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J Thorac Cardiovasc Surg 2002;123:246-257
© 2002 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease (CHD)

Outcome after reconstruction of discontinuous pulmonary arteries

From Children's Hospital Boston, Harvard Medical School, Departments of Cardiac Surgery,^a Cardiology,^b and Biostatistics,^c Boston, Mass.

Received for publication May 1, 2001. Revisions requested June 6, 2001; revisions received July 25, 2001. Accepted for publication Aug 1, 2001. Address for reprints: Richard A. Jonas, MD, Children's Hospital Boston, Cardiac Surgery, 300 Longwood Ave, Boston, MA 02115 (E-mail: richard.jonas{at}tch.harvard.edu).

Objective: This study was undertaken to determine outcomes of and optimal treatment strategies for reconstruction of congenital or acquired discontinuity of branch pulmonary arteries.
Methods: Between 1985 and 2000 pulmonary artery continuity was established in 102 patients with discontinuous central pulmonary arteries and normal peripheral arborization. Data were obtained retrospectively.
Results: Techniques to connect both pulmonary arteries included direct pulmonary artery–pulmonary artery anastomosis (n = 33), tube graft interposition (n = 47), or pulmonary arterial implantation in right ventricular–pulmonary arterial conduits (n = 22). Among patients with biventricular repair (n = 66), survival was 85% ± 8% at 5 years, and freedom from surgical or interventional pulmonary arterioplasty was 31% ± 11%. At most recent follow-up, mean branch pulmonary arterial z scores were –0.5 ± 1.6 (right pulmonary artery) and –1.4 ± 1.3 (left pulmonary artery). Mean right to left ventricular pressure ratio was 0.61 ± 0.26, and this value was more than 0.75 in 13 of 58 cases. Fifteen of 51 had a lung perfusion mismatch of more than 75:25, and in 9 of 58 one branch pulmonary artery was occluded. Twenty-two patients who underwent primary establishment of antegrade pulmonary artery flow without previous shunt procedures had comparable survival and reintervention rates, with a tendency toward higher pulmonary arterial z scores and lower right to left ventricular pressure ratios. Among patients with single-ventricle repair (n = 33), 5-year survival was 93% ± 8% and freedom from pulmonary arterioplasty was 39% ± 9%. Ten of 19 patients had a lung perfusion mismatch, and one branch pulmonary artery was occluded in 4 of 31. Overall, a direct pulmonary artery anastomosis was associated with better survival (P = .006). The presence of aortopulmonary collaterals was a risk factor for pulmonary artery occlusion (P = .03).
Conclusion: Good survival can be achieved for patients with pulmonary artery discontinuity, but this requires frequent reinterventions. Direct pulmonary artery– pulmonary artery anastomoses and control of all collateral vessels may further improve outcome.

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