: 51%-99%). At follow-up (18 ± 12 months), all patients are free of symptoms, requiring no medications.
Conclusion: The integrated approach to total repair of pulmonary atresia, ventricular septal defect, and major aortopulmonary collaterals by preoperative calculation of total neopulmonary arterial index, right ventricular outflow tract reconstruction (when required), and intraoperative flow study may lead to optimal intermediate results.

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