Left Pulmonary Artery Kinking Caused by Outflow Tract Dilatation After Transannular Patch Repair of Tetralogy of Fallot Doff B. McElhinney, Andrew J.

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Left Pulmonary Artery Kinking Caused by Outflow Tract Dilatation After Transannular Patch Repair of Tetralogy of Fallot Doff B. McElhinney, Andrew J. Parry, V.Mohan Reddy, Frank L. Hanley, Paul Stanger The Annals of Thoracic Surgery Volume 65, Issue 4, Pages 1120-1126 (April 1998) DOI: 10.1016/S0003-4975(98)00112-X

Fig. 1 Mechanism of left pulmonary artery (LPA) kinking after repair of tetralogy of Fallot, with pulmonary regurgitation and right heart dilatation. The right ventricular outflow tract (RVOT) dilates, elongates, and rotates craniad and leftward. The normally acute angle between the main pulmonary artery (PA) and the right pulmonary artery (RPA) becomes obtuse, while the normally obtuse angle between the main PA and LPA becomes acute. The resulting redundancy of the LPA enables it to kink, especially if it is tethered to the undersurface of the arch by an intact ligamentum arteriosum. The Annals of Thoracic Surgery 1998 65, 1120-1126DOI: (10.1016/S0003-4975(98)00112-X)

Fig. 2 Preoperative magnetic resonance imaging study performed 3 months preoperatively in patient 5, who had left pulmonary artery obstruction caused by both kinking and focal stenosis. (A) Transverse T1-weighted image showing severe rotation of the pulmonary trunk (M), resulting in kinking of the left pulmonary artery (L) at its origin, which is shifted to the rightward-posterior aspect of the pulmonary trunk. (B) A transverse image 10 mm caudal to the scan depicted in part A, showing the obtuse transverse angle between the pulmonary trunk and the right pulmonary artery (R) (A = ascending aorta; D = descending aorta.) The Annals of Thoracic Surgery 1998 65, 1120-1126DOI: (10.1016/S0003-4975(98)00112-X)

Fig. 3 Angiograms of patient 5 6 years after repair, just before right ventricular outflow tract revision and repair of left pulmonary artery obstruction with kinking. (A) Anteroposterior and (B) lateral projections of a right ventriculogram performed 1 month before pulmonary outflow tract revision demonstrate an enlarged right ventricle, a massively dilated and leftward-rotated right ventricular outflow tract, and kinking of the left pulmonary artery at its origin (now posterior to the pulmonary trunk). Note that the left lung vasculature is substantially less opacified by contrast than the right. (C) Selective left pulmonary artery injection in a left anterior oblique projection highlights the kinked origin of the left pulmonary artery from an unusually posterior and rightward point. The Annals of Thoracic Surgery 1998 65, 1120-1126DOI: (10.1016/S0003-4975(98)00112-X)

Fig. 3 Angiograms of patient 5 6 years after repair, just before right ventricular outflow tract revision and repair of left pulmonary artery obstruction with kinking. (A) Anteroposterior and (B) lateral projections of a right ventriculogram performed 1 month before pulmonary outflow tract revision demonstrate an enlarged right ventricle, a massively dilated and leftward-rotated right ventricular outflow tract, and kinking of the left pulmonary artery at its origin (now posterior to the pulmonary trunk). Note that the left lung vasculature is substantially less opacified by contrast than the right. (C) Selective left pulmonary artery injection in a left anterior oblique projection highlights the kinked origin of the left pulmonary artery from an unusually posterior and rightward point. The Annals of Thoracic Surgery 1998 65, 1120-1126DOI: (10.1016/S0003-4975(98)00112-X)

Fig. 4 (A) Dilated right ventricular outflow tract with previous transannular patch (TP), showing kinked left pulmonary artery. (B) Correction of left pulmonary artery kinking after allograft (H) conduit reconstruction of the right ventricular outflow tract. (C) Alternative technique for correction of left pulmonary artery when another form of stenosis is present and a segment of stenotic left pulmonary artery is resected. The shortened left pulmonary artery is reimplanted into the side of the allograft (H) conduit. The Annals of Thoracic Surgery 1998 65, 1120-1126DOI: (10.1016/S0003-4975(98)00112-X)