The clamshell incision for bilateral pulmonary artery reconstruction in tetralogy of fallot with pulmonary atresia Giovanni Battista Luciani, MDa, Winfield.

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Presentation transcript:

The clamshell incision for bilateral pulmonary artery reconstruction in tetralogy of fallot with pulmonary atresia Giovanni Battista Luciani, MDa, Winfield J. Wells, MDa, Apichai Khong, MDb, Vaughn A. Starnes, MDa The Journal of Thoracic and Cardiovascular Surgery Volume 113, Issue 3, Pages 443-452 (March 1997) DOI: 10.1016/S0022-5223(97)70356-8 Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 1 Diagram showing an operative view of the surgical field after completion of the bilateral thoracosternotomy and insertion of two Finochietto retractors. The thymic lobes have been resected in toto. The pericardial sac has been incised and the margins have been suspended with four stay sutures. Exposure of the heart and great vessels is represented. The topography of true pulmonary arteries (continuous and broken lines) and of AP collateral arteries (dotted lines) offering dual blood supply to both lungs is also shown. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 443-452DOI: (10.1016/S0022-5223(97)70356-8) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 2 Diagram showing an operative view after completion of the bilateral thoracosternotomy and insertion of two Finochietto retractors. The four pericardial stay sutures have been suspended to the right side and a lung retractor has been used to retract the left lung medially. Prompt exposure of the descending thoracic aorta and of the origin of two large AP collateral arteries is represented. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 443-452DOI: (10.1016/S0022-5223(97)70356-8) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 3 Diagram representing the preoperative anatomy of the pulmonary circulation in a 6-year-old girl (patient 2). Three large AP collaterals (1, 2, 3) are evident. The native pulmonary arteries are hypoplastic (right pulmonary artery [RPA] and left pulmonary artery [LPA]). The Journal of Thoracic and Cardiovascular Surgery 1997 113, 443-452DOI: (10.1016/S0022-5223(97)70356-8) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 4 Intermediate step in the surgical procedure of unifocalization and pulmonary artery reconstruction. The collaterals have been separated from their aortic origin and the left lung collaterals (1 and 2) have been incised laterally for a side-to-side anastomosis. The native pulmonary arteries have been opened from hilum to hilum. RPA, Right pulmonary artery; LPA, left pulmonary artery. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 443-452DOI: (10.1016/S0022-5223(97)70356-8) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 5 After homograft patch angioplasty of the branch pulmonary arteries, the reconstructed left collateral (1 and 2) is connected end-to-side to the left pulmonary artery (LPA) with use of a homograft tube extension via the posterior mediastinum. The right collateral (3) is anastomosed end-to-side to the right pulmonary artery (RPA) directly. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 443-452DOI: (10.1016/S0022-5223(97)70356-8) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 6 Diagram of the pRV/pLV ratio in 8 of 10 patients undergoing complete repair of complex ToF/PA through a bilateral thoracosternotomy. Comparison of preoperative (preop) ratio with follow-up pressure ratio shows significant decrease in all patients (0.98 ± 0.05 vs 0.44 ± 0.13, p < 0.01). The Journal of Thoracic and Cardiovascular Surgery 1997 113, 443-452DOI: (10.1016/S0022-5223(97)70356-8) Copyright © 1997 Mosby, Inc. Terms and Conditions

Fig. 7 Actuarial freedom from any reintervention in 10 patients undergoing repair of complex ToF/PA through a bilateral thoracosternotomy between October 1993 and December 1995. The Journal of Thoracic and Cardiovascular Surgery 1997 113, 443-452DOI: (10.1016/S0022-5223(97)70356-8) Copyright © 1997 Mosby, Inc. Terms and Conditions