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J Thorac Cardiovasc Surg 2001;122:392-393
© 2001 The American Association for Thoracic Surgery
Brief Communications |
From the Department of Pediatric Cardiovascular Surgery, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Received for publication Nov 20, 2000. Accepted for publication Dec 20, 2000. Address for reprints: Masaaki Yamagishi, MD, Department of Pediatric Cardiovascular Surgery, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamikyo-ku, Kyoto, 602-8566, Japan (E-mail: myama{at}koto.kpu-m.ac.jp).
Controversy exists regarding the optimal repair for interrupted aortic arch (IAA), ventricular septal defect (VSD), and left ventricular outflow tract (LVOT) obstruction.
1-5 We developed a new operative technique for reconstructing IAA of neonatal type B, hypoplasia of the ascending aorta (AAo), and valvular aortic stenosis without the use of autologous or prosthetic material.
Clinical summary
A male neonate weighing 3100 g was referred to our hospital with cyanosis and respiratory distress. Two-dimensional echocardiography showed type B IAA, patent ductus arteriosus, subarterial VSD, and valvular aortic stenosis. The aortic valve was bicuspid and the annular diameter measured 3.0 mm. The infundibular septum was deviated posteriorly. Because aortic flow was decreased because of a left-to-right shunt through VSD, a significant pressure gradient across the aortic valve and subaortic portion was not detected by Doppler echocardiogram.
Surgical repair was performed at 13 days of age. Arterial cannulas were separately inserted into the brachiocephalic artery and the descending aorta (DAo). Venous return cannulas were inserted into the superior and inferior venae cavae. The right upper and lower parts of the body were perfused throughout the repair. Circulatory arrest was not used. After institution of moderate hypothermic cardiopulmonary bypass, the patent ductus arteriosus was ligated and divided. Ductal tissue was totally resected from the DAo. The main pulmonary artery (MPA) was transected at its bifurcation. The AAo was also transected at the level of pulmonary bifurcation (Figure 1, B). The pulmonary artery bifurcation was translocated anterior to the AAo and MPA stump. The anterior and posterior walls of the distal AAo stump were incised vertically to enlarge the orifice. The superior aspect of the DAo orifice was enlarged by an incision a few millimeter long toward the left subclavian artery. The inferior half of the orifice of the DAo was anastomosed to the posterior half of the MPA orifice with running 7-0 polydioxanone sutures (PDS; Ethicon, Somerville, NJ)(Figure 1, C). The posterior half of the distal AAo orifice was directly anastomosed to the superior half of the DAo orifice with running 7-0 PDS sutures(Figure 1, D and F). A hole with a diameter of 7 mm was made on the right posterolateral wall of the MPA. The proximal AAo stump was anastomosed to the pulmonary hole. Neoaortic arch reconstruction was accomplished by a direct end-to-end anastomosis between the anterior aspect of distal AAo stump and the MPA stump with running 7-0 PDS sutures(Figure 1, E and F). All arterial stumps were within easy reach and thus excessive tension was not produced on all anastomoses. Subsequently, right ventriculotomy was performed just beneath the pulmonary anulus. Intraventricular rerouting was performed through the ventriculotomy with a bovine pericardial patch (Bio-Vascular, Inc, St Paul, Minn) and pledget-reinforced mattress sutures. Continuity between the right ventricle and pulmonary bifurcation was established with an autologous pericardial roll with a diameter of 12 mm. The pericardial roll was equipped with a tricuspid valve constructed of an expanded polytetrafluoroethylene membrane (W.L. Gore & Associates, Inc, Flagstaff, Ariz).
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Comment
A standard operative strategy for IAA with VSD is a 1-stage repair consisting of direct end-to-side anastomosis of the aortic arch 1,2 and enlargement of the LVOT by resection 1 or displacement 2 of the posteriorly malaligned infundibular septum. However, in IAA with valvular aortic stenosis and/or hypoplasia of the AAo, persistence of LVOT 1 and/or aortic arch obstruction is inevitable after standard operations. At present, the surgical option is limited to Norwood 3 or Ross-Konno operations 4,5 in such cases. Our original technique offers obvious advantages over conventional ones. A suitable combination of the great arterial stump provides a wide neoaortic arch with laminar flow. Tension-free natural anastomoses of the aortic arch may reduce potential restenosis and preserve the geometry of the semilunar valves, thus preventing semilunar valve regurgitation. LVOT obstruction is completely avoided by dual systemic pathways from the left ventricle. Avoidance of use of prosthetic material means preservation of the growth potential of the aortic arch. Anterior translocation of the pulmonary artery bifurcation evades compression by the reconstructed aortic arch. This technique can be adapted to most cases of IAA.
References
This article has been cited by other articles:
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  H. Uemura, I. Adachi, K. Kagisaki, F. Shikata, and T. Yagihara Intermediate Results After a Modified Yasui Procedure With the Lecompte Maneuver Ann. Thorac. Surg., July 1, 2007; 84(1): 284 - 286. [Abstract] [Full Text] [PDF]
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