Abstract
Extrinsic compression of airways is one the most important causes of respiratory insufficiency in the perioperative period in children with congenital heart disease. This is especially true of pathologies that involve surgery of the aortic arch or conduit replacement of the right ventricular outflow tract. However bronchial obstruction is uncommon in the setting of bidirectional cavopulmonary shunt alone.We report the case of an infant with a functionally univentricular heart who had a bidirectional superior cavopulmonary shunt and disconnection of the main pulmonary artery from the ventricular mass with oversewing of pulmonary valve. Post-operatively the patient desaturated due to compression of left main bronchus by the left pulmonary artery anteriorly and the descending aorta posteriorly. This was clearly defined by CT based on 3D-modelling of the airways and great vessels. The child was managed conservatively by ventilator support, selective bronchial suctioning and systemic steroids with a successful outcome.
Highlights
The current approach to the surgical management of patients with univentricular hearts is staged repair, which includes neonatal surgery to establish a source of controlled pulmonary blood flow and eliminate systemic outflow obstruction, followed successively by bidirectional superior cavopulmonary shunt (BSCPS) and a Fontan completion
Respiratory compromise is an important cause of desaturation following a BSCPS and is usually due to consolidation or collapse of the lung parenchyma and/or collections of fluid or air in the pleural space
Compression of the left main bronchus between the left pulmonary artery anteriorly and the descending aorta posteriorly has been described in a 3-month-old child following patch augmentation of aortic arch and closure of ventricular spetal defect (VSD).3
Summary
The current approach to the surgical management of patients with univentricular hearts is staged repair, which includes neonatal surgery to establish a source of controlled pulmonary blood flow and eliminate systemic outflow obstruction, followed successively by bidirectional superior cavopulmonary shunt (BSCPS) and a Fontan completion. Brochoscopy and CT angiography revealed compression of left main bronchus by pulmonary artery anteriorly and descending aorta posteriorly. Cardiac catheterization showed patent BSCPS and branch pulmonary arteries and no decompressing veins. The endotracheal tube was maneuvered into the left main bronchus and hand ventilation attempted, but it was too difficult to inflate the left lung, and this was clearly observed on screening. This raised a strong possibility of bronchial obstruction. CT angiography confirmed impingement of the left main bronchus between pulmonary artery anteriorly and descending aorta posteriorly (Figure 1). The processed files were exported as STL files into 3-matic (Materialise, Leuven, Belgium) to create the various images of interest
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