A new approach to correction of tetralogy of Fallot with absent pulmonary valve

A new technique for primary repair of tetralogy of Fallot with absent pulmonary valve syndrome is suggested. In addition to the standard intracardiac portion of tetralogy of Fallot repair, this approach includes translocation of the pulmonary artery anterior to the aorta, shortening of the ascending aorta, and shortening and plication of the pulmonary artery. This new technique should eliminate compression of the tracheobronchial tree caused by impingement by the pulmonary artery.     

Technical modification of the neoaortic reconstruction in Norwood procedure: sparing of anterior wall of the main pulmonary artery

Abstract   The growth potential of the neoaorta after the stage I Norwood procedure could be limited when the patient has a small ascending aorta. Patients with hypoplastic left heart syndrome usually have a large main pulmonary artery (MPA) and from its posterior wall both pulmonary arteries arise. We describe a modified technique that spares a large anterior wall of the MPA in the neoaortic reconstruction of Norwood procedure to enhance the growth potential of the neoaorta.     

Intermediate results with correction of tetralogy of Fallot with absent pulmonary valve using a new approach.

OBJECTIVE: The intermediate results achieved with a new technique for primary repair of tetralogy of Fallot with absent pulmonary valve syndrome are reported. METHOD: Apart from correction of tetralogy of Fallot, this approach includes translocation of the pulmonary artery anterior to the aorta and away from the tracheobronchial tree. Since November 1998 this technique has been employed in three symptomatic newborns and three infants with a diagnosis of tetralogy of Fallot with absent pulmonary valve. The median age at surgery was 37 days (range 14-256 days). The median weight at operation was 3.4 kg (range 2.9-4 kg). All patients had severe respiratory problems and congestive heart failure with cyanosis. RESULTS: There was no early or late death during the follow-up (median 27 months). One patient required redo due to failure to thrive as a consequence of right ventricle volume overload. Valved conduit was inserted to pulmonary position. Respiratory symptoms disappeared or were significantly reduced in all patients. Postoperative computed tomographic scan showed no compression of trachea and main bronchi, pulmonary artery was away from tracheobronchial tree in all patients. Patients are doing well with adequate growth. CONCLUSIONS: The new technique described here has a potential to reduce or eliminate bronchial compression by pulmonary artery. Translocation of pulmonary artery anterior to the aorta takes the dilated pulmonary artery away from the trachea and bronchial tree. This approach was found to be technically feasible and can be useful especially in symptomatic newborns and infants.     

A modified technique for repair of the anomalous origin of the right pulmonary artery from the ascending aorta.

We report a modified technique of right pulmonary artery implantation to the main pulmonary artery with interposition of a tube created from the great arterial wall for an anomalous origin of the right pulmonary artery from the right lateral aspect of the ascending aorta. This technique offers extra autologous tissue length and reduced tension at the anastomotic site. It also offers the possibility to place the anomalous right pulmonary artery anterior to the ascending aorta, avoiding the aortic compression. This technique was employed successfully in a 15-week-old female.     

Isolated anomalous origin of right coronary artery from the main pulmonary artery

The anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital cardiac malformation and usually associated with other cardiac anomalies. Most patients with isolated ARCA from MPA remain asymptomatic, but they may develop myocardial ischemia and even sudden death. We reported an asymptomatic 7-year-old boy referred for evaluation of a heart murmur. Isolation of ARCA from MPA was diagnosed by echocardiography and then confirmed by cardiac catheterization and angiography. The right coronary artery was re-implanted into the ascending aorta. A preoperative thallium-201 myocardial perfusion showed a myocardial ischemia pattern in the anterolateral septal area after a dipyridamole stress test; the ischemia was completely resolved after surgery.     

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.     

New technique in the transfer of an anomalously originated left coronary artery to the aorta.

A 21-month-old girl with an anomalous origin of the left coronary artery underwent a transfer of the left coronary artery to the aorta using a new technique of coronary prolongation. Because the anomalous left coronary artery arising from the left anterior aspect of the pulmonary trunk was too short to reach the aorta, a simple transfer of the left coronary artery to the aorta was deemed impossible. Therefore, a transfer was performed with the help of a coronary prolongation technique using the cuff of the pulmonary trunk and an aortic flap. The new route of the left coronary artery was established anterior to the pulmonary trunk. Postoperative angiography showed a patent left coronary artery without any narrowing or kinking, as well as an improved contractility of the left ventricle. Postoperative cardiac scintigraphy showed a decreased ischemic area. This technique is thus considered applicable when the orifice of the anomalous left coronary artery is too distant from the aorta for a direct anastomosis.     

Truncus arteriosus with interrupted aortic arch: successful correction in a neonate

Truncus arteriosus (type II) with interrupted aortic arch (type B) was successfully repaired at 11 days of age using anterior translocation of the pulmonary arteries, resection of the ductus arteriosus, and direct anastomosis between the descending aorta and truncus. This technique permitted wide reconstruction of the aortic arch and minimized the number of suture lines. It also positioned the right ventricle-pulmonary artery conduit anteriorly, which may simplify its subsequent replacement.     

Anterior translocation of the right pulmonary artery for airway obstruction caused by pulmonary hypertension

Both the bronchi are often severely squeezed by the dilated pulmonary artery in infants with ventricular septal defect and pulmonary hypertension. To relieve the considerable residual airway obstruction, the right pulmonary artery is translocated anteriorly to the ascending aorta concomitantly with the intracardiac repair. This technique is a useful procedure for infants with intractable respiratory failure caused by a dilated pulmonary artery.     

Anomalous origin of the left coronary artery from the pulmonary artery A case using the autologous pulmonary arterial wall graft.

A 10-year-old girl with anomalous origin of the left coronary artery from the pulmonary artery underwent a two coronary system reconstruction with a new technique. Her left coronary artery was stenotic next to its origin and had a severe adhesion with the aorta. We made a bypass grafting between the aorta and the left coronary artery with a roll shaped transected main pulmonary arterial wall graft. The postoperative angiogram showed a good patency of a reconstructed left coronary artery. This technique is considered useful surgical option for bypass grafting to the left coronary artery when the left coronary artery has an obstructive lesion or a difficulty to dissect and mobilize.     

The use of a cusp-bearing homograft patch to the outflow tract and pulmonary artery in Fallot's tetralogy and pulmonary valvular stenosis

A technique is described for maintaining pulmonary valve competence whilst widening the hypoplastic pulmonary artery ring found invariably in Fallot's tetralogy and pulmonary valve stenosis. A homograft composed of the aortic cusps, a portion of ascending aorta, and the anterior mitral leaflet is used. One, two, or three cusps may be replaced or added by variations of technique. The right ventricular outflow tract and the pulmonary trunk are also widened. The operation is applicable to children, and adult homografts can be used. The ring should be widened to a circumference of from 6 to 8 cm. so as to prevent residual pressure gradients. One or two cusp replacements are favoured in the hope that growth will proceed because a continuous portion of natural pulmonary artery and ring remains untouched. An advantage of the technique is the small ventriculotomy required to excise the infundibular obstruction and close the ventricular septal defect. Four case histories are presented. Three patients have survived operation and are doing well. Up to six months post-operatively no serious pulmonary incompetence has developed.     

Ruptured papillary muscle after mitral valve replacement with preservation of chordae tendineae

We report a new technique of left coronary artery implantation to the aorta with interposition of a tube created from the great arterial wall for anomalous left coronary artery from pulmonary artery. This technique was used in 3 patients, of which 2 patients survived. It achieves two coronary artery repair and avoids problems related to extensive mobilization of coronary artery for translocation. It is easily reproducible.     

"Spiral-cuff" technique for repair of anomalous left coronary artery from the pulmonary artery

We describe a new technique for coronary transfer in the repair of anomalous origin of the left coronary artery from the pulmonary artery. The left coronary artery is elongated with the native pulmonary artery wall to form a spiral-shaped coronary cuff to construct an unstretched new left coronary artery system from the ascending aorta. A postoperative angiographic scan showed good flow of the left coronary artery without any kinking or narrowing. This technique is considered useful when an anomalous coronary artery arises a long way from the ascending aorta.     

Anatomical reconstruction of aorta and pulmonary trunk in patients with an aortopulmonary window

We report a modified technique for repair of aortopulmonary window in which a native pulmonary artery flap is created and the aortopulmonary window is completely divided. The pulmonary artery flap is used to reconstruct the ascending aorta, and the defect in the pulmonary trunk is closed with an autologous pericardial patch. This repair avoids the use of a fabric patch with its inherent disadvantages and allows anatomical reconstruction of both the ascending aorta and the pulmonary trunk with low risk of early or late distortion of the aortic and pulmonary root structures.     

Aortic origin of the right pulmonary artery: a cause of heart failure in infancy at high altitude

The development of technique for surgical correction of aortic origin of the right pulmonary artery is described. In the first patient, aged 7 years, the operation was performed via bilateral thoracotomy, with standby for extracorporeal circulation, and the right pulmonary artery was anastomosed directly to the left, using side clamps on both aorta and left pulmonary artery. The currently preferred procedure is to operate as early as possible in infancy, using perfusion at 30 degrees C with ventricular fibrillation and without cross-clamping of the aorta. Wide mobilization of the pulmonary artery probably prevents stenosis at the end-to-side anastomosis.     

Description of a new technique for reimplanting the anomalous right pulmonary artery

Anomalous origin of the right pulmonary artery from the ascending aorta is a rare congenital lesion with a high mortality and morbidity if early diagnosis is not made and correction is not undertaken. We describe the repair of such a lesion using a double-trapdoor technique of pulmonary artery reimplantation.     

Aberrant right pulmonary artery and double outlet ventricle: one-stage repair

We report a 13-month-old male child with anomalous origin of the right pulmonary artery from the ascending aorta and a double outlet right ventricle. Aortic wall was used for elongation of the pulmonary artery and side-to-end connection to the pulmonary trunk. Special emphasis is made on this particular operative technique for strictly laterally originating right pulmonary artery that requires no prosthetic material, avoids extreme stretching, and may enable normal growth potential.     

自体肺动脉组织一期矫治主动脉弓病变合并心内畸形

目的 探讨自体肺动脉组织一期矫治主动脉弓病变合并心内畸形的手术方法和治疗效果.方法 1993年4月至2009年11月,共25例主动脉弓病变合并心内畸形的患儿接受了一期矫治手术.男性17例,女性8例;年龄26 d～6.5岁,平均11个月;体质量3.0～14.5 kg,平均12.4 kg.其中6例患儿为主动脉弓缩窄,6例为主动脉弓中断,13例为主动脉弓发育不良.手术技术包括切开肺动脉前壁,切除动脉导管,应用部分自体肺动脉壁重建主动脉弓,重建肺动脉,并同时矫治合并心内畸形.结果 24例患儿术后恢复顺利,1例患儿死于围手术期肺动脉高压危象.随访心脏超声及心脏CT检查证实主动脉弓重建及心内畸形矫治满意.术后未发生神经系统及其他并发症.随访过程中,患儿生长发育正常,主动脉弓无再狭窄.结论 自体肺动脉具有生长潜力且柔韧性好,是一种理想的重建主动脉弓的材料.一期矫治手术治疗先天性主动脉弓病变合并心内畸形可以得到满意的结果.     

Pulmonary artery sling: results with median sternotomy, cardiopulmonary bypass, and reimplantation

Background. The classic surgical approach to pulmonary artery (PA) sling has been through a left thoracotomy with division of the left PA and reimplantation into the main PA anterior to the trachea. Another approach is anterior left PA translocation with distal tracheal resection. Since 1985, we have repaired PA sling with a median sternotomy approach, cardiopulmonary bypass, and division and reimplantation of the left PA into the main PA with simultaneous repair of associated tracheal stenosis. The purpose of this review is to determine the outcome of that strategy.

Methods. From 1985 to 1998, 16 infants had surgical treatment of PA sling, 14 had left PA division and reimplantation into the MPA, 2 patients had repair using the translocation technique. Mean age at repair was 6.9 months, median age was 4 months. All infants, except 1 with an absent right lung, were operated on at the time of diagnosis. All had rigid bronchoscopy, which revealed associated complete tracheal rings in 12 patients. Seven patients had tracheal repair with pericardial tracheoplasty, 4 had repair using a tracheal autograft technique, and 2 had a distal tracheal resection (one for tracheomalacia). Of the 2 patients having the translocation technique, 1 had a severely hypoplastic right lung and the other had complete absence of the right lung.

Results. There has been no operative mortality. Hospital stay ranged from 5 to 188 days (mean 36 ± 42 days). There was 1 late death 7 months postoperatively from respiratory complications of pericardial tracheoplasty. All left pulmonary arteries are patent and blood flow to the left lung by nuclear scan (n = 10) ranges from 24% to 46% (mean 35% ± 9%).

Conclusion. The strategy of median sternotomy, cardiopulmonary bypass, and left PA division and reimplantation into the main PA with simultaneous tracheal repair has resulted in a low operative mortality and excellent patency of the left pulmonary artery. Results with repair of the commonly associated complete tracheal rings has recently improved with the use of the free tracheal autograft technique.     

Growth of the pulmonary anulus and pulmonary arteries after the Waterston anastomosis.

Twenty-six patients with tetralogy of Fallot underwent angiocardiography before a Waterston shunt and again several years later, prior to complete repair (mean interval 40 +/- 15.6 [SD] months). The ratio between the diameter of the pulmonary valve anulus (PVA) and that of the descending thoracic aorta (Ao) increased by 0.32 +/- 0.233, significantly more than is reported to occur after a Blalock-Taussig anastomosis (p = 0.0001). This increase had some relation to the interval between the two angiographic studies (r = 0.34, p = 0.08) and to the mean pressure in the main pulmonary artery (MPA) at the time of the second study (r = 0.35, p = 0.08). The ratio of diameter of the right (RPA) and left pulmonary arteries (LPA) and that of the Ao also increased by 0.24 +/- 0.226 and 0.20 +/- 0.201, respectively. These data suggest that an initial large aortopulmonary shunt may result in less need for transannular patching at complete repair.