Ann Thorac Surg 1996;61:990-992
© 1996 The Society of Thoracic Surgeons
Case Report
Anterior Pulmonary Translocation Without Conduit for the Repair of Truncus Arteriosus
Seimei Nakae, MD,
Masaaki Kawada, MD,
Shingo Kasahara, MD,
Naoki Kuroyama, MD,
Satoshi Hiraishi, MD,
Hirokuni Yoshimura, MD
Departments of Thoracic and Cardiovascular Surgery and Pediatrics, Kitasato University Hospital School of Medicine, Kanagawa, Japan
Accepted for publication September 5, 1995.
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Abstract
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A technique with autologous tissue for the correction of type III truncus arteriosus is described. The truncal root was excised as a cylinder that incorporated pulmonary arteries and that was translocated anterior to the ascending aorta. The proximal section of the cylinder was closed and the pulmonary tract was reconstructed with anastomosis of a widely opened distal section to the right ventricle. Autologous pericardium was sutured to the entire surface of the pulmonary tract.
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Introduction
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A 16-day-old male infant who had tachypnea and signs of congestive heart failure was examined. Echocardiography confirmed the diagnosis as a type III truncus arteriosus and equivalent pulmonary hypertension. However, truncal valve regurgitation was not observed. Primary repair was performed when the infant was 30 days of age.
The patient was placed on cardiopulmonary bypass with an arterial line placed high in the ascending aorta and bicaval cannulation. The patent ductus was divided and the heart was decompressed through the vent in the left atrium. Entire neck arteries and both of the pulmonary arteries were extensively dissected. The ascending aorta was cross-clamped and cardioplegia was induced. The truncal root was transected at the level of the superior ridge of the pulmonary arteries. A cylinder graft of truncal root was excised beneath the level of the inferior ridge of the pulmonary arteries (Fig 1A
). This autologous cylinder graft that incorporated pulmonary arteries was translocated anterior to the ascending aorta. Then the aorta was reconstructed with direct anastomosis.
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Fig 1. . (A) Dashed lines on the truncal root indicate transection of the truncus that incorporated pulmonary arteries. Arrowed line indicates incision in the right ventricle. A vent (V) was placed in the left atrium through the left atrial appendage. (B) Autologous cylinder graft was translocated anterior to the aorta, and the ascending aorta was reconstructed by direct end-to-end anastomosis with 6-0 absorbable sutures. The proximal section of the graft was closed transversely between pulmonary orifices.
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The proximal section of the graft was closed transversely, and the distal section was widely opened with the anterosuperior edge of the graft pushed down (Fig 1B
). This edge was anastomosed to the edge of the vertical incision in the right ventricle to complete the floor of the pulmonary tract (Fig 2A). Typical outlet type of ventricular septal defect was closed through the right ventricle. After the aorta was unclamped, an autologous pericardial patch was placed to the entire surface of the pulmonary tract (Fig 2B). We observed a pressure gradient of 5 mm Hg across the anastomosis of the pulmonary tract, a gradient of 5 mm Hg between the pulmonary trunk and right pulmonary artery, and a right-to-left ventricular peak systolic pressure ratio of 0.45 immediately after operation.
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Fig 2. . (A) The floor of the pulmonary tract was constructed by anastomosis of the anterior edge of the distal section and edge of the incision of the right ventricle. Cannulas for the extracorporeal circulation are not shown. (B) Autologous pericardial patch without mounted valve was placed.
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The patient had left phrenic nerve palsy, which might be related to the cold injury during myocardial topical cooling. The patient made a spontaneous recovery and has been doing well. Significant acceleration of the pulmonary blood flow velocity was not observed 8 months after operation.
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Comment
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Anterior translocation of the pulmonary bifurcation was proposed by Lecompte and associates [1] to reconstruct pulmonary tract in the truncus arteriosus. Several methods of direct anastomosis of the detached pulmonary artery to the right ventricle are available for the correction of the truncus arteriosus [2–4]. Autologous tissue has a potential to grow with the pulmonary tract as the child grows. These methods do not require the use of a prosthetic conduit and may reduce the reoperation rate with several complications in early childhood. We use the anterior truncal wall to create the pulmonary tract, leaving the posterior wall of the truncal root to keep the continuity of the pulmonary artery in type I and II truncus [5, 6]. However, this method is not suitable in type III truncus because each pulmonary artery that arises from the lateral aspect of the truncus cannot be separated and mobilized with the patch partition from the truncal root.
The technique described by Reid and associates [4] can also be suitable for type III truncus arteriosus. Retraction and stretch of the pulmonary bifurcation may be minimized with a widely opened distal section of the cylinder, and adequate size of the floor of the new pulmonary tract may be obtained. Hence the pulmonary caliber does not deform, even the part that is over the ascending aorta. This method provides a wide enough floor between the right ventricle and the branch of the pulmonary arteries.
In type III truncus, we recommend transverse closure of the proximal section, preventing the deformity of the pulmonary orifices that can occur when the anterior translocation of the truncal root is used. Anterior translocation of the pulmonary branches has been thought to be responsible for pulmonary branch stenosis. However, clinically significant pulmonary branch stenosis may not occur [7]. Concerning the growth of the pulmonary artery, preventing the turbulence of the pulmonary blood flow is essential in this method. We did not use a cusp-bearing outflow patch in this patient because a monocusp occupies the space of the constructed short pulmonary trunk and might be a cause of turbulence. Pulmonary stenosis due to the peel overgrowth at the monocusp was experienced in one of our series of this type of operation. In addition, the only advantage to using a cusp mounted on a patch is that pulmonary regurgitation is prevented for a short period in the presence of increased vascular resistance. Nevertheless, the growth of the pulmonary tract and fate of the pulmonary regurgitation still remain a matter of concern, and follow-up is essential. We think this method is most suitable for the correction of type III truncus arteriosus without using any synthetic materials.
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Footnotes
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Address reprint requests to Dr Nakae, Department of Thoracic and Cardiovascular Surgery, Kitasato University Hospital School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa 228, Japan.
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References
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- Lecompte Y, Neveux JY, Leca F, et al. Reconstruction of the pulmonary outflow tract without prosthetic conduit. J Thorac Cardiovasc Surg 1982;84:727–33.[Abstract]
- Sharma BK, Pilato M, Ott DA. Surgical repair of type II truncus arteriosus without a conduit. Ann Thorac Surg 1990;50:478–81.
- Viet Tu T, Bical O, Leca F, Neveux JY. Reconstruction plastique de la voie pulmonarire dans le truncus areteriosus communis. La Presse Med 1984;28:13–8.
- Reid KG, Godman MJ, Burns JE. Truncus arteriosus. Successful surgical correction without valved conduit. Br Heart J 1986;56:388–90.[Abstract/Free Full Text]
- 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]
- Nakae S, Kawada A, Kurata A, et al. Autologous pulmonary arterial flap for repair of truncus arteriosus in neonate and small infants. J Jpn Assoc Thorac Surg 1994;42:1335–42.
- Sidi D, Planche C, Kachaner J, et al. Anatomic correction of simple transposition of the great arteries in 50 neonates. Circulation 1987;75:429–35.[Abstract/Free Full Text]
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Abstract
Introduction
