J Thorac Cardiovasc Surg 2006;132:695-696
© 2006 The American Association for Thoracic Surgery
A novel ascending aortic extension and plication technique for narrowing the retroaortic space
Hajime Sakurai, MDa,*,
Shinichi Mizutani, MDa,
Noriyuki Kato, MDa,
Sadanari Sawaki, MDa,
Takahisa Sakurai, MDa,
Junya Sugiura, MDa,
Masaki Matsushima, MDb
a Department of Cardiovascular Surgery, Social Insurance Chukyo Hospital, Nagoya, Japan
b Department of Pediatric Cardiology, Social Insurance Chukyo Hospital, Nagoya, Japan.
Received for publication May 16, 2006; accepted for publication May 22, 2006.
* Address for reprints: Hajime Sakurai, MD, Department of Cardiovascular Surgery, Social Insurance Chukyo Hospital, 1-1-10, Sanjo, Minami-ku, Nagoya 457-8510, Japan (Email: hajime_sakurai{at}chukyo-hosp.jp).
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Drs Kato, Sawaki, Sugiura, Sakurai, Matsushima, and Mizutani (left to right)
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Postoperative pulmonary artery branch or airway compression occasionally follows narrowing of the retroaortic space after aortic arch reconstruction or with an enlarged ascending aorta caused by increased aortic flow accompanying congenital heart disease.1,2
Some authors have interposed a prosthetic graft or pulmonary autograft to extend the aorta to increase the retroaortic space.2–4 This report presents a new surgical technique that enlarges the retroaortic space by extending and plicating the ascending aorta without a prosthetic graft or autograft.
Clinical Summary
A 1
-year-old girl with a double-outlet right ventricle, multiple large ventricular septal defects, and pulmonary atresia had successfully undergone 2 modified Blalock-Taussig shunts. She underwent a bidirectional Glenn shunt with a pulmonary artery patch plasty using autopericardium for a nonconfluent pulmonary artery. Pre-Fontan angiography demonstrated severe narrowing of the left pulmonary artery and pulsatile anterior left pulmonary arterial compression by the large ascending aorta (Figures 1, A, and E1, A), which was confirmed by means of computed tomography (Figure E1, B).
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Figure 1. A, Pre-Fontan angiography showing narrowing of the retroaortic space with an enlarged ascending aorta. B, Postoperative angiography showing the extended and plicated ascending aorta and enlarged retroaortic space.
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Figure E1. Pre-Fontan angiography (A) and reconstructed computed tomography with the aortic arch removed (B), showing the stenotic left pulmonary artery and anterior pulmonary arterial compression by the ascending aorta. SVC, Superior vena cava; LPA, left pulmonary artery.
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At 2 years of age, weighing 8.2 kg, she underwent an extracardiac Fontan procedure concomitant with aortic extension and plication. After a median sternotomy, cardiopulmonary bypass was instituted with aortic arch cannulation (Figure 2). Cardiac arrest was achieved by means of cardioplegia after crossclamping. The clamp was applied from just proximal to the origin of the brachiocephalic artery to the inner curvature of the aortic arch. The ascending aorta was transected obliquely, from about 2 cm above the sinotubular junction on the right side of the aorta to the opposite side of the origin of the brachiocephalic artery on the left. After transecting the aorta, the left pulmonary artery was enlarged by anastomosing an obliquely trimmed 18-mm polytetrafluoroethylene graft (Gore-Tex graft; W. L. Gore and Associates, Flagstaff, Ariz). Then the inferior vena cava was cut from the right atrium. A second cardioplegia infusion was added retrogradely through the coronary sinus. The left side of the distal stump of the ascending aorta was plicated, reducing its diameter to near-normal size. The right side of the proximal stump was plicated similarly. Then both stumps were anastomosed with nonabsorbable monofilament sutures posteriorly and absorbable sutures anteriorly. The anastomosis between the inferior vena cava and polytetrafluoroethylene graft completed the extracardiac Fontan procedure.
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Figure 2. A, Diagram illustrating the obliquely transected ascending aorta. B, Both stumps were plicated and anastomosed.
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The patient had an uneventful recovery. The postoperative aortogram showed that the diameter of the ascending aorta was reduced and that the retroaortic space and left pulmonary artery were enlarged (Figure 1, B).
Discussion
In cyanotic patients the aortic roots are usually larger than normal because of a large right-to-left shunt and many collateral arteries.1 Occasionally, such an enlarged aorta or the aorta after a complex aortic arch reconstruction procedure causes pulmonary artery branch compression or central airway obstruction.1–3 This is especially likely to affect pulmonary artery branches that have been enlarged with a patch.
Baker and colleagues2 reported ascending aortic extension with prosthetic graft interposition to open the retroaortic space and relieve pulmonary artery narrowing. They expected no significant pressure gradient to develop across the short segment of the graft, although the graft used was smaller than the normal adult arch. However, they stated that further follow-up is needed to validate the long-term effectiveness of the technique. Others have described transverse aortic arch extension by using a pulmonary autograft to increase the space within the aortic arch.4 This technique has potential complications, including future arch calcification, stenosis, or dilatation, and requires careful long-term follow-up.4
McElhinney and associates1 reported using reduction ascending aortoplasty to reduce the diameter by imbricating or plicating the aortic wall with sutures. However, it is difficult to enlarge the retroaortic space adequately because their technique does not cut the aortic wall. Pulmonary artery stenting is another approach to overcome vascular compression in retroaortic space narrowing.5 However, it has potential problems, such as erosion of the pulmonary artery and bronchus, especially in younger patients.2 The use of a ring-reinforced graft for pulmonary artery enlargement might also result in bronchial compression.
Compared with reported methods, the technique described here has the following advantages: (1) aortic extension without the use of a prosthetic graft or autograft; (2) simultaneous aortic plication for an enlarged aorta; (3) potential for growth, even in younger children; and (4) excellent exposure of the branch pulmonary artery for plasty if needed. Although the aortic crossclamp time is slightly longer with our technique than with graft interposition, we consider the time tolerable in candidates for the Fontan operation because they are usually older than early infants.
References
- McElhinney DB, Reddy VM, Pian MS, Moore P, Hanley FL. Compression of the central airways by a dilated aorta in infants and children with congenital heart disease. Ann Thorac Surg 1999;67:1130-1136.[Abstract/Free Full Text]
- Baker CJ, Wells WJ, Derby CA, Rizi S, Starnes VA. Ascending aortic extension for enlargement of the aortopulmonary space in children with pulmonary artery stenosis. Ann Thorac Surg 2005;80:1647-1651.[Abstract/Free Full Text]
- Curran RD, Mavroudis C, Backer CL. Ascending aortic extension for right pulmonary artery stenosis associated with ventricular-to-pulmonary artery conduit replacement. J Card Surg 1997;12:372-379.[Medline]
- Mitchell MB, Campbell DN, Toews WH, Khan TZ. Autograft aortic arch extension and sleeve resection for bronchial compression after interrupted aortic arch repair. Ann Thorac Surg 2002;73:1969-1971.[Abstract/Free Full Text]
- Moore JW, Spicer RL, Perry JC, Mathewson JW, Kirkpatrick SE, George L, et al. Percutaneous use of stents to correct pulmonary artery stenosis in young children after cavopulmonary anastomosis. Am Heart J 1995;130:1245-1249.[Medline]
