Use of autogenous aortic and main pulmonary artery flaps for repair of anomalous origin of the right pulmonary artery from the ascending aorta

Abstract

in patients with origin of the right (RPA) or left pulmonary artery from the ascending aorta, the RPA or, much less commonly, the left pulmonary artery arises from the ascending aorta in the presence of separate aortic and pulmonary valves and without the interposition Of ductal tissue. 1" 2 The RPA usually originates from the right posterior aspect of the ascending aorta. 3 Physiologically, the alteration creates a large left-to-right shunt. The contralateral lung is therefore subjected to the entire right ventricular output in addition to flow contributed by associated anomalies, such as patent ductus arteriosus, aortopulmonary septal defect, atrial septal defect, or ventricular septal defect, which have been present in greater than 60% of previous reports. 1 4 Without early operation the natural history of this condition is dismal, with a mortality rate of approximately 70% at 6 months of age and 80% at I year of age. 5 Armer and associates 6 reported the first successful anatomic repair of anomalous origin of the RPA from the ascending aorta with interposition of a polyester fiber graft between the RPA and the main pulmonary artery (MPA). The first successful primary repair was reported by Kirkpatrick, Girod, and King. 7 Traditionally, primary repair is generally reserved for those patients in whom the RPA originates from the posterior aspect of the aorta in close proximity to the MPA. s When the RPA arises from the right lateral aspect of the aorta, the right hilum is often mobilized medially to allow apposition of the RPA and MPA without tension. Alternatively, an interposition synthetic graft is placed either anterior or posterior to the aorta 5, 9 We propose a modified native tissue repair that reduces tension on the RPA-MPA anastomosis. The ascending aorta, proximal aortic arch vessels, the MPA, and both branch pulmonary arteries are widely mobilized. As soon as cardiopulmonary bypass has been established, the RPA is temporarily clamped or snared. The patent ductus arteriosus, if present, is doubly ligated and divided. After crossclamping of the aorta, the anterior aortic circumference is incised transversely at the level of the RPA origin (Fig. 1). Under direct vision, the remaining aortic circumference is transected, with a generous cuff of posterior aortic wall left around the RPA origin (Fig. 2). Alternatively, the posteromedial aspect of the aortic wall can be left intact. Utmost care should be taken to avoid compromise of the left