George M. Alfieris, MD, Michael F. Swartz, PhD

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Presentation transcript:

Technique for the Repair of Truncus Arteriosus to Maintain Pulmonary Artery Architecture George M. Alfieris, MD, Michael F. Swartz, PhD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 16, Issue 3, Pages 191-204 (September 2011) DOI: 10.1053/j.optechstcvs.2011.06.001 Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 13 Freedom from reoperation curve for the 22 patients who received our modified repair for TA. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 1 Truncus ateriosus, type I, II, and III. In TA type I, there is a common anterior-posterior window between the main pulmonary artery and the ascending aorta. In type II, the branch pulmonary arteries arise from the posterior portion of the aorta, and in type III, the branch pulmonary arteries arise from the lateral aspects of the ascending aorta. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 2 Historic TA repair. The heart has been arrested; the pulmonary arteries have been excised from the truncal root and moved anterior and laterally, establishing a pulmonary artery bifurcation adjacent to the ascending aorta. The truncal root has been repaired using a patch. The dotted line represents the location of the right ventriculotomy, which is used to expose the ventricular septal defect. Ao = aorta; Laa = left atrial appendage; Lpa = left pulmonary artery; Raa = right atrial appendage; Rpa = right pulmonary artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 3 Historic TA repair with a right ventricular to pulmonary artery valved conduit. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 4 Pulmonary artery angiogram 6 years after repair from a patient treated with the standard approach mobilizing the pulmonary arteries and moving them laterally. The angiogram demonstrates right pulmonary artery stenosis (arrow) just lateral to the pulmonary artery bifurcation. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 5 Our approach with TA type I. The heart has been cross-clamped. A hockey-stick incision has been made in the truncus extending onto the left main pulmonary artery. Retraction using 2 ragnels demonstrates the right pulmonary artery orifice superiorly and the common anterior-posterior window inferiorly. Looking inferiorly within the incision allows optimal access and visualization of the truncal valve in case of repair. Ao = aorta; Lpa = left pulmonary artery; Pa = pulmonary artery; Raa = right atrial appendage. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 6 A 0.4-mm PTFE patch is used to close the defect within the trunk using a running 6-0 Prolene suture. Care must be taken not to injure or incorporate the right pulmonary artery orifice within the suture line or patch. Once the PTFE patch has septated the truncal root, the original truncal arteriotomy functions as the new pulmonary artery bifurcation. The dotted line represents the location for the right ventriculotomy, which will be used to repair the ventricular septal defect and establish right ventricle to pulmonary artery continuity. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 7 A right ventriculotomy is made and the ventricular septal defect is exposed. The ventricular septal defect is exposed again using 2 ragnel retractors. A 0.4-mm PTFE patch is brought into the field, and using a running 6-0 Prolene suture, the defect is repaired. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 8 The aortic homograft is thawed and prepared in the usual fashion. The dotted line indicates the approximate position of the distal anastomosis. MV = mitral valve. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 9 The proximal end of the conduit is sewn into place using a 6-0 Prolene suture. The anterior leaflet of the mitral valve is used as a hood for the proximal anastomosis. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 10 The proximal anastomosis has been completed and the homograft is then tailored to limit the amount of graft tissue. The distal end of the conduit is sewn into place with a running 6-0 Prolene suture. MV = mitral valve. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 11 The complete repair after establishing right ventricle to pulmonary artery continuity. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions

Figure 12 Pulmonary artery angiogram of a patient who underwent our modified repair to maintain the pulmonary artery architecture, which demonstrates widely patent pulmonary arteries. Operative Techniques in Thoracic and Cardiovascular Surgery 2011 16, 191-204DOI: (10.1053/j.optechstcvs.2011.06.001) Copyright © 2011 Elsevier Inc. Terms and Conditions