Asian Cardiovasc Thorac Ann 2008;16:412-413
© 2008 Asia Publishing EXchange Ltd
Surgical Palliation for Taussig-Bing Anomaly with Multiple Lesions
Kota Agematsu, MD,
Mitsuru Aoki, MD,
Yuji Naito, MD,
Tadashi Fujiwara, MD
Department of Cardiovascular Surgery, Chiba Children’s Hospital, Chiba, Japan
For reprint information contact: Kota Agematsu, MD Tel: 81 33 353 8111 Fax: 81 33 356 0441 Email: agematsuagain{at}yahoo.co.jp, Department of Cardiovascular Surgery, Chiba Children’s Hospital, 579-1, Heta-cho, Midori-ku, Chiba city, Chiba, 266-0007, Japan.
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ABSTRACT
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A successful surgical palliative procedure, consisting of an arterial switch operation, pulmonary artery banding, and arch repair, was performed in a neonate with Taussig-Bing anomaly and aortic arch interruption, subaortic stenosis, and multiple muscular ventricular septal defects. Such anatomical complexity made treatment difficult. This palliative procedure allows future biventricular repair.
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INTRODUCTION
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The hemodynamic profile of Taussig-Bing heart is similar to that of transposition of the great arteries, and it can be successfully repaired by an arterial switch operation (ASO) and ventricular septal defect (VSD) closure or intraventricular rerouting in neonates or young infants.1 However, associated cardiac lesions make it difficult to treat this condition. We describe a palliative procedure for Taussig-Bing anomaly associated with multiple muscular VSDs, subaortic stenosis (SAS), and aortic arch interruption.
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CASE REPORT
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A 1-day-old boy weighing 3.05 kg was referred to our hospital with cyanosis. His arm and leg oxygen saturations were maintained at 70% and 90%, respectively. He was diagnosed with Taussig-Bing anomaly, interrupted aortic arch (Celoria-Patton type A), multiple muscular VSDs, SAS, and patent ductus arteriosus. Preoperative cardiac catheterization revealed hypertrophy of the subaortic conus septum and Shaher type 4 coronary artery. Preoperative cardiac echocardiography showed a subarterial VSD and multiple muscular VSDs. A palliative procedure, consisting of ASO, pulmonary artery banding (PAB), and arch repair, was selected because of the SAS and multiple muscular VSDs. The patient underwent the operation when he was 9 days old. Under general anesthesia, a full median sternotomy was performed. The great arteries were found side by side, and the discrepancy between the ascending aorta measuring 6.4 mm and the main pulmonary artery measuring 11.3 mm in diameter was marked (Figure 1
). Cardiopulmonary bypass was established with bicaval drainage and ascending and descending aortic perfusion. Cardiac arrest was induced with cold crystalloid cardioplegic solution. The ductus arteriosus was divided and the ASO and arch repair were performed without circulatory arrest (Figure 2). The pulmonary artery was translocated anteriorly (Lecompte maneuver) with enlargement of the neo-pulmonary root using autologous pericardium. Pulmonary artery banding was undertaken to regulate pulmonary blood flow, using a band circumference of 19 mm. Weaning from cardiopulmonary bypass was uneventful. Delayed sternal closure was carried out on postoperative day 13. Postoperative echocardiography demonstrated good ventricular function with trivial aortic valve regurgitation. The patient was discharged on postoperative day 54, with systemic oxygen saturation of 86%.
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Figure 1. Operative view: the great arteries were found side by side, and the size discrepancy between the ascending aorta and main pulmonary artery was remarkable.
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Figure 2. The arterial switch and interrupted arch reconstruction were performed simultaneously. Asc = ascending, Des = descending.
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DISCUSSION
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Taussig-Bing anomaly includes a wide spectrum of all types of double-outlet right ventricle with subpulmonary VSD and many associated anomalies such as coarctation of the aortic arch (> 50% of patients) and SAS. Palliative or definitive surgical repair is required in early infancy.2,3 Definitive repair can be achieved by 2 surgical approaches: intraventricular rerouting (Kawashima); or ASO and VSD closure.4 In addition, a Fontan-type procedure may be proposed as a solution to even more complex forms. In the past, a palliative procedure of PAB and arch repair for arch obstruction was performed initially, with complete repair in childhood. However, early 1-stage complete repair of Taussig-Bing malformation has been recommended recently because of improved results of neonatal ASO and VSD closure. The disadvantages of 2-stage repair include pressure and volume loading of the ventricle, persistent cyanosis and congestive heart failure with PAB, which might increase the incidence of neo-aortic valve insufficiency after ASO, and sub-pulmonary hypertrophy that might complicate definitive repair in the future. Despite these drawbacks, a staged strategy is still appropriate in complex cases with other intracardiac and aortic arch anomalies.5
In this case, complete 1-stage repair was impossible because of the multiple muscular VSDs and SAS. We discussed 3 options for palliative surgical procedures in this patient: simple PAB and arch repair, which was unsuitable because of the SAS; Damus-Kaye-Stansel anastomosis, systemic-pulmonary artery shunt, and arch repair, which would negate the possibility of future biventricular repair; and ASO, PAB, and arch repair, which retains the possibility of biventricular repair if the multiple muscular VSDs would close. Pulmonary artery banding was thought to be needed because SAS might not be enough to reduce the pulmonary artery blood flow. Open palliation during the neonatal period and mismatched size of the great arteries are associated with increased risk3. Aortic arch obstruction also increases the risk1. In this case, a size discrepancy was observed between the great arteries, but our procedure of arch reconstruction made it possible to switch them. Our approach of ASO, PAB, and arch repair might be challenging, but it can be considered as an option for Taussig-Bing anomaly with aortic arch interruption, SAS, and multiple muscular VSDs.
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REFERENCES
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- Wetter J, Sinzobahamvya N, Blaschczok HC, Cho MY, Brecher AM, Gravinghoff LM, et al. Results of arterial switch operation for primary total correction of the Taussig-Bing anomaly. Ann Thorac Surg 2004;77:41–7[Abstract/Free Full Text]
- Parr GV, Waldhausen JA, Bharati S, Lev M, Fripp R, Whitman V. Coarctation in Taussig-Bing malformation of the heart. Surgical significance. J Thorac Cardiovasc Surg 1983;86:280–7.[Abstract]
- Comas JV, Mignosa C, Cochrane AD, Wilkinson JL, Karl TR. Taussig-Bing anomaly and arterial switch: aortic arch obstruction does not influence outcome. Eur J Cardiothorac Surg 1996;10: 1114–9.[Abstract]
- Kawashima Y, Fujita T, Miyamoto T, Manabe H. Intraventricular rerouting of blood for the correction of Taussig-Bing malformation. J Thorac Cardiovasc Surg 1971;62:825–9.[Medline]
- Griselli M, McGuirk SP, Ko CS, Clarke AJ, Barron DJ, Brawn WJ. Arterial switch operations in patient with Taussig-Bing anomaly influence of staged repair and coronary anatomy on outcome. Eur J Cardiothorac Surg 2007;31:229–35.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
