Modified arterial switch operation by spiral reconstruction of the great arteries in transposition Ing-Sh Chiu, MD, PhD, Shye-Jao Wu, MD, Ming-Ren Chen,

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Presentation transcript:

Modified arterial switch operation by spiral reconstruction of the great arteries in transposition Ing-Sh Chiu, MD, PhD, Shye-Jao Wu, MD, Ming-Ren Chen, MD, Meng-Luen Lee, MD, Mei-Hwan Wu, MD, PhD, Jou-Kou Wang, MD, PhD, Hung-Chi Lue, MD The Annals of Thoracic Surgery Volume 69, Issue 6, Pages 1887-1892 (June 2000) DOI: 10.1016/S0003-4975(00)01423-5

Fig 1 Types of coronary arteries in 9 patients, 5 of them had juxtacommissural origin of the coronary arteries. (j, j′, j′′ = juxtafacing commissure; jn, j′n = juxta-nonfacing commissure. See Chiu and associates [6, 11] for details.) The Annals of Thoracic Surgery 2000 69, 1887-1892DOI: (10.1016/S0003-4975(00)01423-5)

Fig 2 Techniques of modified arterial switch operation with the neopulmonary trunk in a left anterior portion (Cases 4, 5, 7, and 8). The semilunar valves were all omitted for clear illustration. (A) The aorta was amputated. The posterior wall of the pulmonary trunk (PT) was not divided. Four J-shaped incisions were made on facing part of the great arteries. The anterior wall of the PT will be cutback along the dashed line to augment the pulmonary pathway. The nonfacing aortic sinus was incised to facilitate exposure. (B) The lateral edges of two J-shaped incisions facing each other were sutured together (depicted by X-stitches) to form the aortopulmonary window. Then, the semi-flap of the PT was placed into the opposite aortic sinus and sutured (depicted by l-stitches) in such a way that it acted as the posterior wall of neoPT and as the anterior wall of the neoaorta. The suture for the other two semi-flaps in sinus 2 was not yet finished. (C) The cephalic edge of the pulmonary semi-flap was sutured to the inner wall of sinus 1 (depicted by heavy l-stitches) cephalic to the coronary orifice to cover it. The distal aorta was sutured to the posterior wall of the PT along the light dashed line. (D) The neoaortic anastomosis was finished. The flap of the facing commissure in the old aorta was fixed to the anterior wall of the PT (depicted by Y-stitches). The anterior lip of the cutback PT was everted to the left, and attached to the cephalic cut edge of the aortic sinus 1 (depicted by X-stitches) to form the floor of the pulmonary pathway. The cut edge of PT was attached to the posterior aorta. (E) The cut edges of right pulmonary artery were attached to the posterior outer wall of the aorta along the dotted line to enlarge the orifice. Cutback on the left pulmonary artery was done as needed. (F) Finally, the anterior defect of the pulmonary pathway was patched with an untanned pericardium. The Annals of Thoracic Surgery 2000 69, 1887-1892DOI: (10.1016/S0003-4975(00)01423-5)

Fig 3 Techniques of modified arterial switch operation with the neopulmonary trunk in a right anterior portion (Case 6). The semilunar valves were all omitted for clear illustration. The main differences from Figure 2 are described below. The PT was divided right anteriorly, then along the left anterior portion (A); cut back along the dashed line (B); everted to the right (C); attached to the cephalic cut edge of aortic sinus 2 (D); to its wall, the cephalic edge of the pulmonary semi-flap was sutured to cover the coronary orifice (C), in this way to form the floor of the pulmonary pathway (E). The cutback left pulmonary artery was attached to the posterior wall of the aorta (D,E). Finally, its roof was patched (F). The Annals of Thoracic Surgery 2000 69, 1887-1892DOI: (10.1016/S0003-4975(00)01423-5)

Fig 4 Follow-up angiocardiogram of Case 5 shows good curvature of aorta and patent coronary arteries (arrows) (upper panels). Right ventriculogram in the middle panels shows that the pulmonary trunk was filled smoothly, and the right pulmonary artery coursed behind the aorta (C); there was no anterior and upward tilting of the pulmonary bifurcation by the usual Lecompte maneuver (D). The levophase of the left pulmonary arterial injection in the lowest panels showed the resumption of the spiral relationship of the great arteries. The pulmonary trunk, with a catheter (arrowheads) in its lumen, located left (E) and anterior (F) to the ascending aorta. (A,C,E) Frontal projection; (B,D,F) lateral projection. The Annals of Thoracic Surgery 2000 69, 1887-1892DOI: (10.1016/S0003-4975(00)01423-5)