Ann Thorac Surg 1995;60:697-698
© 1995 The Society of Thoracic Surgeons
Case Report
Truncus Arteriosus With Interrupted Aortic Arch: Successful Correction Using Autologous Flap
Seimei Nakae, MD,
Masaaki Kawada, MD,
Shingo Kasahara, MD,
Zon Bo Lin, MD,
Satoshi Hiraishi, MD,
Hirokuni Yoshimura, MD
Departments of Thoracic and Cardiovascular Surgery and Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
Accepted for publication March 9, 1995.
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Abstract
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A newborn baby with type II truncus arteriosus and type B interrupted aortic arch was successfully treated by creating a pulmonary tract using autologous flap made from truncal wall without excision of the pulmonary artery and by reconstructing the aortic arch with direct anastomosis. This method provided excellent hemodynamics with wide reconstruction of the pulmonary tract without conduit.
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Introduction
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Primary repair for truncus arteriosus with interrupted aortic arch is currently accepted as a conventional surgical procedure in the neonate [1–5]. We report successful use of an autologous flap made from truncal wall without excision of the pulmonary artery to reconstruct new pulmonary tract. Autologous tissue is expected to facilitate pulmonary tract growth [6], and this method is available in truncus with simultaneous reconstruction of the interrupted aortic arch.
A female baby weighing 3.2 kg required treatment for respiratory distress with type II truncus arteriosus and type B interrupted aortic arch. Echocardiography demonstrated a mild regurgitation across the truncal valve. At the 11th day of life, complete repair was performed because severe acidosis had progressed.
Through a median sternotomy, the entire brachiocephalic arteries, descending aorta, and aberrant origin of the right subclavian arteries were extensively dissected. Cardiopulmonary bypass was instituted with bicaval venous cannulas and a 10F straight arterial cannula placed in the aortic arch through the ductus from the truncus. Snares for the pulmonary arteries were tightened, and dissection was extended as far along the descending aorta as possible while the temperature decreased to 15°C. The brachiochephalic vessels were snared, and cardioplegic solution was infused from the truncus when total circulatory arrest was established. The ductus was divided and ductal tissue was entirely excised after removal of the arterial line. The descending aorta was anastomosed to the upper left lateral aspect of the ascending aorta and to the partly adjacent common carotid artery. A truncal arterial flap was created from the truncal wall, which appears more dominant at the anterolateral aspect of the ascending aorta (Fig 1
). Vertical incisions were placed at the right lateral side of the truncal wall from the opening of the divided ductus in the direction of the right sinus of Valsalva. The truncal flap was pushed down so that it hinged above the sinus of Valsalva toward the ventriculotomy. Then an oval equine pericardial patch was placed in the sinus of Valsalva to separate the systemic and pulmonary arteries. This patch was carefully sutured to prevent right pulmonary obstruction and distortion of the small ascending aorta. Then cardiopulmonary bypass was reinstituted with the 10F straight arterial cannula placed in the aortic arch through the aberrant right subclavian artery behind the ascending aorta, which was divided at the right side of the mediastinum. The ventricular septal defect was closed through the right ventricle. The truncal flap was connected to the edge of the ventriculotomy. A few stitches were added between the patch of the ventricular septal defect and flap to reinforce the connection. A monocusp mounted equine pericardial patch was placed over the new pulmonary tract. There was no significant hemorrhage, primary sternal closure was easily performed, and excellent hemodynamics were maintained.
The pressure ratio between the right and left ventricles was 0.4, and the pressure gradient across the pulmonary tract was 10 mm Hg. There was a 17-mm Hg pressure gradient in the ascending aorta immediately after operation. These pressure gradients did not progress and were even reduced to less than 10 mm Hg in the ascending aorta and pulmonary tract 6 months after operation. Her cardiac involvement was stable, and she was able to resume her normal development 6 months after operation.
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Comment
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Autologous flap for truncus arteriosus as proposed by Barbero-Marcial and associates [6] does not involve excision of the pulmonary artery or use an extracardiac conduit in type I truncus arteriosus. There is a potential for the new pulmonary tract to grow, and the possibility of a subsequent operation in childhood is reduced with our method. We applied modification of the anterolateral truncal flap method for type II truncus and interrupted aortic arch. The truncus connected to the ductus appears to be the more dominant component in patients with interrupted aortic arch [7]; this facilitates creation of a large flap even after excision of ductal tissue. This makes it easier to create a large flap than in a patient without interrupted aortic arch. The truncal flap was mobilized and connected to the edge of the right ventriculotomy to create the floor of the new pulmonary tract. An oval patch should be placed precisely in the sinus of Valsalva to separate the systemic root from both the right and left pulmonary arteries. In addition, the suture line of the septation patch should not be placed inside to avoid ascending aortic narrowing while also avoiding obstruction of the right pulmonary orifice and right coronary artery. However, a patient with a small left pulmonary artery arising from the lateral aspect of the truncus as in type III may not be a candidate for this method. These are anatomic limitations in applying an autologous flap that remains in truncal pulmonary continuity. In this combination, the pulmonary artery must be excised from the truncus and connected to the right ventricle [8]. Interposition of the left atrial appendage may also reduce left pulmonary distortion [6]. The newly constructed pulmonary tract did not appear to be compressed even in the small chest cavity of a neonate. This advantage may be due to the ideal positioning of the new pulmonary tract, which was placed rather lower and more posterolateral than the ascending aorta.
Primary repair with direct anastomosis is a conventional method in interrupted aortic arch. The short period of circulatory arrest allows safe and wide reconstruction of the aortic arch. Distortion of the small ascending aorta is recognized as a potential hazard with angled truncal-pulmonary septation placed along the right pulmonary orifice to the left side of the truncal valve. This is due to a size discrepancy between the truncal valve diameter and that of the ascending aorta, particularly in the interrupted aortic arch. This might be a cause of the mild pressure gradient in the ascending aorta in our patient. However the pressure gradients in both the ascending aorta and pulmonary tract were even reduced. Further follow-up is essential to examine the growth of both the pulmonary tract and the aortic arch including the ascending aorta.
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Footnotes
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Address reprint requests to Dr Nakae, Department of Thoracic and Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Sagamihara, 228 Kanagawa, Japan.
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References
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- Sano S, Brawn WJ, Mee RBB. Repair of truncus arteriosus and interrupted aortic arch. J Cardiac Surg 1990;5:157–62.[Medline]
- McKay R, Miyamoto S, Peart I, et al. Truncus arteriosus with interrupted aortic arch: successful surgical correction in a neonate. Ann Thorac Surg 1989;48:587–9.[Abstract]
- Fujiwara K, Yokota Y, Okamoto F, et al. Successful surgical repair of truncus arteriosus with interrupted aortic arch in infancy by an anterior approach. Ann Thorac Surg 1988;45:441–4.[Abstract]
- Raudkivi PJ, Sutherland GR, Edwards JC, Keeton BR, Monro JL. Truncus arteriosus with type B interrupted aortic arch: correction in the neonate. Pediatr Cardiol 1990;11:117–9.[Medline]
- Di Donato RM, Fyfe DA, Puga FJ, et al. Fifteen-year experience with surgical repair of truncus arteriosus. J Thorac Cardiovasc Surg 1985;89:414–22.[Abstract]
- Barbero-Marcial M, Riso A, Atik E, Jatene A. A technique for correction of truncus arteriosus type I and II without extracardiac conduits. J Thorac Cardiovasc Surg 1990;99:364–9.[Abstract]
- Moes CAF, Freedom RM. Aortic arch interruption with truncus artertiosus or aorticopulmonary septal defect. Am J Radiol 1980;135:1011–6.[Abstract]
- Sharam AK, Pilato M, Ott DA. Surgical repair of type II truncus arteriosus without conduit. Ann Thorac Surg 1990;50:478–81.
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Abstract
Introduction
