Pulmonary artery sling: reimplantation versus antetracheal translocation.

BACKGROUND: We compared two repair techniques for pulmonary artery sling. The first comprised detachment of the aberrant left pulmonary artery from the right pulmonary artery and its implantation into the main pulmonary artery, and the second, translocation of the left pulmonary artery anterior to the trachea (without implanting it into the main pulmonary artery), resection of tracheal stenosis, and end-to-end reconstruction of the trachea. METHODS: Five symptomatic infants (3 boys and 2 girls; median age 5 months; range, 3 weeks to 11 months) with pulmonary artery sling were operated on through a median sternotomy with aid of cardiopulmonary bypass. In 3 patients, the left pulmonary artery was transected from the right pulmonary artery and implanted into the main pulmonary artery. In addition, the anterior trachea was augmented with a pericardial patch (n = 2). In the remaining 2 patients, associated tracheal stenosis was resected, the left pulmonary artery was translocated anterior to the trachea, and the trachea was reconstructed. RESULTS: All 5 infants survived the operation. The 3 patients in whom the left pulmonary artery was implanted into the main pulmonary artery had an uncomplicated postoperative course. All 3 patients, at a follow-up of 10 months to 7.9 years, were free of symptoms; the left pulmonary artery was documented to be widely patent. The remaining 2 patients in whom the left pulmonary artery was translocated anterior to the trachea could not be extubated. In both patients the distal trachea was compressed anteriorly by the left pulmonary artery. One of these patients died at 1 week postoperatively secondary to tracheal dehiscence. In the other patient, the left pulmonary artery was implanted into the main pulmonary artery with good result; at a follow-up of 3.9 years, mild residual stridor has persisted. CONCLUSIONS: In pulmonary artery sling, implantation of the aberrant left pulmonary artery into the main pulmonary artery, if necessary combined with anterior tracheoplasty, reliably eliminates tracheal and esophageal compression and maintains antegrade flow into the left pulmonary artery. Translocation of the left pulmonary artery anterior to the trachea without implanting it into the main pulmonary artery is not favored because that might result in anterior compression of the trachea. In addition, we are concerned about growth of the circumferential tracheal anastomosis in neonates and infants.     

Right pulmonary artery obstruction after pulmonary artery banding.

Serial assessment of pulmonary artery flow by Doppler echocardiography was carried out in 15 infants after pulmonary artery banding. Three infants were identified as having branch pulmonary artery obstruction based on diastolic pulmonary artery flow. It is concluded that this flow profile may be specific for branch pulmonary artery obstruction after pulmonary artery banding.     

Left superior pulmonary artery sling

A pulmonary artery sling is formed when the left pulmonary artery originates from the right pulmonary artery and encircles the distal trachea, coursing between the trachea and esophagus to reach the hilum of the left lung. Pulmonary artery slings are often associated with distal tracheal narrowing, due to either intrinsic stenosis or secondary compression by the anomaly itself. We report a very rare case in which the left superior pulmonary artery originated from the right pulmonary artery and then acted as a sling, the left inferior pulmonary artery originated from the pulmonary trunk.     

Left pulmonary artery coarctoplasty by using the right pulmonary artery flap near the arterial duct

Coarctation of the left pulmonary artery may coexist with tetralogy of Fallot or pulmonary atresia with ventricular septal defect. Various surgical methods, such as autologous pericardial patching and intraoperative pulmonary artery stenting, have been used for solving this condition. We proposed a simple and effective technique for treating patients with left pulmonary artery coarctation and pulmonary atresia with ventricular septal defect by using the right pulmonary artery flap for left pulmonary artery coarctoplasty, plus central shunt creation by V-Y plasty.     

Staged hybrid left pulmonary artery rehabilitation in post-fontan left pulmonary artery hypoplasia

Left pulmonary artery hypoplasia in the setting of Fontan circulation predisposes to pulmonary artery discontinuity. We describe a novel approach to correct post-Fontan left pulmonary artery discontinuity by a strategy to produce isolated left pulmonary artery growth, followed by a catheter-based reincorporation of the left pulmonary artery into the Fontan circuit.     

Surgical treatments of nonconfluent pulmonary arteries with congenital cardiac defects]

Pulmonary artery angioplasty or reconstruction was performed in seven patients with nonconfluent pulmonary arteries and congenital cardiac defects. Age of these patients were ranged from 6 months to 41 years old. Five of them had pulmonary truncal atresia and complex cardiac anomalies. Two of these five patients demonstrated nonconfluent pulmonary arteries due to deformities at ductal insertion of pulmonary arteries. Three patients had had previous systemic to pulmonary artery shunt operations which caused pulmonary artery distortions. Other two patients had intrapulmonary arterial obstructions due to pulmonary artery thrombosis. Patch pulmonary artery plasty was carried out in three patients, dilatation of severe stenotic pulmonary artery was done in one patient simultaneously with pulmonary valvotomy. Central shunt operation was added in one patient with the pulmonary artery which was unable to be reconstructed. Last two patients underwent intrapulmonary artery reconstruction with the rolled pericardial graft. Hospital death occurred in one patient with unproperly increased pulmonary blood flow by central shunt. Average follow-up period of these six survivors after operation was 1.4 +/- 0.8 years. As definite repairs, two patients had Fontan operation, two patients had right ventricle to pulmonary artery reconstruction. And remaining two patients are still to be followed until sufficient growth of pulmonary artery suitable for Fontan operation.     

Repair of tetralogy of Fallot with obstruction of right pulmonary artery; report of a case

Patients with tetralogy of Fallot showing unilateral obstruction of a pulmonary artery, especially the right pulmonary artery, are a high-risk group for pulmonary hypertension after repair. This case of tetralogy of Fallot with the obstruction of the right pulmonary artery received a Blalock-Taussig shunt at 7 months old, and the occluded right pulmonary artery caused empyema after surgery. At 2 years old, a cardiac catheter study showed a pulmonary artery index of 193.6 mm2/m2, so we undertook intracardiac repair. After the repair, she showed a relativery favorable clinical course. Systolic pulmonary artery pressure and right ventricular pressure were about 30 and 50 mmHg, respectively. We considered that tetralogy of Fallot with obstruction of right pulmonary artery could be repaired, as long as the pulmonary artery index was within the limits of indication and the left ventricle was well-developed.     

A rare complication of pre-Eisenmenger patent ductus arteriosus: Pulmonary artery dissection

INTRODUCTIONPulmonary artery dissection associated with patent ductus arteriosus is usually seen in patients with pulmonary hypertension and Eisenmenger's syndrome. This paper presents a case with pre-Eisenmenger patent ductus arteriosus complicated by pulmonary artery dissection, and explains how she was surgically treated.PRESENTATION OF CASEThe transthoracic echocardiography of a 21-year-old woman complaining of effort dyspnea revealed patent ductus arteriosus. Contrast-enhanced thoracic computed tomography scan showed patent ductus arteriosus and dissection in the main pulmonary artery extending from the edge of the patent ductus arteriosus orifice to the pulmonary valve. The patent ductus arteriosus was divided with pledgeted prolene suture and the dissected aneurysmal portion of the pulmonary artery was resected by surgery. Dacron graft interposition was applied to the main pulmonary artery.DISCUSSIONBecause rupture causes cardiogenic shock and sudden death, diagnosis is rare in the living subject and pulmonary artery dissection is frequently detected in autopsy. A case with pulmonary artery dissection as a result of patent ductus arteriosus has been reported in the literature, but the patient died in the preoperative period. In our study, the patient was not diagnosed to have Eisenmenger's syndrome, but had pulmonary artery dissection, a complication arising from patent ductus arteriosus. The patient underwent curative surgery that included pulmonary artery dissection repair and closure of the patent ductus arteriosus.CONCLUSIONIn addition to pulmonary artery aneurysm, pulmonary artery dissection must also be considered as a complication in cases of patent ductus arteriosus with high pulmonary artery pressure diagnosed in adulthood.     

Juxtaductal pulmonary artery coarctation. An underestimated cause of branch pulmonary artery stenosis in patients with pulmonary atresia or stenosis and a ventricular septal defect

An angiographic and clinical study was performed to establish the prevalence of juxtaductal pulmonary artery coarctations in patients with pulmonary atresia or stenosis and a ventricular septal defect or a complex intracardiac defect. The present study is an adjunct to a previously reported portmortem study, in which the incidence of these pulmonary artery coarctations was found to be unexpectedly high. Pulmonary artery coarctations were identified angiographically in 10 of the 15 patients with pulmonary atresia. One additional patient had a bilateral ductus arteriosus and confluent pulmonary arteries, but did not have a pulmonary artery coarctation. Pulmonary artery coarctations were much less prevalent in the cases with pulmonary stenosis (5/50). However, these pulmonary artery coarctations appeared identical to those of the cases with pulmonary atresia. Fourteen pulmonary artery coarctations were located in the pulmonary artery at the side of the ductus arteriosus; this was left sided in 12 and right sided in two patients. In one patient the side of the ductus could not be established. The types and the locations of the pulmonary artery coarctations in the present study were identical to those in the previous postmortem study. Ductal tissue was found in many of the pulmonary artery coarctations of the postmortem study and is likely to be present in the clinical cases as well. The majority of the angiographically identified pulmonary artery coarctations were subsequently confirmed at operation or at autopsy. The clinical outcome and follow-up of the patients is discussed, and it is concluded that juxtaductal pulmonary artery coarctations should be specifically looked for before and during any type of surgical intervention in these patients.     

Primary repair of pulmonary artery sling with double outlet right ventricle and distal tracheal stenosis

The fate of patients with pulmonary artery sling depends on associated tracheal lesions. Distal tracheal stenosis involving the carina frequently results in lethal obstruction due to secretion or inflammatory edema. Further-more, associated complex cardiac anomalies with excessive pulmonary flow make the situation more complicated. We present a case of successful simultaneous one-stage repair of pulmonary artery sling, double outlet right ventricle and distal tracheal obstruction. Pulmonary artery sling was relieved by relocation of the left pulmonary artery (left pulmonary artery to main pulmonary artery) and a tracheoplasty (resection and end-to-end anastomosis). We advocate early aggressive simultaneous repair of pulmonary artery sling with tracheal stenosis and concomitant repair of intracardiac anomalies whenever possible.     

硝普钠经肺动脉直接输注对肺动脉高压的疗效观察

目的　观察硝普钠对二尖瓣置换术后肺动脉高压的疗效。方法　对二尖瓣置换术后具有肺动脉高压的患者 ,由颈内静脉或锁骨下静脉放置Swan -Ganz导管监测其血液动力学指标 ,采用硝普钠经肺动脉端直接输注进行治疗 ,观察硝普钠治疗前后上述血液动力学指标的变化情况。结果　采用硝普钠进行治疗后 ,患者的平均动脉血压 (MAP)、平均肺动脉压 (MPAP)、外周血管阻力指数 (SVRI)及肺血管阻力指数 (PVRI)较用药前明显下降 (P <0 0 5 ) ,而每搏输出量 (SV)、心输出量(CO)及心脏指数 (CI)较用药前明显增高 (P <0 0 5 )。结论　由肺动脉直接输注硝普钠可有效降低二尖瓣置换术后的肺动脉高压 ,并可提高患者的心输出量     

Late recurrence of cardiac sarcoma presenting as giant pulmonary artery aneurysm

We report the case of a 46-year-old woman who had undergone cardiac transplantation for a malignant, right ventricular sarcoma. Five years later, she experienced pulmonary hypertension and a pulmonary artery aneurysm. Medical management of the pulmonary hypertension being unsuccessful, she underwent surgical exploration of the pulmonary artery aneurysm and bilateral pulmonary endarterectomy. Intra-operative findings revealed pulmonary artery sarcoma and an unresectable pulmonary artery aneurysm.     

Acquired pulmonary stenosis and pulmonary artery compression

Three patients suffering from acquired pulmonary stenosis are described resulting from compression of the main pulmonary artery by anterior mediastinal teratoma, Hodgkin's disease, and aneurysm of the ascending aorta, respectively; also four others who had compression of the right or left primary branch of the pulmonary artery. The pulmonary artery compression was demonstrated angiographically in every case, and in the patient with right and left pulmonary artery compression the main pulmonary artery pressure tracing was characteristic of bilateral pulmonary artery stenosis. Cardiac catheterization and selective angiography are indicated in patients who have evidence of right ventricular outflow obstruction to determine the site and severity of the obstruction and to differentiate between extrinsic compression and intrinsic stenosis.     

Successful early surgical recruitment of the congenitally disconnected pulmonary artery

BACKGROUND: Our purpose was to document our experience with early recruitment of congenitally disconnected pulmonary arteries and to assess subsequent pulmonary artery growth and function. METHODS: Patients born in the 10-year period from 1989 to 1999 with a disconnected pulmonary artery diagnosed in infancy and treated in our unit were studied. To be included patients had nonconfluent pulmonary arteries with one or both completely disconnected from the main pulmonary artery. This series did not include patients with acquired stenosis causing occlusion of a pulmonary artery. Echocardiography, cardiac catheterization, MRI, lung perfusion scans, and intraoperative assessment were used to gauge pulmonary artery growth and function. RESULTS: Seven patients with a disconnected pulmonary artery associated with intracardiac conotruncal congenital cardiac disease underwent successful early surgical recruitment of the affected pulmonary artery at 3 months of age or younger. Median follow-up from date of first operation was 4.2 years (range, 1.6 to 13.4). All 7 patients had postrecruitment lung perfusion scans showing a mean of 44% (range, 27% to 78%) of total pulmonary flow through the affected lung. Significant growth in the diameter of the recruited native pulmonary artery was demonstrated in all patients. There were no deaths reported in our series to date. CONCLUSIONS: The rare possibility of a congenitally disconnected pulmonary artery needs to be considered in all patients with a conotruncal cardiac anomaly. To facilitate surgical correction, ensure subsequent growth of the pulmonary artery, and optimize associated lung development, early diagnosis and surgical recruitment is recommended.     

Fontan operation for patients with severe distal pulmonary artery stenosis,atresia, or a single lung

In the absence of a ventricular pump, the status of the pulmonary circulation is crucial to the success of the Fontan operation. In an updated version (1999) of the optimal criteria for the Fontan operation, several of these criteria address the pulmonary circulation: pulmonary artery pressure, pulmonary vascular resistance, pulmonary artery size, and absence of significant pulmonary artery branch stenosis. This chapter reviews the role of the pulmonary circulation in a successful Fontan operation, with a particular emphasis on surgical techniques to repair severe distal or hilar pulmonary artery stenosis or atresia. The special situation of the patient with a single pulmonary artery is also addressed. Severe hilar pulmonary artery stenosis or atresia can be repaired by the technique of intrapulmonary pulmonary artery reconstruction with pericardial patch or tube and allow the successful completion of the Fontan operation. In the selected patient with a single pulmonary artery and optimal hemodynamics, the Fontan operation is possible with good outcome. However, further experience is needed in a larger number of patients to assess the long-term outcome of these treatment strategies. Copyright © 2002 by W.B. Saunders Company     

The surgical treatment of congenital coronary to pulmonary artery fistula.

Six patients with coronary to pulmonary artery fistula underwent surgical treatment between January 1973 and August 1975. All fistula terminated in the main pulmonary artery just distal to the pulmonary valve. Two patients had severe coronary artery disease associated with the fistula. In all patients, the fistula was over-sewn from within the pulmonary artery in addition to ligation to the fistulous vessel on the surface of the pulmonary artery or heart, cardiopulmonary bypass being employed. Two patients underwent concomitant aortocoronary artery saphenous vein bypass for occlusive coronary artery disease. Follow-up data revealed that three patients were free of symptoms and two were improved, while one was lost to follow-up.     

Anomalous origin of the right pulmonary artery from the ascending aorta: a report of three cases

Three patients with anomalous origin of the right pulmonary artery from the ascending aorta were reported. Case 1 was a 16-day-old girl with the right pulmonary artery arising from the base of the ascending aorta. Division and direct anastomosis of the anomalous vessel to the pulmonary trunk were successfully performed. Case 2 was a 4-month-old girl with the kinked and stenotic right pulmonary artery arising from the distal ascending aorta. At the time of surgery, however, the right pulmonary artery had been completely occluded and the pulmonary hypertension of the main pulmonary trunk had been disappeared. The chest was closed without any corrections. Case 3 was a 17-month-old girl with the stenotic right pulmonary artery arising from the distal ascending aorta. The stenotic lesion of the right pulmonary artery was longitudinally incised and anastomosed with the PTFE graft in an end-to-end fashion, followed by the end-to-side anastomosis of the graft and the pulmonary trunk.     

Therapeutic considerations in congenital absence of the right pulmonary artery. Use of internal mammary artery as a preparatory shunt

Congenital unilateral absence of a pulmonary artery is rare. When present, it is usually associated with other cardiac malformations. In this communication an infant with coarctation of the aorta, ventricular septal defect and absent right pulmonary artery is reported. After correction of the first two defects, due to persistent respiratory difficulty, the infant had exploration of the right pulmonary hilum in hopes of finding a pulmonary artery remnant and re-establishing blood flow to that lung. A small hilar vessel supplying all three lobes of the right lung was found and as a first stage, to enhance pulmonary arterial growth, a palliative systemic to pulmonary artery shunt was performed utilizing a large internal mammary artery. This is the first report of a case in which the internal mammary artery is used in an infant to establish systemic to pulmonary arterial flow in congenital unilateral absence of a pulmonary artery.     

Outcome after reconstruction of discontinuous pulmonary arteries

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.     

THE SURGICAL TREATMENT OF CONGENITAL CORONARY TO PULMONARY ARTERY FISTULA

Six patients with coronary to pulmonary artery fistula underwent surgical treatment between January 1973 and August 1975. All fistulee terminated in the main pulmonary artery just distal to the pulmonary valve. Two patients had severe coronary artery disease associated with the fistula. In all patients, the fistula was over-sewn from ivithin the pulmonary artery in addition to ligation of the fistulous vessel on the surface of the pulmonary artery or heart, cardiopulmonary bypass being employed. Two patients underwent concomitant aortocoronary artery saphenous vein bypass for occlusive coronary artery disease. Follow-up data revealed that three patients were free of symptoms and two were improved, while one was lost to follow-up.