Repair Of Common Arterial Trunk Research Articles

Common Arterial Trunk Repair at the Red Cross War Memorial Hospital, Cape Town: A 20-Year Review of Surgical Practice and Outcomes.

This study describes the 20-year experience of managing common arterial trunk (CAT) in a low-and-middle-income country and compares the early and medium-term outcomes following the transition from conduit to nonconduit repair at the Red Cross War Memorial Children's Hospital. Single-center retrospective study of consecutive patients aged less than 18 years who underwent repair of CAT from January 1999 to December 2018 at the Red Cross War Memorial Children's Hospital. Patients with interrupted aortic arch or previous pulmonary artery banding were excluded. Fifty-four patients had CAT repair during the study period. Thirty-four (63.0%) patients had a conduit repair, and 20 (37.0%) patients had a nonconduit repair. There were two intraoperative deaths. Thirty-day in-hospital mortality was 22.2% (12/54). Overall, in-hospital mortality was 29.6% (16/54). Eight (21.1%) late mortalities were observed. The actuarial survival for the conduit group was 77.5%, 53.4%, and 44.5% at 6, 12, and 27 months, respectively, and the nonconduit group was 58.6% at six months. The overall freedom from reoperation between the conduit group and nonconduit group was 66.2% versus 86.5%, 66.2% versus 76.9%, and 29.8% versus 64.1% at 1, 2, and 8 years, respectively. The outcomes following the transition to nonconduit repair for CAT in a low- and middle-income setting appear to be encouraging. There was no difference in mortality between conduit and nonconduit repairs, and importantly the results suggest a trend toward lower reintervention rates.

Surgical Repair of Common Arterial Trunk With Ventriculoarterial Septal Defect and Dual Orifice Truncal Valve

We present a case of a rare example of a ventriculo-arterial septal defect found in a patient with a common arterial trunk, with balanced aortic and pulmonary components, but with separate valvar orifices within the common truncal valve. We managed the lesion using a two-patch approach. Performing a palliative procedure to relieve the elevated right ventricular pressure aided in the preservation of the pulmonary component of the common valve. We validated the success of the technique using postoperative computerized tomography and four-dimensional flow magnetic resonance imaging.

Common arterial trunk repair after infancy.

Common arterial trunk repair after infancy.

Surgical outcomes of common arterial trunk repair beyond infancy.

The aim of this study is to analyze the clinical outcomes of common arterial trunk repair beyond infancy in terms of both early- and long-term outcomes. Between January 2003 and December 2019, 56 patients underwent repair for common arterial trunk beyond infancy at our institute. Median age was 34.5months, 51.8% were females, and 48.2% were males. 48.2% were type 1, 46.4% were type 2, and 5.4% were type 3. 17.9% patients underwent direct connection technique for right ventricular outflow tract reconstruction; remaining received a conduit. The most common type of truncal valve anatomy was tricuspid (82.1%). Early mortality was 7%. Univariable analysis identified age (p = 0.003), weight (p = 0.04), duration of ventilation (p = 0.036), and pulmonary hypertensive crisis (p ≤ 0.001) as factors affecting early mortality. In our overall cohort of beyond infancy repair for common arterial trunk, at 10years, the survival, freedom from reintervention for right ventricular outflow tract reconstruction, freedom from ≥ moderate conduit obstruction, freedom from impaired right ventricle function, and freedom from ≥ moderate truncal valve regurgitation were 76.7%, 89.7%, 74%, 88.6%, and 66.3%, respectively. Repair for common arterial trunk in patients presenting beyond 1year of age is challenging; however, it can be done with satisfactory early and late outcomes in terms of mortality and reintervention.

Catheter closure of residual muscular VSD after common arterial trunk repair using Amplatzer muscular occluder (patient number 3 in Table S1). VSD, ventricular septal defect.

Catheter closure of residual muscular VSD after common arterial trunk repair using Amplatzer muscular occluder (patient number 3 in Table S1). VSD, ventricular septal defect.

Right ventricular structure and function after novel repair of common arterial trunk

ObjectivesIn an attempt to enhance applicability and outcomes of corrections of common arterial trunk, we have recently described a novel method of correction based on the concept of morphodynamism, and preserving the structure of the right ventricle. The intermediate influence of this operation on right ventricular (RV) structure and function have not been described. Methods and resultsThirty eight Patients (age: 1–12 months) underwent the novel repair. There were 2 early and 4 late deaths. All patients underwent early CT scans, 12 had repeat CT and 8 had MRI after 1 year or more from the operation. Detailed computerized analysis of the RV size, shape, pattern of contraction and function was performed. The shape and size were preserved, at the second investigation, with no evidence of dilatation of the neo-RV outflow, which appeared to contribute to overall function of the RV. The directional pattern of contraction showed enhanced longitudinal and radial contributions with minimal twisting. The movement of the RV free wall and septum were almost equal, with normal shape of the septum. The instantaneous pattern of contraction followed a consistent peristalsis sequence with significant contraction of both the body and the neo-outflow. The pulmonary regurgitant fraction, at follow up, varied from 22% to 42% (30 ± 6%) with preserved RV to pulmonary artery ventriculo-arterial coupling. ConclusionThe size, shape and pattern of contraction of the RV following the novel common arterial trunk repair appears to be well preserved in the intermediate term.

Tracheobronchial Release for Left Bronchus Compression After Aortic Arch Repair

Narrowing of the retroaortic space after repair of common arterial trunk (CAT) with interrupted aortic arch (IAA) is a well-known issue. We present a newborn with CAT, IAA, and functionally univentricular heart (tricuspid atresia) who underwent repair of CAT, IAA, and left ventricle-to-pulmonary artery (LV-to-PA) conduit placement with the Lecompte maneuver. The patient suffered from left bronchus compression postoperatively, which was relieved by tracheobronchial release.

Repair of common arterial trunk: palliation and delayed correction as a viable alternative strategy in selected patients.

OBJECTIVESPrimary repair of common arterial trunk (CAT) is burdened by high mortality rates, especially in the presence of multiple risk factors. Timing, possible palliative methods, optimal management of associated cardiac lesions and handling of a poor preoperative state are still under discussion.METHODSWe retrospectively analysed all patients who underwent surgery for CAT in our institution between 2008 and November 2020. We included 22 patients, 11 of whom received primary correction (PC) and 11 of whom underwent initial palliation by partial repair, leaving the ventricular septal defect open and connecting the right ventricle to the pulmonary arteries with a small valveless right ventricle-to-pulmonary artery conduit. A delayed correction (DC) was performed after 11.5 ± 3.6 months.RESULTSThe overall operative mortality was 4.5%; 1 patient (affected by severe truncal valve stenosis and presenting in a poor state preoperatively) in the DC group died after palliation. The incidence of postoperative pulmonary hypertensive crisis was significantly higher in the PC group (P = 0.027). No patient from either group required postoperative extracorporeal support. Survival rates after 6 years differed slightly (PC group, 90%; DC group, 70%; log-rank = 0.270).CONCLUSIONSPC of CAT remains an optimal surgical approach for patients with an expected low mortality. However, our data support palliation and DC as a suitable alternative strategy, especially in the presence of significant risk factors like interrupted aortic arch, poor preoperative condition or complex surgical anatomy.

Outcomes after common arterial trunk repair: Impact of surgical technique

To compare the risk of mortality and re-intervention after common arterial trunk (CAT) repair for different surgical techniques, especially for reconstruction of the right ventricle outflow tract (RVOT) with left atrial appendage without a monocusp. We retrospectively included patients with repaired CAT who were followed-up at our institution between 2000 and 2018. A Cox proportional-hazards model was used to investigate risk factors on overall survival and freedom from re-intervention in univariable and multivariable analyses. One hundred and twenty-nine patients were included in the study. The median follow-up was 8.8 years. 15 patients (11.6%) died after the initial repair. The ten-year survival rate was 88.2% with the poorest outcome for CAT type IV (64.3%; P < 0.01). In multivariable analysis, coronary anomalies (HR = 11.63 [3.84–35.29], P < 0.001) and CAT with interrupted aortic arch (HR = 6.50 [2.10–20.16], P = 0.001) were risk factors for mortality. Initial repair without valvulation of the RVOT was not associated with an increased risk of mortality (HR = 0.37 [0.11–1.24], P = 0.11). The median age at re-intervention was 3.6 years [7.3 days-13.1 years]. At 10 years, freedom from re-intervention was higher in the group repaired with left atrial appendage compared to the valved conduit group, 73.3% and 17.2% ( P < 0.001), respectively. In multivariable analysis, using a valved conduit at repair (HR = 4.79 [2.45–9.39], P < 0.001), truncal valve insufficiency (HR = 2.92 [1.62–5.26], P < 0.001) and Di George syndrome (HR = 2.01 [1.15–3.51], P = 0.01) were risk factors for re-intervention. CAT type IV and coronary anomalies were risk factors for mortality after CAT repair. The RVOT reconstruction technique with left atrial appendage was not associated with neither short- nor middle-term higher post-operative mortality. This technique was also associated with a significant increase in the time to re-intervention when the latter was required.

Outcomes after common arterial trunk repair: Impact of the surgical technique

ObjectivesWe compared the risk of mortality and reintervention after common arterial trunk (CAT) repair for different surgical techniques, in particular the reconstruction of the right ventricle outflow tract with left atrial appendage (LAA) without a monocusp. MethodsThe study population comprised 125 patients with repaired CAT who were followed-up at our institution between 2000 and 2018. Statistical analysis included Cox proportional hazard models. ResultsMedian follow-up was 10.6 years. The 10-year survival rate was 88.2% (95% confidence interval [CI], 80.6-92.4) with the poorest outcome for CAT type IV (64.3%; 95% CI, 36.8-82.3; P < .01). In multivariable analysis, coronary anomalies (hazard ratio [HR], 11.63 [3.84-35.29], P < .001) and CAT with interrupted aortic arch (HR, 6.50 [2.10-20.16], P = .001) were substantial and independent risk factors for mortality. Initial repair with LAA was not associated with an increased risk of mortality (HR, 0.37 [0.11-1.24], P = .11). The median age at reintervention was 3.6 years [7.3 days-13.1 years]. At 10 years, freedom from reintervention was greater in the group with LAA repair compared with the valved conduit group, 73.3% (95% CI, 41.3-89.4) versus 17.2% (95% CI, 9.2-27.4) (P < .001), respectively. Using a valved conduit for repair (HR, 4.79 [2.45-9.39], P < .001), truncal valve insufficiency (HR, 2.92 [1.62-5.26], P < .001) and DiGeorge syndrome (HR, 2.01 [1.15-3.51], P = .01) were independent and clinically important risk factors for reintervention. ConclusionsFor the repair of CAT, the LAA technique for right ventricle outflow tract reconstruction was associated with comparable survival and greater freedom from reintervention than the use of a valved conduit.

Outcomes after common arterial trunk repair in children

The persisting controversy on the repair of the right outflow tract in common arterial trunk led us to analyze the outcomes of children operated at our institution. We identified 153 children diagnosed with CAT between 2000 and 2017. Six patients died before first surgery and were excluded. Types of CAT were classified according to the modified Van Praagh classification. We included 147 patients: CAT A1 ( n = 89, 60.6%), CAT A2 ( n = 32, 21.7%), CAT A3 ( n = 8, 5.4%), and CAT A4 ( n = 18, 12.3%). The mean follow-up was 10 ± 4.4 years. Seventeen patients (11.6%) died after surgery. Mean survival was 88.2% at 5 years. Survival of CAT A4 was significantly lower than for other types (65% at 5 years; P < 0.01). In multivariate analysis, quadricuspid truncal valve anatomy ( P = 0.02, HR = 3.15, 95% CI [1.1961 to 8.3066]) and bovine xenograft valve conduit for the right ventricle outflow tract (RVOT) repair ( P = 0.04, HR = 2.34 [0.8584 to 6.4221]) were the two risk factors for mortality. Seventy-nine patients (53.7%) needed reintervention (surgery or percutaneous). Freedom from reintervention at 5 years was 51.7%. The risk for reintervention was similar in different types of CATs ( P = 0.65). The vast majority of reinterventions were done in the RVOT (96.2%). In univariate analysis, the use of bovine xenografts valve conduit ( P = 0.047, HR = 1.62 [1.12 to 2.51]) and porcine xenografts ( P < 0.01, HR = 2.46 [1.54 to 3.92]) were associated with a higher risk of reinterventions, while autologous connections of the pulmonary artery with the left atrial appendage or pericardial patch were associated with a reduced risk ( P < 0.0001, HR = 0.25 [0,1267 to 0,4779]). The anatomical type of CAT did not influence the risk for reintervention after repair. Autologous reconstruction of the pulmonary artery with autologous tissue limits the risk for reintervention on the RVOT during childhood.

Successful surgical repair for common arterial trunk with anterior crisscross pulmonary arteries and right aortic arch causing right bronchial compression

A 1-month-old girl with common arterial trunk, anteriorly originated crisscross pulmonary arteries, unusual running right aortic arch and severe pulmonary hypertension was initially palliated by bilateral pulmonary artery banding. She developed sudden respiratory failure at 80days old; and computed tomography revealed that the right main bronchus was severely compressed by the proximal aortic arch. When common arterial trunk repair was performed, the dominant aortic component of the common trunk incorporating both branch pulmonary arteries was cylindrically resected. End-to-end anastomosis of truncal root and distal ascending aorta was therefore performed to anteriorly retract the proximal arch, thereby relieving bronchial stenosis. The patient experienced an uneventful postoperative course, and postoperative computed tomography showed widely patent right main bronchus.

Neonatal quadricuspid truncal valve repair with left coronary artery unroofing

Neonatal quadricuspid truncal valve repair with left coronary artery unroofing

Outcomes after common arterial trunk repair in children

The persisting controversy on the repair of the right outflow tract in common arterial trunk led us to analyze the outcomes of children operated at our institution. We identified 153 children diagnosed with CAT between 2000 and 2017. Six patients died before first surgery and were excluded. Types of CAT were classified according to the modified Van Praagh classification. We included 147 patients: CAT A1 ( n = 89, 60.6%), CAT A2 ( n = 32, 21.7%), CAT A3 ( n = 8, 5.4%), and CAT A4 ( n = 18, 12.3%). The mean follow-up was 10 ± 4.4 years. Seventeen patients (11.6%) died after surgery. Mean survival was 88.2% at 5 years. Survival of CAT A4 was significantly lower than for other types (65% at 5 years; P < 0.01). In multivariate analysis, quadricuspid truncal valve anatomy ( P = 0.02, HR = 3.15, 95%CI [1.1961 to 8.3066]) and bovine xenograft valve conduit for the right ventricle outflow tract (RVOT) repair ( P = 0.04, HR = 2.34 [0.8584 to 6.4221]) were the two risk factors for mortality. Seventy-nine patients (53.7%) needed reintervention (surgery or percutaneous). Freedom from reintervention at 5 years was 51.7%. The risk for reintervention was similar in different types of CATs ( P = 0.65). The vast majority of reinterventions were done in the RVOT (96.2%). In univariate analysis, the use of bovine xenografts valve conduit ( P = 0.047, HR = 1.62 [1.12 to 2.51]) and porcine xenografts ( P < 0.01, HR = 2.46 [1.54 to 3.92]) were associated with a higher risk of reinterventions, while autologous connections of the pulmonary artery with the left atrial appendage or pericardial patch were associated with a reduced risk ( P < 0.0001, HR = 0.25 [0.1267 to 0.4779]) ( Fig. 1 ). The anatomical type of CAT did not influence the risk for reintervention after repair. Autologous reconstruction of the pulmonary artery with autologous tissue limits the risk for reintervention on the RVOT during childhood.

971The burden of reinterventions after common arterial trunk repair in infants: contemporary results from a national database

971The burden of reinterventions after common arterial trunk repair in infants: contemporary results from a national database

Common Arterial Trunk Repair by Means of a Handmade Bovine Pericardial-Valved Woven Dacron Conduit.

Surgical repair of common arterial trunk (CAT) by means of a homograft conduit has become a standard practice. We report our experience in the correction of this heart disease with a handmade bovine pericardial-valved woven Dacron conduit as an alternative procedure to homografts, with a focus on early, mid-term, and long-term results. We designed a retrospective study that included 15 patients with a mean age of 1.5 years (range: three months to eight years), who underwent primary repair of simple CAT. Right ventricular outflow tract was reconstructed in all the cases with this handmade graft that was explanted at the time of its biological stenotic degeneration. A peeling procedure was performed at this time, in order to reconstruct the right ventricle-to-pulmonary artery continuity. Overall mortality was 13.3% (one death at the early postoperative primary repair and the other at the mid-term postoperative peeling reoperation). Actuarial survival rate was 93.3%, 86.7%, and 86.7% at 5, 10, and 15 years, respectively. All of the 14 survivors developed stenosis of the handmade conduit at the mid-term period (8 ± 3 years), but after the peeling procedure, 13 survivors remain asymptomatic to date. Primary repair of common arterial trunk using a handmade conduit can be performed with very low perioperative mortality and satisfactory mid-term and long-term results, which can be favorably compared with those reported with the use of homografts. When graft obstruction develops, peeling procedure is a good option because it does not affect the overall survival, although long-term outcomes warrant further follow-up.

Surgical Treatment of Common Arterial Trunk in Patients Beyond the First Year of Life

Common arterial trunk (persistent truncus arteriosus) is a rare cardiac defect requiring surgical repair early in life because of the fast development of pulmonary vascular obstructive disease. We present our institutional experience with patients having common arterial trunk who are diagnosed after one year of age. Between August 2010 and May 2013, a total of 1,436 patients were treated for congenital cardiac defects at our institution. Common arterial trunk was treated surgically in seven patients older than one year of age (three males, four females; age: 13 months to 5 years, mean: 2.8 ± 2.04 years). All patients underwent cardiac catheterization in order to determine operability. All patients had the aortic dominant type of common arterial trunk. The pulmonary vascular resistance and Qp/Qs ratio before and after oxygen inhalation were mean 9.04 + 4.2 (range: 3.8 and 10.7) wood units and 4.67 ± 2.3 (range: 3 and 6.5) wood units and 3.3 + 1.8 (range: 1.42 and 5.3) and 4.98 + 2.2 (range: 4 and 6.2), respectively. All patients underwent elective primary repair. The ventricular septal defect was closed in all patients, five with a nonvalved patch and two with a unidirectional check-valved patch. Early postoperatively, patients were sedated, hyperventilated, and received nitric oxide for a minimum of 24 hours. There was no early or late mortality. The mean length of hospital stay was 9.3 ± 5.7 days, and mean duration of follow-up was 214 ± 59 days. Complete repair of common arterial trunk in patients older than one year of age is feasible in appropriately selected cases. Preoperative cardiac catheterization to assess reactivity of the pulmonary vascular bed is important as are appropriate strategies for postoperative management. Together, these elements make it possible to achieve primary repair with excellent outcomes despite late presentation.

Early postoperative interventional ASD-closure for severe atrial right to left shunt in a neonate with common arterial trunk

Although closure of an atrial septal defect (ASD II) with an occluding device in the first year of life is not a routine procedure, it is a feasible treatment, even in neonates. Case reports on the off-label use of Amplatzer devices have been repeatedly published, but there are no reports on using the Amplatzer Duct Occluder (ADO) to close an atrial septal defect in a neonate. We report on a successful catheter closure of an ASD II with ADO in a severely cyanotic neonate, seven days after surgical repair of common arterial trunk. Due to progressive cyanosis and clinical signs of right ventricular failure, which developed after common arterial trunk repair, the neonate underwent cardiac catheterization. Diastolic filling impairment of the right ventricle (right ventricle hypertrophy, pulmonary regurgitation, and residual right ventricle outflow tract obstruction) was thought to be the cause of impaired right ventricle diastolic filling, resulting in the right-to-left shunt at the atrial level. Under transesophageal echocardiographic guidance, ADO was delivered through a 5 French sheath into the atrial septal defect. Amplatzer duct occluder closed the defect and proved to be stable in position after disconnection. During the procedure, the child was stable and then transferred to the intensive care unit with significantly improved oxygen saturation. This is the first report on placing a duct occluder in the atrial septal position, which is a novel procedure for-small neonates.

Feasability of a valveless RV-PA connection in primary repair of common arterial trunk

Objective: To report our experience with valveless RV-PA connection in common arterial trunk (CAT) regarding survival and reintervention rate.

Inverted Left Atrial Appendage Masquerading as a Cardiac Mass

An inverted left atrial appendage is a rare phenomenon post cardiac surgery. The lesion presents as an additional mass in the left atrium, which would trigger unnecessary concerns and frequently, a battery of tests. The lesion can be easily diagnosed using echocardiography. We report a case of inverted left atrial appendage in a patient post repair of common arterial trunk. Echocardiographic pictures and features which help to identify this lesion as well as to differentiate it from other possible left atrial mass are described. This article aimed to improve the awareness of sonographers toward this rare but possible post operative lesion.