Eur J Cardiothorac Surg 2002;22:148-150
© 2002 Elsevier Science NL
A modified technique for repair of the anomalous origin of the right pulmonary artery from the ascending aorta
Edvin Priftia,b*,
Giacomo Fratib,
Adrian Cruceana,
Vittorio Vaninia
a Department of Pediatric Cardiac Surgery, "G. Pasquinucci" Hospital, Massa, Italy
b I.R.C.C.S. NEUROMED, Via Atinense, N.18, 86077 Pozzilli, Italy
Received 14 September 2001;
received in revised form 11 February 2002;
accepted 26 March 2002.
* Corresponding author. G. Pasquinucci Hospital, CREAS-IFC-CNR, Via Aurelia Sud, 54100, Massa, Italy. Fax: +39-0585-493616
e-mail: edvinprifti{at}hotmail.com
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Abstract
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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.
Key Words: Anomalous origin • Right pulmonary artery • Double flap technique
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1. Introduction
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An anomalous origin of the right pulmonary artery (RPA) from the ascending aorta is a hazardous congenital malformation due to the surgical difficulties of implanting the anomalous branch to the main pulmonary artery (MPA). Direct implantation of the RPA is generally reserved for those patients in whom the RPA originates in close proximity to the MPA. When the RPA arises from the right lateral or postero-lateral aspect of the ascending aorta, the direct implantation procedure is difficult, due to a greater distance between the anomalous RPA and MPA. Alternatively, interposition of a synthetic graft [1,2], homograft [1,3] or other techniques using autologous tissue such as aortic ring flap [4], aortic cuff [5] or pericardial patch have been employed successfully. However, such techniques do not offer enough tissue length in cases when the RPA originates more anteriorly from the right lateral aspect of the aorta. We propose a modified technique (double flap technique) employing native tissue, which offers greater tissue length and, as a consequence, reduced tension at the RPA–MPA anastomosis.
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2. Surgical technique
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A midline longitudinal sternotomy is performed. The ascending aorta, proximal aortic vessels, the MPA and LPA are widely mobilized. The patent ductus arteriosus if present is doubly ligated and divided. The anomalous RPA is identified, encircled with a sylastic vascular loop and carefully mobilized for a long tract, including the first part of the lobar branches, and after establishing a hypothermic cardiopulmonary bypass and aortic cross-clamping it is temporarily closed with a tourniquet. The ascending aorta is transected obliquely, according to the longitudinal axes of the RPA, above and beneath the RPA origin, providing a symmetric large aortic ring almost 1.5 times more than the RPA diameter (Fig. 1A)
. Then, an anterior vertical incision of the MPA, at the origin of the LPA, is performed extending superiorly to half of the LPA circumference and inferiorly to the MPA providing a symmetric pulmonary flap with a similar width (more than 1.5 times the RPA diameter) as the aortic flap. Two transversal incisions creating a right angle with the first longitudinal incision, nearly half the MPA circumference, are performed, creating a posterior pulmonary flap (Fig. 1A). Under direct vision, after measuring the length of the created pulmonary flap, the aortic ring is cut transversely, leaving a small aortic flap posteriorly, and an anterior aortic flap is created in order to balance the posterior pulmonary flap (Fig. 1A). The ascending aorta is retracted posteriorly and an end-to-end anastomosis employing a 6/0 Prolene suture is performed (Fig. 1B). The anterior half of the suture line is completed with interrupted sutures, in order to allow tissue growth. The pulmonary flap is sutured to the small posterior aortic flap, anterior to the ascending aorta (Fig. 1B). Then, the anterior aortic flap is anastomosed to the pulmonary flap and MPA using a 7/0 Prolene suture (Fig. 1C). The newly created communication between anomalous RPA and MPA remains anterior to the ascending aorta (Fig. 1D).
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Fig. 1. Double flap surgical technique. (A) Aortic and pulmonary flap preparation. (B) Anterior positioning of the aortic and pulmonary flaps and posterior anastomosis. (C) The aortic flap is lied down to the main pulmonary artery; anterior anastomosis between flaps starting from the main pulmonary trunk. (D) Newly created communication between the anomalous right pulmonary artery and the main pulmonary artery. LPA, left pulmonary artery; MPA, main pulmonary artery; AO, aorta, RPA, right pulmonary artery.
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This technique was employed in a 15-week-old female (Fig. 2A,B)
. The baby was discharged 10 days after the surgical correction and 10 months after repair a residual gradient through the anastomotic site of 4 mmHg was found.
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Fig. 2. The preoperative angiographic images. (A) Anomalous origin of the right pulmonary artery from the ascending aorta. (B) The origin of the left pulmonary artery from the main pulmonary artery trunk.
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3. Comments
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The anomalous origin of one pulmonary artery is an unusual congenital cardiac anomaly. Without early surgical correction the natural history of this condition is dismal and has a high mortality [6]. Physiologically such a malformation creates a large left-to-right shunt. The contralateral lung is therefore subjected to the entire right ventricular output in addition to flow contributed by associated anomalies such as patent ductus arteriosus, atrial septal defect or ventricular septal defect [5].
The origin site of the anomalous RPA branch is different. Some authors [7,8] advocated the existence of two forms: a proximal one – the RPA originates from the ascending aorta close to the valvar plane, and a distal one – the RPA arises via a patent ductus arteriosus [6]. The third form of presentation is the origin site close to the innominate artery. Usually, the origin site of the anomalous RPA is from the postero-lateral aspect of the ascending aorta [3]. In our case, the anomalous RPA originated from the right lateral aspect of the aorta almost in the midpoint between the innominate artery and the aortic valvar plane.
An anatomic correction of the anomalous origin of the RPA from the ascending aorta, by detaching, followed by reattachment to the MPA, is preferable to the interposition of a prosthetic graft, because the later technique fails to accommodate larger flow volumes with the patient's growth [2]. In a series of eight patients presenting this malformation, we found a higher residual gradient through the anastomotic site in those undergoing direct reimplantation techniques or interposition of a prosthetic graft versus patients undergoing repair techniques employing extra native tissue length, probably due to the reduced growth at the anastomotic site during childhood.
The available technique reported by Van Son and Hanley [5] employing an aortic cuff and a small posterior pulmonary flap or the technique reported by Gybels et al. [4] using an aortic ring offer excellent outcomes in cases when the RPA originates from the postero-lateral aspect of the ascending aorta. However, such techniques do not offer enough extra autologous tissue length which would permit the placement of the newly created RPA anterior to the ascending aorta, especially when the RPA originates more anteriorly as its usual origin from the right lateral wall of the ascending aorta. An end-to-end anastomosis of the ascending aorta will retract it more posteriorly, which may induce the possibility of later obstruction of the newly created RPA placed posterior to the aorta due to aortic compression. In such cases, the modification of the Van Son and Hanley [5] technique reported here may be advantageous in allowing for extra autologous tissue length, making possible the placement of the newly created communicating tube anterior to the ascending aorta. The double flap technique offers the possibility of less tension at the anastomotic site and decreases the risk of kinking or stenosis of either branch of the pulmonary artery. This is an easily reproducible technique that should be part of the surgical armamentarium.
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References
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Top
Abstract
1. Introduction
