Asian Cardiovasc Thorac Ann 2008;16:254-255
© 2008 Asia Publishing EXchange Ltd
Ascending Aortic Transection: Useful Adjunct in Pulmonary Artery Reconstruction
Ashutosh Singh, MCh,
Ganapathy S Krishnan, MCh,
Ravi Agarwal, MCh,
Dhiren Dave, MCh,
Kotturathu M Cherian, FRACS
Department of Cardiac Surgery, Dr. KM Cherian Heart Foundation, International Center for Cardiovascular and Thoracic Diseases, Frontier Lifeline Hospital, Chennai, India
For reprint information contact: Kotturathu M Cherian, FRACS, Tel: 91 44 4201 7575, Fax: 91 44 2656 5150, Email: drkmc{at}airtelbroadband.in, International Center for Cardiovascular and Thoracic Diseases, Frontier Lifeline Hospital, R-30-C, Ambattur Industrial Estate Road, Mogappair, Chennai 600 101, India.
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ABSTRACT
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Pulmonary artery reconstruction is frequently needed during surgery for congenital heart disease. Exposure of the main pulmonary artery and its branches is difficult if they are hypoplastic with a large anteriorly placed aorta. In redo operations, adhesions make this not only technically difficult, but also prone to bleeding. We electively transected the ascending aorta in 36 patients to facilitate pulmonary artery exposure, without complications or significant prolongation of cross clamp time.
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INTRODUCTION
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Transection of the ascending aorta for pulmonary artery (PA) reconstruction has been described in a few case reports of surgical correction of tetralogy of Fallot with distorted pulmonary anatomy or right PA pseudoaneurysm following an ascending aorta-right PA shunt.1–3 In patients with tetralogy of Fallot and absent pulmonary valve, aortic transection has been performed as part of the Lecompte maneuver and pulmonary arterioplasty to prevent left bronchial compression.4 We have extended the indications for this procedure to facilitate the exposure necessary for extensive repair of intrapericardial PAs during a variety of congenital heart operations.
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TECHNIQUE
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The procedure is performed via a median sternotomy and standard cardiopulmonary bypass instituted by aortic-bicaval cannulation with moderate hypothermia. Myocardial protection is achieved with antegrade cold blood cardioplegia administered into the aortic root after clamping the ascending aorta. The aortopulmonary septum is dissected and the ascending aorta is freed completely from the main PA and its branches. The ascending aorta is transected between the aortic cross clamp and the cardioplegia pursestring suture (Figure 1
). The cardiac end of the aorta is retracted inferiorly using the cardioplegia pursestring suture, while the cephalic end is retracted superiorly using an additional adventitial stitch, opening up the confluence of the main and branch pulmonary arteries. After reconstruction of the PAs, the aorta is reanastomosed using a single layer of continuous Prolene suture (Figure 2).
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Figure 1. The ends of the transected ascending aorta retracted to expose the proximal right pulmonary artery.
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DISCUSSION
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From February 2004 to April 2006, 36 patients underwent elective transection of the ascending aorta to expose intrapericardial PAs. Operations included intracardiac repair of tetralogy of Fallot with severe pulmonary stenosis or atresia (n = 13), Rastelli procedure (n = 7), bidirectional Glenn shunts (n = 9), unifocalization procedures (n = 5), tetralogy of Fallot with aortopulmonary window to the right PA (n = 1), and Norwood stage II (n = 1); 8 of these 36 patients were redo sternotomy cases. The branch PAs and bifurcation were augmented with autologous pericardium in most cases. A non-valved bovine jugular vein conduit and retroaortic innominate vein patch were used in two cases. The patient having a Norwood stage II procedure had left PA ostial stenosis. We avoided transection of the neoaorta during reconstruction. Postoperative catheterization revealed a significant residual gradient across the left PA along with poor left lung perfusion. We revised the left pulmonary augmentation by transecting the neoaorta and reconstructing the left PA and the bifurcation, extending to the proximal right PA. Compared to our corrections without aortic transection, the mean cardiopulmonary bypass time was only 15 ± 5 min longer, and aortic cross clamp time was 8 ± 4 min longer in this group. There was no incidence of bleeding postoperatively.
Pulmonary artery reconstruction is often required during corrective surgery for congenital heart disease. By virtue of its spiral course around the ascending aorta, the distal main PA, its bifurcation, and the proximal right PA lie posterior to the ascending aorta and underneath the arch. This anatomic relationship in association with hypoplastic PAs and a large, anteriorly placed aorta makes exposure of the branch PAs difficult. Also, during redo operations, dense intrapericardial adhesions make dissection in this region not only technically difficult but also prone to bleeding. This makes reconstruction technically difficult to perform, resulting in a suboptimal outcome. Aortic transection facilitates exposure of the distal main PA, confluence and branches up to the hilum, especially in patients with difficult anatomy and sternal re-entry. It does not prolong cardiopulmonary bypass time, and is not associated with any added morbidity. We recommend this maneuver in patients requiring exposure of the main PA, its bifurcation, and branches during surgery for congenital heart disease, especially if adequate exposure is critical for successful repair.
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REFERENCES
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- Yamamoto N, Reul GJ, Kidd JN, Cooley DA, Hallman GL. A new approach to repair of pulmonary branch stenosis following ascending aorta-right pulmonary artery anastomosis. Ann Thorac Surg 1976;21:237–42.[Abstract]
- Ergin MA, Griepp RB. Total correction of tetralogy of Fallot. How to deal with the complicated ascending aorta-right pulmonary artery anastomosis. J Thorac Cardiovasc Surg 1979;77:469–73.[Abstract]
- Monarrez CN, Rao PS, Moore HV, Strong WB. False aneurysm of the right pulmonary artery. New complication of the aorta-right pulmonary anastomosis. J Thorac Cardiovasc Surg 1979;77:738–41.[Abstract]
- Hraska V. A new approach to correction of tetralogy of Fallot with absent pulmonary valve. Ann Thorac Surg 2000;69:1601–3.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
