Pulmonary Artery Anastomosis Research Articles

Extracardiac modification of the Fontan operation without use of prosthetic material

Extracardiac modification of the Fontan operation without use of prosthetic material

The management of tetralogy of fallot with pulmonary atresia and diminutive pulmonary arteries

Since September 1991, 14 consecutive patients with tetralogy of Fallot, pulmonary atresia, and diminutive pulmonary arteries have undergone staged repair. All patients had multiple aortopulmonary collateral arteries and the ductus arteriosus was absent in 11. Mean sizes of the right and left pulmonary arteries were 2.2 ±0.7 mm and 1.9 ±0.8 mm, respectively (range 0.5 to 3.0 mm). Eight patients (57%) have subsequently received complete repair. Age at initial procedure (shunt, right ventricle–pulmonary artery conduit, or direct aorta–pulmonary artery anastomosis) in this group was 5.3 ±6.8 months. The number of operative procedures to achieve complete repair was 2.9 ±0.8 per patient (range 2 to 4). Intraoperative postrepair peak right ventricle–left ventricle pressure ratio was 0.57 ±0.17. Six of 8 patients (75%) required additional interventional procedures (mean 1.5 ±1.2 per patient) for angioplasty of peripheral pulmonary artery stenoses, coil embolization of aortopulmonary collateral arteries, or intraoperative insertion of intravascular pulmonary artery stents. Mean follow-up from complete repair was 8.7 ±8.3 months (range 0.5 to 23.8 months) and is complete. There was one in-hospital death at 45 days, and one late cardiac death at 20.3 months. Six patients had initial palliative operations (unifocalization, right ventricle–pulmonary artery conduit, direct aorta–pulmonary artery anastomosis, or transannular outflow patch) but have not undergone complete repair. Age at initial procedure in this group was 27.9 ± 56.9 months (range 0.27 to 155 months), and mean follow-up from initial procedure was 10.9 ± 11.2 months (range 0 to 31.4 months). The operative mortality rate was 33% (2 of 6 patients). There was one late noncardiac death at 5.3 months. Three patients are awaiting further intervention or repair. This experience suggests that complete repair is feasible even in patients with extremely diminutive pulmonary arteries (≤3.0 mm). Pulmonary artery growth is facilitated by early (3 to 6 month) establishment of central pulmonary artery flow by right ventricle–pulmonary artery conduit (pulmonary arteries >1.5 mm) or by direct ascending aorta–pulmonary artery anastomosis (pulmonary arteries <1.5 mm). Subsequent interventional catheterization and operative procedures as required for pulmonary artery stenoses and coil embolization of collateral arteries allow continued recruitment of central pulmonary arteries and may obviate or minimize the need for unifocalization procedures. (J THORAC CARDIOVASC SURG 1995;110:1521-33)

Modified surgical techniques for relief of aortic obstruction in {S,L,L} hearts with rudimentary right ventricle and restrictive bulboventricular foramen

Modified techniques of aortopulmonary anastomosis were performed in six neonates with atrioventricular and ventriculoarterial discordance [S,L,L], double-inlet left ventricle, and restrictive bulboventricular foramen area (mean index 1.10 cm2/m2) with unobstructed aortic arch (n = 3) or with hypoplasia (n = 2) or interruption (n = 1) of the aortic arch. In cases of unobstructed aortic arch, a flap of autogenous aortic tissue was used to augment the posterior aspect of the anastomosis of the main pulmonary artery to the ascending aorta, thus creating the potential for anastomotic growth; this technique is applicable regardless of the position of the ascending aorta relative to the main pulmonary artery. In case of levo-transposition of the aorta with hypoplasia or interruption of the aortic arch, a modified Norwood procedure was performed, in that the proximal ascending aorta was divided at the same level as the main pulmonary artery with subsequent homograft patch augmentation from the main pulmonary artery-ascending aorta anastomosis to the level of the proximal descending aorta; this technique avoids a spiraling incision of the aorta and therefore reduces the risk of torsion of the aortic root with its inherent risks of obstruction of the coronary circulation and aortic or pulmonary valve regurgitation. There was no early or late mortality. At a mean follow-up of 16 months, in all patients, there was unobstructed aortic outflow, as evidenced by echocardiographic absence of a significant ventricular-aortic systolic gradient (mean 4.5 +/- 4 mm Hg) and absence of distal aortic arch obstruction. There was no evidence of aortic or pulmonary valve regurgitation. The reported modified techniques provide effective relief of restrictive bulboventricular foramen and aortic obstruction in [S,L,L] hearts.

Pressure gradient across the pulmonary artery anastomosis during lung transplantation

Perioperative monitoring of pulmonary artery (PA) pressures in lung transplant recipients is critical. This report characterizes an intraoperative gradient across the PA anastomosis in a series of patients undergoing bilateral sequential lung transplantation. Hemodynamic measurements were obtained in a series of 10 patients before anesthetic induction, during one-lung ventilation/perfusion of the newly transplanted first lung with the PA catheter proximal and distal to the anastomosis and after arrival in the intensive care unit. The following measurements were recorded: central venous pressure, cardiac output, PA occlusion pressure, and systemic and pulmonary arterial pressures (systolic, diastolic, mean). Although a systolic pressure gradient of more than 10 mm Hg across the anastomosis was observed in all patients, there was a significant variation in systolic (13 to 59 mm Hg), diastolic (2 to 10 mm Hg), and mean (5 to 27 mm Hg) PA gradients. Mean proximal systolic PA pressure measurements (56.2 +/- 20.6 mm Hg) were greater when compared to measurements obtained distal to the anastomosis (28.6 +/- 10.1 mm Hg, p = 0.001) and to those obtained in the postoperative period (32.1 +/- 9.7 mm Hg, p = 0.004). The present study demonstrates that during single-lung ventilation and perfusion, the PA pressure measured proximally may not reflect accurately the pressure distal to the vascular anastomosis.

Late re-interventions following arterial switch operations in transposition of the great arteries*Incidence and surgical treatment of postoperative pulmonary stenosis

Seventy-six patients were studied after arterial switch operation (ASO) between May 1977 and February 1992. Pulmonary artery reconstruction was initially performed by: conduit interposition in 5 patients, direct main pulmonary artery anastomosis and button patches in 60 patients, and pantaloon-like patch repair in 11 patients. Pulmonary stenosis developed in 17 patients (22%), requiring a total of 26 late re-interventions. Re-intervention was required in four out of five patients operated with pulmonary artery conduits, 11 out of 60 with a button patch repair and 2 out of 11 following pantaloon-type repair. In this series pulmonary artery stenosis (PS) involving the pulmonary valve occurred in 9/17 patients. Involvement of the pulmonary valve was related to the technique of pulmonary artery reconstruction. In these patients surgery is necessary. Balloon angioplasty can be a valuable tool when the stenosis is more distal. The incidence of PS was not influenced by the type of reconstruction or the use of Lecompte's maneuver.

New modification of the Damus-Kaye-Stansel operation

We report a successful modification of the Damus-Kaye-Stanael operation for transposition of the great arteries when the coronary arteries are unsuitable for transfer. The procedure includes creation of a neoaorta with end-to-end anastomosis of the proximal pulmonary artery to the distal ascending aorta and creation of an aortopulmonary window between the proximal great arteries. A valved conduit is interposed between the right ventricle and the distal pulmonary artery.

Two-suture technique for pulmonary artery anastomosis in orthotopic heart transplantation

Distortion of the pulmonary artery anastomosis due to the size mismatch between the recipient's pulmonary trunk and the donor's pulmonary artery was the cause of acute right ventricular failure after cardiac transplantation. The problem was corrected with a two-suture technique, which has been used subsequently.

Pulmonary artery sling

Eighteen patients who underwent surgical treatment of pulmonary artery sling at this institution since 1969 were reviewed. Four of them had associated tracheal stenoses produced by complete cartilaginous rings (stovepipe trachea). All patients underwent operation. The median age at operation was 180 days (range, 27 days to 54 months). In the 14 patients with isolated pulmonary sling, the operation consisted of division of left pulmonary artery and reimplantation into the main pulmonary artery anterior to the trachea. In the 4 patients with stovepipe trachea, the stenotic tracheal segment was resected on cardiopulmonary bypass and the left pulmonary artery was brought anterior to the trachea before the latter was reanastomosed to the main pulmonary artery. There were no early deaths. One patient died late. The pulmonary artery anastomosis was patent in all 14 patients investigated postoperatively. Three patients have residual tracheobronchial problems. One patient is mentally retarded and is institutionalized. All other patients are symptom-free and growing normally and have normal chest radiographs.

Reduced-size lung transplantation from adult to neonatal sheep

Lung transplantation continues to be limited by donor availability. This shortage is particularly acute in the pediatric population. A model was developed in sheep to simulate human pulmonary transplantation from adults into newborns. Pulmonary allografts were performed in 8 neonatal lambs (<10 days old) weighing between 2.5 and 5 kg. Unrelated adult sheep donors were used (weighing 55 to 82 kg). The recipient body weight was approximately 6% that of the donor, but ranged from 4% to 8%. Ipsilateral or contralateral upper lobe allografts were used, although the latter required inversion prior to implantation. All venous anastomoses utilized left atrial cuffs. The pulmonary arterial and bronchial anastomoses were constructed end-to-end. Following implantation the lobes were further contoured to fit within the recipient hemithorax using a linear surgical stapler. Animals were immunosuppressed with cyclosporine. Two animals died 1 week postoperatively but the remaining six survived 1 to 5 months. Postoperative lung scans at 10 to 14 days confirmed satisfactory ventilation and perfusion of the allografts. All vascular anastomoses were intact at postmortem examination. Primary bronchial healing was accomplished without an omental wrap. We conclude that successful lung transplantation can be performed from adult donors into neonatal recipients. Preservation of the maximal arterial and venous length during native pneumonectomy is essential to allow matching of the vascular cuffs. Short donor lobar bronchi may be responsible for the reliable primary healing. Improved immunosuppression will be required to assess long-term function and growth of these reduced-size allografts.

Anomalous origin of the right pulmonary artery from the ascending aorta

Five cases of anomalous origin of the right pulmonary artery from the ascending aorta were seen at our hospital. Patients 1 and 2 had an intact right pulmonary artery originating from a right posterior aspect (proximal form), and primary anastomosis of the right pulmonary artery and main pulmonary trunk was performed. Patients 3 and 4 showed a narrowing right pulmonary artery originating from near the base of the innominate artery (distal form). The stenotic right pulmonary artery was reconstructed with an 8-mm graft in patient 3, whereas patient 4 became inoperable because complete obstruction had developed in the right pulmonary artery during the 3 months that the patient was waiting to undergo operation. In patient 5, primary anastomosis was undertaken, but morphologically the anomalous origin was of the distal form, so the occurrence of stenosis in the reconstructed right pulmonary artery was a matter of concern. The morphological type was found to be related to the surgical options in this anomaly. Therefore, primary anastomosis was considered the best choice for a correction of the proximal form, whereas a graft interposition with a resection of the stenotic portion on the right pulmonary artery was deemed preferable in the distal form.

Nuclear magnetic resonance imaging of the palliative operation for hypoplastic left heart syndrome

Electrocardiographic-gated nuclear magnetic resonance (NMR) imaging has been shown to be effective for the evaluation of congenital heart disease, particularly in supracardiac regions. This study evaluated the postoperative status after a stage I palliative operation (Norwood procedure) for hypoplastic left heart syndrome. The NMR images from three patients were compared with those of angiography and depicted all components of the reconstructed supracardiac and intracardiac anatomy after this operation. Nonobstructive anastomosis of the main pulmonary artery to the proximal aorta was clearly demonstrated in each patient. The caliber of the central or branch pulmonary artery, patency and caliber of the systemic to pulmonary artery shunt and the size of the atrial communication were also depicted in each patient and these findings corresponded with angiographic results.The results suggest that NMR imaging is effective for assessing the results of initial palliative surgery for hypoplastic left heart syndrome, which seems to be important for managing patients before subsequent definitive surgery.

The Damus-Stansel-Kaye procedure: Anatomical determinants and modifications

Seven of 119 patients undergoing anatomical correction for transposition of the great arteries and Taussig-Bing anomalies without pulmonary stenosis had the Damus-Stansel-Kaye procedure and the rest, the arterial switch. The age of the patients having the Damus-Stansel-Kaye procedure ranged from 0.5 year to 5 years (mean age, 2.2 ± 1 years). Four patients had transposition, 2 had Taussig-Bing anomaly, and 1 had corrected transposition. Indications for the Damus-Stansel-Kaye procedure were side-by-side great arteries associated with difficult coronary anatomy (5 patients), single coronary system (1 patient), and subaortic stenosis (1). A graft between the ascending and descending aorta for interrupted aortic arch made mobilization and posterior displacement of the ascending aorta for the arterial switch difficult. Subaortic stenosis (1 patient), subpulmonary ventricular septal defect (2 patients), and restrictive ventricular septal defect (4) precluded the Rastelli procedure. In 6 patients, the main pulmonary artery was transected at the band, a proximal main pulmonary artery to aorta anastomosis was complemented with a synthetic patch, and a right ventricle to distal main pulmonary artery valved conduit was inserted. Four patients had closure of the aortic outflow. Two patients had postoperative bleeding and 2, heart block. The only patient who did not have transaction of the main pulmonary artery, an omission that led to an obstructed conduit at the distal anastomosis, died late. Two patients subsequently needed aortic outflow closure for critical aortic insufficiency. The Damus-Stansel-Kaye procedure has a definite role and can be safely performed in patients with transposition of the great arteries and Taussig-Bing anomalies. Aortic outflow closure minimizes the risk of aortic insufficiency. Transection of the distal main pulmonary artery allows a wide open conduit to main pulmonary artery anastomosis.

Catheterizing modified Blalock-Taussig shunts and ascending aorta to pulmonary artery shunts

Assessing the anatomy, pressure and resistance of the pulmonary vascular bed is an essential part of the preoperative evaluation of patients with congenital heart disease. In patients with pulmonary atresia or other complex defects when anterograde passage of a catheter into the pulmonary artery is not possible, pulmonary venous wedge pressures have been used to assess the pulmonary arterial pressure, and angiograms recorded close to systemic to pulmonary artery shunts have been used to assess the anatomy of the pulmonary vascular bed. These techniques often do not provide accurate information. It is preferable to directly measure pulmonary artery pressure and pulmonary vascular resistance, and perform angiography in the pulmonary artery. White 1 previously described a technique for catheterizing Blalock-Taussig (B-T) shunts (subclavian artery to pulmonary artery anastomosis) using specially preformed catheters. In this report we describe a method of retrograde catheterization of the pulmonary artery via modified B-T shunts and ascending aorta to pulmonary artery shunts. A number of catheters, Gensini (USCI, Billerica, Massachusetts), pigtail (Cordis, Miami, Florida), GL (Goodale-Lubin, USCI, Tewksbury, Massachusetts), have been used at our institution to enter such shunts. We have found that the shunts may be most easily catheterized using a Cordis Judkins 5Fr right coronary artery catheter with a 4-cm curve.

Tricuspid atresia or severe stenosis with partial common atrioventricular canal: Anatomic data, clinical profile and surgical considerations

The anatomic findings in 11 cases of tricuspid atresia and in two cases of severe tricuspid stenosis, both combined with partial common atrioventricular (AV) canal, are presented in detail. Twelve cases were documented by postmortem examination and the diagnosis was confirmed by echocardiography and surgical observation in the one living patient. Clinical data available in nine cases and cardiac catheterization data obtained in eight are included in this report.In three cases (23%)—two with tricuspid atresia and one with extreme tricuspid stenosis—the tricuspid valve and right ventricle exhibited characteristics seen in Ebstein's anomaly. In all 13 cases, the great arteries were normally related. The ventricular septal defects(s) in 10 (82%) of the 12 postmortem cases rapidly became smaller and this resulted in marked diminution of the pulmonary blood flow and severe hypoxia. Only three of the eight patients with available cardiac catheterization and angiocardiographic data snowed the scooped-out appearance of the left ventricular septal surface characteristic or AV canal defects. By contrast, two-dimensional echocardiography, available in the three most recent cases, accurately demonstrated all the defects present and represents the diagnostic method of choice.Early surgical intervention to establish a systemic to pulmonary artery anastomosis is essential for survival. More definitive surgical treatment can be achieved later by an atriopulmonary or cavopulmonary anastomosis with or without replacement of the cleft and often regurgitant mitral valve. The one living patient exemplifies this approach. This is the largest series of this unusual type of tricuspid atresia reported to date.

Transposition of the great arteries with posterior aorta: Anatomic repair

An uncommon but historically important form of transposition of the great arteries (S,D,D) was originally recognized in 1971. The unusual features of an aorta that is posterior and to the right of the pulmonary artery, a hypoplastic subaortic conus, and a well-developed subpulmonary conus influenced the evolution of the contemporary classification of conotruncal abnormalities and concepts of their development. Presented in this report is the case of a patient with transposition of the great arteries (S,D,D) and posterior aorta treated by an arterial switch operation. The unusual orientation of the great arteries did not preclude coronary transplantation or a satisfactory pulmonary arterial anastomosis. Moreover, the ventricular septal defect, which is characteristic of this atypical form of transposition of the great arteries, was most accessible for closure through the native aortic valve.

A Reconsideration of Risk Factors for the Fontan Operation

We reviewed our experience in 38 patients who underwent a Fontan operation. In the first five patients ages 7.5 to 23 years (mean, 15 years), a conduit was placed from the right atrium to the small right ventricle or the pulmonary artery (PA). The remaining 33 patients, ages 7 months to 14 years (mean, 4.8 years), had a modified Fontan operation with direct systemic venous or right atrial to PA anastomosis. The diagnoses were tricuspid atresia (n = 14), single ventricle (n = 10), hypoplastic right or left ventricle (n = 9), double-outlet right ventricle with inlet ventricular septal defect and pulmonary atresia or stenosis (n = 3), criss-cross ventricles and transposition of the great arteries (n = 1), and atrioventricular canal and anomalous pulmonary venous connection (n = 1). Thirty-two patients had previous surgery. Other procedures included PA banding (n = 7), systemic to PA shunts (n = 25), Norwood operation (n = 3), and a Damus-Kaye-Stansel anastomosis (n = 1), repair of total anomolous pulmonary venous connection (n = 1), a Blalock-Hanlon atrial septectomy (n = 1), and enlargement of a restrictive ventricular septal defect (n = 1). There were four operative deaths (10.5%), three from low cardiac output and one from subaortic obstruction. There were no deaths in patients younger than 3 years of age (n = 13). Subaortic obstruction developed in six of the seven patients who had pulmonary artery banding and resulted in three deaths. In our experience, diagnosis, previous surgery, type of previous operation, PA pressure, and younger age are not risk factors for early or late death. Subaortic obstruction is a major risk factor for late death. Accordingly we now perform a Damus-Kaye-Stansel anastomosis combined with a systemic to PA shunt in those children with excessive pulmonary blood flow who anatomically are likely to develop subaortic obstruction. A modified Fontan operation can be performed any time after 1 year of age and in some patients after 6 months of age, providing the anatomy and physiology of the patient are acceptable.

Late hemodynamic results after orthotopic heart transplantation in early infancy

To study the late hemodynamic results after infant orthotopic heart transplantation, five late survivors, as of October 1988, underwent right and left cardiac catheterization and endomyocardial biopsy. Mean age at transplantation was 1.4 +/- 1.5 months. Mean post-transplantation period was 17 +/- 5.6 months. All patients were on maintenance immunotherapy. The systemic and mixed venous saturations were normal, with no intracardiac shunt. The atrial and pulmonary artery anastomoses were widely patent. Three patients had coarctation of the aorta with a respective gradient of 24, 26, and 30 mm Hg; two were successfully treated by balloon angioplasty. The right-side hemodynamics were normal in all patients. Left ventricular pressures were elevated only in the patients with coarctation. The ventricular ejection fraction was normal. The right ventricular endomyocardial biopsy revealed no evidence of rejection. The mean cardiac index was 4.7 liter/min/m2 (range, 3.68-5.9). These data indicate excellent hemodynamic results and support orthotopic heart transplantation as therapy for selected neonates and infants with incurable heart disease.

Anomalous origin of one pulmonary artery from the ascending aorta: a review of echocardiographic, catheter, and morphological features.

Six patients with anomalous origin of one pulmonary artery from the ascending aorta were reviewed. Four had anomalous origin of the right pulmonary artery and two had anomalous origin of the left pulmonary artery from the ascending aorta. Two of these six patients had tetralogy of Fallot. Two patients died in the first month of life. No changes in the pulmonary vasculature were seen at necropsy. Corrective surgery was attempted in two patients with associated tetralogy of Fallot when they were two years old but both died. At necropsy there was severe pulmonary vascular disease in the lung supplied by the anomalous pulmonary artery but no pulmonary vascular hypertensive changes in the lung supplied by the pulmonary artery from the right ventricle. Two recent patients underwent successful anastomosis of the anomalous pulmonary artery to the main pulmonary artery at three months and one month and three weeks of age respectively. Intraoperative lung biopsy in the latter patient showed early changes in both lungs. Both echocardiography and cardiac catheterisation were used in the diagnoses. Systemic or suprasystemic pressures were found in the pulmonary artery arising from the right ventricle as well as the anomalous pulmonary artery in the three patients without tetralogy of Fallot. Anomalous origin of a pulmonary artery from the ascending aorta is a distinct entity and differs from other aorto-pulmonary arterial connections. Early surgical intervention is recommended in all patients (including those patients with associated tetralogy of Fallot) because of the risk of rapid development of irreversible pulmonary vascular disease.

Sequentially paced heterotopic heart transplant in the left chest provides improved circulatory support for the failed left ventricle: A potential biologic bridge to orthotopic transplantation

Acute experimental transplantation of an allograft heart in a heterotopic position was performed in 14 sheep. The donor heart was implanted in the left side of the chest with left atrial, aortic, and pulmonary artery anastomoses. Hemodynamic studies were performed to evaluate the physiologic effects of the procedure, particularly when recipient left ventricular failure was produced by inflow and outflow obstruction. Pacing techniques were developed and tested to coordinate the rhythm of the two hearts either synchronously or sequentially with variable intervals between depolarization of the two hearts. Hemodynamic studies were performed to evaluate the rhythm that would most optimize the physiology. The cardiac index remained essentially unchanged when the dominant circulatory support was shifted from recipient left ventricle to donor left ventricle by producing recipient left ventricular failure (3.79 +/- 0.6 to 3.30 +/- 0.8, p = no significant difference). Consistent and reliable paced rhythms were achieved in each case. The cardiac index was significantly higher when the hearts were paced sequentially rather than synchronously (3.76 +/- 0.5 versus 3.29 +/- 0.5, p less than 0.04). Allograft donor hearts small in size or slightly inadequate otherwise, which may be unsuitable for orthotopic heart transplantation, may still be used heterotopically for short-term support. Their use would maximize the use of all donor organs and the survival of patients awaiting a suitable organ. Further, it may also be possible to use sequentially paced xenografts heterotopically for short-term left ventricular assistance as a bridge to orthotopic heart transplantation.

Right ventricular failure after heart transplantation caused by a kink in the pulmonary artery anastomosis

Right ventricular failure after heart transplantation caused by a kink in the pulmonary artery anastomosis