Invited commentary

Abstract

This case report from Dr Guadalupi and coworkers illustrates what I believe to be a sound reconstructive concept. That is, to use living tissue wherever possible when performing vascular and for that matter, any other reconstructions in the rapidly growing child. The technique described in this case report is ingenious and the early result looks good on angiography. In type A3 truncus (Van Praagh [1Van Praagh R, Van Praagh S. The anatomy of common aorticopulmonary trunk (truncus arteriosus communis) and its embryologic complications: a study of 57 necropsy cases. Am J Cardiol 1965;16:406–25.Google Scholar]), the vessel that is not arising from the intrapericardial trunk is likely to be stenotic or to become so soon after birth, particularly if its connection to the descending aorta is by ductus type tissue. If the diagnosis is made soon after birth, as it usually is these days, then there is much to be said for early one stage repair before the pulmonary artery not arising from the trunk becomes proximally stenotic and distally hypoplastic. Another surgical option in this situation is to create a fresh autologous pericardial roll and connect the two pulmonary arteries behind the trunk without transection and then place the conduit directly into the pericardial roll. The anastomoses to right and left pulmonary arteries are done obliquely in the hope of avoiding early anastomotic stenosis in the rapidly growing child. On the other hand, if the full diagnosis is not appreciated and proximal stenosis does not occur at the vessel arising from the descending aorta or distal arch, leading to obstruction and distal hypoplasia, then any reconstructive approach is more difficult. Furthermore, in this scenario heart failure is less likely to be as severe as when both pulmonary arteries in an unobstructed fashion from the trunk and the patient may present too late, with pulmonary vascular disease in the unobstructed vessel and severe hypoplasia of the obstructed vessel. Type A3 truncus arteriosus should indeed be comprehensively repaired within the neonatal period if the diagnosis is made. Certainly this condition should not be left untreated beyond three months of age. The use of the term hemitruncus is surrounded by confusion with two very different definitions available. Van Praagh’s classification of truncus arteriosus is a useful one and includes what some would describe as hemitruncus and excludes what others would describe as hemitruncus (ie, aberrant origin of a pulmonary artery from the ascending aorta in the presence of two ventriculo–arterial valves). Again, I congratulate the authors on their ingenuity and for a well conceived and executed complex reconstructive operation.