Eur J Cardiothorac Surg 2007;31:742-743. doi:10.1016/j.ejcts.2006.12.024
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Anterior translocaton of pulmonary artery without aortic transection in repair of tetralogy of Fallot with absent pulmonary valve
Si Chan Sunga,
Yun Hee Changa,*,
Jong Soo Woob
a Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, 1-10, Ami-dong, Seo-ku, Busan 602-739, South Korea
b Department of Thoracic and Cardiovascular Surgery, Dong-A University Hospital, 3-1, Dongdaesin-dong, Seo-ku, Busan 602-715, South Korea
Received 14 October 2006;
received in revised form 14 October 2006;
accepted 11 December 2006.
* Corresponding author. Tel.: +82 51 240 8363; fax: +82 51 243 9389. (Email: drcrista{at}empal.com).
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Abstract
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We developed a technique of translocation of the pulmonary artery anterior to the ascending aorta without transection of the aorta in the repair of tetralogy of Fallot with absent pulmonary va
lve. Our technique includes detachment of the main pulmonary artery (MPA) from the pulmonary annulus, vertical division of the MPA, anterior translocation of the pulmonary artery with patch augmentation between the vertically divided MPA.
Key Words: Airway • CHD, tetralogy of Fallot • CHD, cyanotic
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1. Introduction
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Tetralogy of Fallot (TOF) with absent pulmonary valve (APV) is a rare variant of TOF characterized by airway compression due to severe dilatation of the pulmonary arteries. Anterior translocation of the pulmonary artery (PA) to eliminate airway compression in repair of TOF with APV was suggested by Hraska [1]. His technique includes translocation of the PA anterior to the aorta, shortening of the ascending aorta, and shortening and plication of the PA. We translocated the PA anterior to the ascending aorta by vertical division of the main pulmonary artery (MPA) and patch augmentation of the divided MPA instead of dividing the ascending aorta. Our technique can move the PA more anteriorly and reduce myocardial ischemic time. We did not perform reduction pulmonary arterioplasty in our two cases.
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2. Technique
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The superior vena cava (SVC) is dissected free with division of the azygos vein to prevent possible SVC compression caused by anterior location of large right PA. Under cardiopulmonary bypass (CPB), the right and left PAs are extensively dissected to their first or second branches. After induction of a short period of ventricular fibrillation, the MPA is detached from the pulmonary annulus, which is temporarily closed with horizontal mattress pledgetted sutures. The heart is then defibrillated. The MPA is evenly divided vertically and the right and left PAs are translocated anterior to the ascending aorta (Fig. 1A). The resultant gap between the vertically divided MPA is filled with untreated autologous pericardial patch. (Fig. 1B). Cardiac arrest is then induced. The anterior two-thirds of the sutures at the pulmonary annulus are released and a small transannular vertical incision is made at the right ventricular outflow tract (RVOT). Extensive infundibulectomy is performed through a small ventriculotomy and through the tricuspid valve. The ventricular septal defect is closed through the right atrium. The posterior half of the reconstructed MPA is connected to the pulmonary annulus and the RVOT was then reconstructed with monocuspid polytetrafluoroethylene valve (Fig. 1C). A small interatrial communication is left open.
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Fig. 1. Operative techniques. (A) The main pulmonary artery is evenly divided vertically after being detached from the pulmonary annulus and (B) the gap between vertically divided MPA is filled with untreated autologous pericardial patch following translocation of the right and left pulmonary arteries anterior to the ascending aorta and (C) the right ventricular outflow portion was reconstructed with monocusp ventricular outflow patch.
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3. Results
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The above technique has been used since April 2004 in two infants with TOF with APV.
3.1 Patient 1
A 51-day-old infant weighing 2960 g with multiple extracardiac anomalies including left cerebral and cerebellar atrophy, left microophalmia, left low set ear, cleft palate and lip presented with severe respiratory insufficiency requiring mechanical ventilation. Aortic cross-clamp and CPB times were 108 and 216 min, respectively. His postoperative course was uneventful. He was extubated 7 days after operation. His hospitalization (3 months) was prolonged because of aspiration pneumonia caused by severe cleft palate and inborn neurologic problems. He has been well without respiratory symptom until he died suddenly at home after an episode of high fever and seizure at his age of 16 months. His chest CT scan taken 16 days after operation showed much wider airway as compared to preoperative chest CT (Fig. 2A).
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Fig. 2. Preoperative and postoperative CT scan images at the level of main bronchus (A: patient 1; B: patient 2).
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3.2 Patient 2
A 46-day-old infant weighing 4530 g who had severe tachypnea with subcostal retraction underwent the above correction. Aortic cross-clamp and CPB times were 144 and 264 min, respectively. He came off bypass on moderate inotropic support and remained hemodynamically stable until the operative night when junctional ectopic tachycardia with progressive hypoxemia developed. These problems were successfully managed by sternal reopening, NO inhalation, hypothermia, and amiodarone infusion. The sternum was closed 4 days after operation. He required ventilatory support for 8 days and was discharged home 25 days after operation. Chest CT scan taken at the age of 5 months showed wider airway (Fig. 2B). Now he is 9-month-old and doing very well.
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4. Discussion
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A variety of surgical techniques mainly focusing on relief of airway compression in repair of TOF with APV have been developed with variable results [2–5]. An anterior translocation of PAs suggested by Hraska in 2000 is an attractive method to eliminate airway compression [1]. An excellent intermediate result of the technique was reported [6]. Dr Hraska stressed shortening of the ascending aorta to allow the aorta to reside posteriorly. However, it is very difficult to decide how much ascending should be resected out. In patients with right aortic arch (our two cases had right aortic arch), right main bronchus compression between the ascending and descending aortas might occur when the ascending aorta is resected too much. On the contrary, if the ascending aorta is not shortened, the right PA can be compressed by the posteriorly translocated ascending aorta. These adverse possibilities stimulated us to modify the technique. We did not mobilize the arch vessels and did not transect the ascending aorta. Instead, the MPA was longitudinally divided and translocated anterior to the ascending aorta followed by patch augmentation between the divided MPA segments. The patch augmentation of the MPA is important to prevent right PA compression by the posteriorly located ascending aorta and to allow the PAs to reside more anteriorly away from the airway. Our technique also can save cardiac ischemic time and avoid troublesome bleeding from suture line of ascending aorta. There was no SVC compression or coronary artery compression in our two cases.
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Acknowledgments
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We appreciate the efforts of Dr Hon Chi Suen in the preparation of this article.
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References
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- Hraska V. A new approach to correction of tetralogy of Fallot with absent pulmonary valve. Ann Thorac Surg 2000;69:1601-1603.[Abstract/Free Full Text]
- Snir E, de Leval MR, Elliott MJ, Stark J. Current Surgical Technique to repair Fallot's tetralogy with absent pulmonary valve syndrome. Ann Thorac Surg 1991;51:979-982.[Abstract]
- McDonnell BE, Raff GW, Gaynor JW, Rychik J, Godinez RI, DeCampli WM, Spray TL. Outcome after repair of tetralogy of Fallot with absent pulmonary valve. Ann Thorac Surg 1999;67:1391-1396.[Abstract/Free Full Text]
- Hew CC, Daebritz SH, Zurakowski D, del Nido PI, Mayer Jr. JE, Jonas RA. Valved homograft replacement of aneurysmal pulmonary arteries for severely symptomatic absent pulmonary valve syndrome. Ann Thorac Surg 2003;73:1778-1785.
- Kirshbom PM, Jaggers JJ, Ungerleider RM. Tetralogy of Fallot with absent pulmonary valve: Simplified technique for homograft repair. J Thorac Cardiovasc Surg 1999;118:1125-1127.[Free Full Text]
- Hraska V, Kantorova A, Kunovsky P, Haviar D. Intermediate results with correction of tetralogy of Fallot with absent pulmonary valve using a new approach. Eur J Cardiothorac Surg 2002;21:711-715.[Abstract/Free Full Text]
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Abstract
1. Introduction
