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J Thorac Cardiovasc Surg 2007;134:1588-1589
© 2007 The American Association for Thoracic Surgery

Brief Communication

Modification of stage II procedure after hybrid palliation (bilateral pulmonary artery banding and ductal stenting) for hypoplastic left-sided heart syndrome: Modified arch reconstruction with retained stented ductus patch

Hospital for Sick Children, Toronto, Ontario, Canada.

Received for publication August 3, 2007; accepted for publication August 14, 2007.

^_* Address for reprints: Christopher Caldarone, MD, Division of Cardiovascular Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8. (Email: christopher.caldarone{at}sickkids.ca).

Bilateral pulmonary artery banding and ductal stenting can be used as a "hybrid" alternative to Norwood-based management for the palliation of neonates with single ventricle physiology.¹ By using the hybrid strategy, first-stage palliation defers cardiopulmonary bypass and arch reconstruction to a second-stage procedure at 4 to 6 months of age. At the second stage, distal aortic arch reconstruction is more difficult than a neonatal Norwood reconstruction because the ductal stent often extends into the descending aorta.

The requirement for resection of all ductal tissue is based on observations that ductus tissue is friable, does not suture well, and will contract after cessation of prostaglandins. After 4 to 6 months, however, stented ductal tissue is robust and handles sutures well. Consequently, the necessity of removing all stented ductal tissue can be questioned.

This report describes a simplified hybrid second-stage procedure that uses stented ductal tissue to reconstruct the aortic arch.

Clinical Summary

A neonate with hypoplastic left-sided heart syndrome underwent uneventful initial hybrid palliation and was discharged. At 6 months of age, he underwent a second-stage procedure. Parental consent and ethical approval from the Hospital for Sick Children Ethics Board-approved Surgical Innovation Program were obtained.

Cardiopulmonary bypass was initiated, the branch pulmonary arteries were occluded, the patient was cooled, and circulatory and cardioplegic arrest was initiated. The main pulmonary artery was transected, and the origin of the branch pulmonary arteries was resected as a single large button (Figure 1, A–C). The area of apposition between the ascending aorta and the stented ductus was then divided to the orifice of the aortic isthmus (Figure 1, D). Regional cerebral perfusion was initiated with inominate cannulation.

View larger version (21K): [in this window] [in a new window]   Figure 1. A, Left lateral view of the main pulmonary artery, ductus, aorta, and banded left pulmonary artery. The arrow indicates the orientation of subsequent views after division of the main pulmonary artery and aorta (red line). B, Resection of a single button incorporating the branch pulmonary arteries (dotted line). C, Orifice of the aortic isthmus (red arrow). D, Incision site is marked. E, Remaining stent on the posterior wall of the aorta is resected (*), and the lateral free edges are reapproximated (arrows). F, After side-to-side approximation of the ascending aorta and main pulmonary artery, continuity with the reconstructed aorta is established.

The branch pulmonary artery bands were removed, and the branches were dilated. Continuity was restored by folding the pulmonary artery button and sewing the anterior free edges together. A bidirectional cavopulmonary shunt was constructed. The patient’s postoperative course was unremarkable, and he was discharged on postoperative day 9. After 1 month, the postoperative echocardiogram demonstrated an unobstructed reconstructed aortic arch.

Discussion

The use of retained stented ductal material to reconstruct the aortic arch offers several advantages over traditional homograft reconstruction.

1 The stented material is "preformed" to fit the contour of the transverse aortic arch.

2 Continuity between the ductal material and the descending aorta avoids the need for exposure of this area, obviates any distal sewn anastomoses. and thereby prevents bleeding and reduces potential for recurrent laryngeal nerve injury.

3 Avoidance of homograft material may improve the potential for future transplantation.²

Potential disadvantages include the following:

1 There is potential for aneurysmal ductal dilation. The retention of the stent deeply embedded in the tissue, however, leaves the tissue "wire-reinforced," and this risk seems small.

2 Any circumferential retention of stent material will likely require reoperation for coarctation; consequently, meticulous removal of the stent in the posterior aorta is important.

3 The growth potential of the isthmus area after stent removal is not known.

The use of retained stented ductal material facilitates the hybrid second-stage procedure and thereby improves the relative merit of the hybrid management strategy in comparison with the Norwood strategy. Long-term follow-up will be required.

References

1. Akintuerk H, Michel-Behnke I, Valeske K, et al. Stenting of the arterial duct and banding of the pulmonary arteries: basis for combined Norwood stage I and II repair in hypoplastic left heart. Circulation 2002;105:1099-1103.[Abstract/Free Full Text]
   
2. Meyera SR, Campbell PM, Rutledge JM, et al. Use of an allograft patch in repair of hypoplastic left heart syndrome may complicate future transplantation. Eur J Cardiothorac Surg 2005;27:554-560.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christopher A. Caldarone Osami Honjo Glen S. Van Arsdell Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Caldarone, C. A. Articles by Van Arsdell, G. S. Search for Related Content PubMed Articles by Caldarone, C. A. Articles by Van Arsdell, G. S.