Aortic Relocation for Transposition Complex with Aortic Arch Obstruction
Atsushi Tateishi, MD,
Masaaki Kawada, PhD,
Hideki Morita, MD1,
Shingo Kasahara, PhD2,
Shunji Sano, PhD2
Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi, Jichi Medical University
1 Division of Cardiovascular Surgery, Jichi Medical University, Tochigi, Japan
2 Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences Okayama, Japan
Atsushi Tateishi, MD, Tel: +81 285 58 7368, Fax: +81 285 44 6271, Email: atateishi{at}jichi.ac.jp, Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi, 3311-1, Shimotsuke, Tochigi 329-0498, Japan.
 |
ABSTRACT
|
|---|
We describe successful primary repair of 2 cases of transposition complex with aortic arch obstruction. A new aortic arch was reconstructed by direct anastomosis between the well-mobilized ascending aorta and the descending aorta. The neoaortic root with transferred coronary arteries was subsequently anastomosed to the undersurface of this new aortic arch. This technique deals with the significant size discrepancy between the 2 great arteries, and anomalous coronary artery patterns.
Key Words: Aortic Coarctation • Transposition of the Great Arteries • Double Outlet Right Ventricle • Congenital
|
INTRODUCTION
|
|---|
Surgical repair of complete transposition of the great arteries or double-outlet right ventricle with subpulmonary ventricular septal defect, (Taussig-Bing anomaly) associated with coarctation of the aorta (CoA) carries a high risk of inadequate repair of associated aortic arch obstruction, including a hypoplastic arch. Liddicoat and colleagues1 and Mavroudis and colleagues2 described a new approach to these complexes, using aortic relocation, in the mid 1990s. We present our experience of aortic relocation without prosthetic material.
|
CASE REPORTS
|
|---|
CASE 1
A 4-day-old neonate, weighing 2.6 kg, was referred to our unit for surgery. Echocardiography disclosed transposition of the great arteries, CoA, and atrial septal defect. Computed tomography showed a dilated pulmonary trunk and a small ascending aorta (Figure 1
). Cardiopulmonary bypass was established with arterial cannulas in the innominate artery and patent ductus arteriosus. The muscular outlet to trabecular malalignment-type ventricular septal defect was closed with a Dacron patch through the tricuspid valve during core cooling. The patent ductus arteriosus was divided, the cannula in the ductus arteriosus was removed, and the descending aorta was dissected out. The ascending aorta (6 mm in diameter) was transected 3 mm above the sinotubular junction. The transected ascending aorta was relocated and directly anastomosed to the equal-sized descending aorta, to create a neoaortic arch. Systemic perfusion was restored without interrupting cerebral perfusion, with an arterial cannula in the innominate artery. After transection of the main pulmonary artery, coronary transfer was performed. The undersurface of the neoaortic arch was incised, the neoaortic root with the reimplanted coronary cuffs was lifted up and anastomosed with the aid of isolated cerebral perfusion.3 A neo-pulmonary artery was reconstructed with harvested autologous pericardium following Lecompte’s maneuver. Intraoperative echocardiography showed no turbulence along the reconstructed aortic arch. The postoperative course was uneventful, and the patient was discharged without any complications. Computed tomography 1 month later demonstrated an unobstructed aortic arch, without kinking (Figure 2).
View larger version (157K):
[in this window]
[in a new window]
|
Figure 1. Preoperative anterior view of 3-dimensional computed tomography in Case 1, showing a dilated pulmonary trunk, relatively small ascending aorta, hypoplastic aortic arch, and coarctation.
|
|
View larger version (177K):
[in this window]
[in a new window]
|
Figure 2. Postoperative posterior view of 3-dimensional computed tomography in Case 1, showing the reconstructed aortic arch without obstruction and no sign of kinking of the branches.
|
|
CASE 2
An infant aged 1 month (body weight 3.9 kg) was referred with the diagnosis of false Taussig-Bing anomaly and CoA. Echocardiography revealed a size discrepancy between the great arteries, and the aorta was positioned anteriorly and to the right of the pulmonary trunk. The coronary pattern was type 3b in Shaher’s classification, and the aortic valve was bicuspid. Surgery was performed in a similar manner as in case 1. The diameters of the ascending aorta, main pulmonary artery, and aortic arch were 6, 15, and 3 mm, respectively. Aortic arch obstruction was alleviated by the same technique as in case 1 (Figure 3). A single coronary artery was transferred by the trapdoor method. The postoperative course was uneventful. Angiography at 1-year follow-up demonstrated an unobstructed aortic arch without kinking.
View larger version (56K):
[in this window]
[in a new window]
|
Figure 3. Diagram of the aortic relocation procedure in Case 2. (A) False Taussig-Bing anomaly and coarctation of aorta. (B) After great artery transection and coronary transfer, the arch is reconstructed by suturing the ascending aorta to the descending aorta, and the neoaorta to the underside of the new aortic arch. (C) The completed repair.
|
|
|
DISCUSSION
|
|---|
There are various morphological problems in transposition of the great arteries or Taussig-Bing anomaly associated with CoA, including a significant size discrepancy between the ascending aorta and the main pulmonary trunk, hypoplastic aortic arch, anomalous coronary arteries, and subaortic stenosis.4 There are several surgical options for the repair of arch anomalies in this type of complex defect. For example, conventional CoA repair is a possible surgical option, including extended end-to-end anastomosis or extensive patch augmentation of the arch with homograft or other materials. There are also problems with repair of arch anomalies, such as residual and recurrent arch obstruction and limited availability of homografts. These issues have resulted in high morbidity and mortality.5
The aortic relocation procedure described here overcomes these problems. Using this method, a large anastomosis of the neoaortic root with a new aortic arch and without obstruction can be achieved with less risk of bleeding. Torsion on the neoaorta with the anomalous coronary artery after extensive reconstruction is also minimized. The risk of recurrent aortic arch obstruction is diminished. Use of prosthetic or homograft materials is avoided. Intraoperative cerebral ischemia can be prevented with continuous cerebral perfusion. Kinking at the origin of the right brachiocephalic artery can be avoided by extensive mobilization of the neck vessels. Further follow-up is necessary to determine the risk of late recurrence of aortic arch obstruction, however, this aortic relocation procedure seems to be an attractive alternative for such difficult cases.
|
REFERENCES
|
|---|
- Liddicoat JR, Reddy VM, Hanley FL. New approach to great-vessel reconstruction in transposition complexes with interrupted aortic arch. Ann Thorac Surg 1994;58:1146–50.[Abstract]
- Mavroudis C, Backer CL, Muster AJ, Rocchini AP, Rees AH, Gevitz M. Taussig-Bing anomaly: arterial switch versus Kawashima intraventricular repair. Ann Thorac Surg 1996; 61:1330–8.[Abstract/Free Full Text]
- Kotani Y, Ishino K, Kasahara S, Yoshizumi K, Honjo O, Kawada, et al. Continuous cerebral and myocardial perfusion during aortic arch repair in neonates and infants. ASAIO J 2006;52:536–8.[Medline]
- Planché C, Serraf A, Comas JV, Lacour-Gayet F, Bruniaux J, Touchot A. Anatomic repair of transposition of great arteries with ventricular septal defect and aortic arch obstruction. One-stage versus two-stage procedure. J Thorac Cardiovasc Surg 1993; 105:925–33.[Abstract]
- Mohammadi S, Serraf A, Belli E, Aupecle B, Capderou A, Lacour-Gayet F, et al. Left-sided lesions after anatomic repair of transposition of the great arteries, ventricular septal defect, and coarctation: surgical factors. J Thorac Cardiovasc Surg 2004; 128:44–52.[Abstract/Free Full Text]
Asian Cardiovasc Thorac Ann 2009;
17:422-424
© 2009 by SAGE Publications
DOI: 10.1177/0218492309338126
TOP
ABSTRACT
INTRODUCTION
