Ann Thorac Surg 1996;62:123-128
© 1996 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Correction of Truncus Arteriosus With Autologous Arterial Flap in Neonates and Small Infants
Seimei Nakae, MD,
Shingo Kasahara, MD,
Naoki Kuroyama, MD,
Zong-Bo Lin, MD,
Satoshi Hiraishi, MD,
Yotaro Agata, MD,
Hirokuni Yoshimura, MD
Departments of Thoracic and Cardiovascular Surgery and Pediatrics, Kitasato University, School of Medicine, Kanagawa, Japan
Accepted for publication February 14, 1996.
 |
Abstract
|
|---|
Background. This study describes the results of techniques using the autologous truncal wall and part of the pulmonary artery for correction in anticipation of the growth of the pulmonary tract in patients with truncus arteriosus.
Methods. Seven consecutive patients with truncus arteriosus were reviewed. The posterior wall of the pulmonary tract was obtained by anastomosing the lower edge of the truncal arteriotomy to the upper corner of the ventriculotomy from the truncus in types I and II. Anterior translocation of the pulmonary artery was performed in a type III. A pericardial patch with or without a monocusp was placed to complete the right ventricular outflow tract.
Results. There were two hospital deaths, one of which was unrelated to a cardiac problem. Postoperative right-to-left ventricular peak pressure ratio was less than 0.55. There was one left pulmonary stenosis due to monocusp adherence in the late postoperative period. The sizes of the pulmonary tract at anastomosis were between 107% and 166% of the normal value between 7 months and 3.8 years of follow-up.
Conclusions. The use of autologous arterial wall instead of a conduit is recommended for the repair of truncus arteriosus to expect growth of the pulmonary tract.
|
Introduction
|
|---|
See also page 129.
Neonatal repair is recommended to prevent progressive pulmonary vascular disease in patients with truncus arteriosus [1–6]. Homograft-valved conduit repair is effective, whereas there is an exceedingly high mortality for pulmonary artery banding [7, 8]. However, a subsequent operation is required early in childhood as long as a synthetic material or bioprosthesis is used 1–6]. Since we acknowledged the excellent hemodynamic results of correction using the autologous truncal arterial flap as introduced by Barbero-Marcial and associates [9], we employed this technique in neonates and small infants. We describe the short-term results of applying these techniques at primary correction instead of conduit repair.
|
Patients and Methods
|
|---|
Between November 1992 and October 1994, 7 patients with truncus arteriosus underwent several types of repair using autologous truncal arterial wall and part of the pulmonary artery for reconstruction of the pulmonary tract. Two patients had Collet and Edwards' type I [10], 4 patients had type II, and 1 patient had type III truncus. Two patients with type II truncus were associated with Celoria and Patton's type B interrupted aortic arch [11] (Table 1
). Diagnosis was confirmed by echocardiography/Doppler examination in all patients. Echocardiographic examination revealed mild truncal valve regurgitation in 4 patients (Table 2). Typical outlet types of ventricular septal defects and normal coronary anatomy were seen in all patients. Patients were referred to our institute between birth and 75 days of age (mean, 13 ± 27.5 days) and follow-up before the operation ranged from 10 to 65 days (mean, 24.7 ± 18.4 days). Patient ages at the time of operation ranged from 11 to 95 days (mean, 38 ± 31 days) after birth. Body weight ranged from 2.6 to 3.9 kg (mean, 3.0 ± 0.4 kg) (see Table 1). Three patients (patients 1, 4, and 7) had been placed on ventilators, and 2 had received catecholamines (patients 4 and 7) preoperatively due to progressive congestive heart failure.
View this table:
[in this window]
[in a new window]
|
Table 2. . Echocardiographic Examination of the Postoperative Pulmonary Regurgitation and Change of Truncal Valve Regurgitation
|
|
After median sternotomy incision, a piece of pericardium was taken in 4 patients (patients 3, 4, 5, and 7). Extensive dissection was performed in the pulmonary arteries in all patients, and the neck arteries were dissected when interrupted aortic arch was present. The heart was cannulated with a distal aortic cannula in 6 patients, and in 1 of the patients with interrupted aortic arch, an arterial line was placed in the truncus (patient 6). Bicaval cannulation was used and cardiopulmonary bypass was instituted. Pulmonary arteries were snared immediately after the beginning of cardiopulmonary bypass, and the heart was vented from the left atrium through the left atrial appendage. The aorta was cross-clamped and cardioplegic solution was infused. In patients with interrupted aortic arch, the descending aorta was dissected as far downstream as possible. Neck arteries were snared and profound hypothermia with total circulatory arrest was used during the reconstruction of the aortic arch with end-to-end anastomosis after excision of the ductal tissue. Moderate hypothermia was achieved in all patients, including the patient who underwent repair of aortic arch interruption.
A vertical incision was made at the middle of the anterior truncal wall and extended in the direction of the left pulmonary artery and the right side of the sinus of Valsalva to create the truncal arterial flap (Fig 1). In 1 of the patients with interrupted aortic arch, a truncal arterial flap was created from the anterolateral truncal wall through an incision from the section of the divided ductus in the direction of the right side of the sinus of Valsalva [12]. Then the communication between the pulmonary artery and truncus was simply closed with a patch in type I truncus (Fig 2). Pulmonary arteries in type II were separated from the truncus with a patch that was placed from the junction of the ascending aorta and truncal wall to the left superior wall of the truncal valve ring in the sinus of Valsalva (Table 3; Fig 3). The ventricular septal defect was closed through a right ventricular incision that was extended in the direction of the truncal root. The inferior edge of the truncal flap that hinged the wall of the sinus of Valsalva was sutured to the superior edge of the right ventricular incision to create the posterior wall of the new pulmonary tract (see Figs 2, 3). Sites of autologous tissue, truncal-pulmonary separation method, and characteristics of the outflow patch are summarized in Table 3. In the patient with type III truncus, the truncal root that incorporated the pulmonary artery was transected as a cylinder (Fig 4). The ascending aorta was directly anastomosed after translocation of the cylinder anterior to the aorta (Fig 4). The proximal section of the cylinder was closed, and the anterosuperior edge of the cylinder was widely opened then anastomosed to the edge of the right ventricular incision (see Fig 4). Autologous or equine preserved pericardial patch was sutured over the entire surface of the new pulmonary tract that incorporated the monocusp valve in 3 patients (Figs 5, 6). Four patients received a nonvalved outflow patch (see Table 3). A monocusp valve was designed as a semilunar valve with its free edge equal to the width of the outflow tract. The free edge of the monocusp valve was attached to the posterior wall of the new pulmonary tract to cover the entire root of the pulmonary tract when the monocusp valve closed.
View larger version (34K):
[in this window]
[in a new window]
|
Fig 1. . Arteriotomy incision in type I truncus that was extended in the direction of the left pulmonary artery as indicated. Dotted line indicates vertical incision of the right ventricle. Heart was vented from the left atrium through the left atrial appendage. The aortic cross-clamp is not shown.
|
|
View larger version (34K):
[in this window]
[in a new window]
|
Fig 2. . Truncal–pulmonary artery communication was patched in type I. The ventricular septal defect was closed through the ventriculotomy, then the flap was turned and connected to the edge of the right ventricular incision to complete the floor of the pulmonary tract in type I.
|
|
View larger version (33K):
[in this window]
[in a new window]
|
Fig 3. . Pulmonary artery was separated from truncus with a pericardial patch that was placed between the junction of the ascending aorta and the left side of the truncal valve ring to circumscribe the left side of the new aortic root in type II truncus.
|
|
View larger version (63K):
[in this window]
[in a new window]
|
Fig 4. . Surgical procedure in type III truncus. The truncal wall was transected as a cylinder. The proximal section of the cylinder was closed transversely, then the cylinder was translocated anterior to the ascending aorta after reconstruction of the ascending aorta. The ventricular septal defect was closed through the right ventricular incision. The distal section of the cylinder was widely opened and connected to the edge of the right ventricular incision.
|
|
View larger version (30K):
[in this window]
[in a new window]
|
Fig 5. . Pericardial patch with or without bearing the monocusp was placed over the area from the anterior surface of the right ventricle to the pulmonary artery.
|
|
View larger version (31K):
[in this window]
[in a new window]
|
Fig 6. . A monocusp-bearing pericardial patch was placed over the area from the entire surface of the right ventricle to the pulmonary artery. The shape of the pulmonary branches was smooth and there was no significant stenosis or kinking of the pulmonary artery.
|
|
|
Results
|
|---|
There was one cardiac death due to severe left ventricular failure that developed during the operation. One patient demonstrated low cardiac output for 5 days after the operation. In the remaining 5 patients, there was no significant low cardiac output throughout the postoperative period.
The 6 surviving patients demonstrated a mean right-to-left ventricular peak systolic pressure ratio less than 0.55 at operation. A mild pressure gradient less than 15 mm Hg across the anastomosis was observed, and there was a 6 mm Hg pressure gradient across the right pulmonary bifurcation in the patient who underwent anterior translocation of the pulmonary artery (Table 4). Continuous infusion of nitroglycerin (1 to 2 µg • kg-1 • h-1) was administered to all patients between 24 and 96 hours after operation to prevent pulmonary hypertensive crisis. However, crisis occurred in 1 patient (patient 3) during decrease of the dose, and the patient was deeply sedated with additional morphine for 2 days. Echocardiographic examination performed within a week after the operation revealed that the average size of the right ventricular outflow tract at anastomosis in 6 patients was 10.2 ± 0.3 mm in diameter and corresponded to 150.8% ± 9.5% of normal pulmonary valve ring diameter [13].
Massive gastric bleeding occurred suddenly in patient 3 on the 14th postoperative day. She had been free from complication with adequate cardiac function, a right-to-left ventricular peak systolic pressure ratio of 0.55, and a pulmonary anastomosis 10 mm in diameter. The patient died of multiple organ failure on the 25th postoperative day, even though endoscopic hemostasis had been performed. An additional operation was performed in 1 patient because of left pulmonary artery obstruction due to pseudointimal tissue proliferation at the distal portion of the monocusp valve 1.4 years after the initial procedure (see Table 1
; Fig 3). Macroscopic findings at operation confirmed growth and smooth intimal proliferation at the posterior tract of the pulmonary artery after removal of the monocusp valve and pseudointimal tissue. Echocardiographic examinations in the 5 late-surviving patients including the 1 who underwent a subsequent operation demonstrated that the right-to-left ventricular peak systolic pressure ratio was estimated between 0.4 and 0.5. The pulmonary tract at the anastomosis grew in a range between 107% and 166% of the normal pulmonary valve ring diameter, and the pressure gradient at anastomoses was less than 10 mm Hg 7 months to 3.8 years after the operation (see Table 4). Mild to moderate pulmonary regurgitation was detected in all patients (see Table 2). The degree of regurgitation in the untreated truncal valve remained unchanged over the follow-up period. Follow-up periods of these 5 patients are 7 months to 3.8 years after operation, and the patients have remained free of symptoms and have normal activity levels.
|
Comment
|
|---|
Relief from progressive pulmonary vascular disease and congestive heart failure is essential, and definitive neonatal repair is now recommended for patients with truncus arteriosus [1–6]. Conduit repair in this subset is widely accepted as a conventional standard method, and it is a significant improvement over the palliative method. These results encouraged us to continue neonatal repair, and further development of surgical methods that follow for the growth of the pulmonary tract is the challenge. There is a high incidence of subsequent operation because of pulmonary tract narrowing when a conduit, homograft, or allograft is used [1–6, 14]. A surgical procedure that is acceptable for neonatal repair with the potential to grow with the pulmonary tract and reduce the reoperation rate is needed.
We used the anterior truncal wall to create the pulmonary tract, leaving the posterior wall of the truncal root intact to maintain the continuity of the pulmonary artery as much as possible [9]. The size of the pulmonary anastomosis grew during the follow-up period, although the size at operation was smaller than that of the conduits often used [1, 2, 5, 14–16]. In addition, this method has the advantage of being free from compression because the pulmonary tract is placed posterolateral to the systemic root even in the small chest cavity [9]. In the patient with interrupted aortic arch and small ascending aorta, we developed the technique by trimming the anterolateral and posterior truncal wall that was apparently dominant in the direction of the ductus as in patient 4 [12]. Separation of the pulmonary artery from the truncus that involves both the right and left pulmonary orifices is relatively more complicated in type II than in type I. However, in the technique using an anterior truncal wall as well as type I truncus, septation of the truncal root is essential and feasible. The size of the septation patch and suture line carries the potential risk of producing a pressure gradient in the small ascending aorta due to the angle of the patch, particularly in a patient with interrupted aortic arch. We performed interposition of the left atrial appendage between the flap and the right ventricle in 1 patient. However, the fate of the interposed atrial appendage for the pulmonary tract is uncertain and there is a potential risk of compressing the left coronary trunk.
Causes of death in our series were not related either to the size of truncal arterial flap or to the surgical method itself. The hinge of the truncal atrial flap was a sufficient distance from the coronary orifices in the patient with normal coronary anatomy, and the cause of death in patient 5 was not due to kinking or obstruction of the coronary artery but rather to myocardial dysfunction that occurred because of a mechanical problem with cardiopulmonary bypass.
The coronary artery anatomy may limit the creation of a truncal arterial flap and placement of the septation patch if it is a high take-off. Patients with anomalous origin of the coronary artery from the pulmonary artery or nonconfluent pulmonary artery are not candidates for this approach. Truncal valve deformity may not increase after a septation patch is placed at the sinus of Valsalva. Interrupted aortic arch is considered to be a surgical risk factor when the patient requires neonatal urgent operation. Careful placement of the septation patch is required to prevent ascending aortic narrowing. Anatomic limitations in applying the autologous anterior truncal flap method were also noted in type III truncus arteriosus. Each pulmonary artery arises from the lateral aspect of the truncal wall and could not be separated from the truncus by patch partition as in type II. Therefore, we developed a method of preventing distortion of the pulmonary orifices and used anterior translocation of the transected cylinder, which incorporated the pulmonary bifurcation as in the Lecompte maneuver 17–19]. Anterior translocation of the pulmonary branches has been thought to be potentially responsible for pulmonary branch stenosis. However, there has not been any significant pulmonary stenosis in this patient to date.
Extensive dissection and adequate mobilization of the pulmonary branches are essential for these techniques to avoid excessive stretching and twisting of the pulmonary arteries. Furthermore, smooth augmentation of the outflow patch was also required to avoid turbulence in the pulmonary blood flow, which has the potential hazard of narrowing the pulmonary tract. We encountered left pulmonary branch stenosis due to pseudointimal tissue overgrowth at the monocusp leaflet. This phenomenon seemed to be related to adherence and turbulence due to a remnant of the large monocusp patch placed in the short pulmonary tract to obtain adequate diastolic coaptation. The only advantage to using a monocusp mounted on a patch is that pulmonary regurgitation is prevented for a short time, especially in the presence of increased pulmonary vascular resistance [20].
Pulmonary hypertensive crisis had occurred in the oldest patient in this series. Two patients in this series were more than 2 months of age at the time of operation because of late referral and delayed consent for operation. Hanley and associates [2] proposed neonatal repair to reduce the prevalence of surgical risks due to the pulmonary vascular morbidity. As a result, pulmonary hypertensive episodes were fewer in patients who underwent operation before 30 days of age.
Although our series is small, the results suggested that there were no significant clinical differences throughout the postoperative period between patients with and without a monocusp-mounted outflow patch. However, mild right ventricular pressure elevation remained and pulmonary regurgitation should be carefully observed compared with that of the tetralogy of Fallot, such as low pulmonary vascular resistance. In our series, the pulmonary tract has developed well in correspondence to patient age after operation, and these results indicate the validity of these surgical approaches. Nevertheless, regarding the growth of the pulmonary tract, a longer follow-up period is needed before drawing conclusions. We should carefully follow up including right ventricular function of the nonvalved repair of truncus arteriosus.
|
Footnotes
|
|---|
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.
|
References
|
|---|
- Bove EL, Lupinetti FM, Pridjian AK, et al. Results of a policy of primary repair of truncus arteriosus in neonate. J Thorac Cardiovasc Surg 1993;105:1057–66.[Abstract]
- Hanley FL, Heinemann MK, Jonas RA, et al. Repair of truncus arteriosus in the neonate. J Thorac Cardiovasc Surg 1993;105:1047–56.[Abstract]
- Sharma AK, Brawn WJ, Mee RBB. Truncus arteriosus. surgical approach. J Thorac Cardiovasc Surg 1985;90:45–9.[Abstract]
- 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]
- Ebert PA, Turley K, Stanger P, Hoffman JIE, Hynmann MA, Rudolph AM. Surgical treatment of truncus arteriosus in the first six months of life. Ann Surg 1984;200:451–6.[Medline]
- Sano S, Brawn WJ, Mee RBB. Repair of truncus arteriosus and interrupted aortic arch. J Cardiac Surg 1990;5:157–62.[Medline]
- McGoon DC, Rastelli GC, Ongley PA. An operation for the correction of truncus arteriosus. JAMA 1968;205:69–73.[Abstract/Free Full Text]
- Pearl JM, Laks H, Drinkwater DC Jr, et al. Repair of truncus arteriosus in infancy. Ann Thorac Surg 1991;52:780–6.[Abstract]
- Barbero-Marcial M, Riso A, Atik E, Jatene A. A technique for correction of truncus type I and II without extracardiac conduit. J Thorac Cardiovasc Surg 1990;99:364–9.[Abstract]
- Collet RW, Edwards JE. Persistent truncus arteriosus. A classification according to anatomic types. Surg Clin North Am 1949;29:1245–70.[Medline]
- Celoria GC, Patton RB. Congenital absence of the aortic arch. Am Heart J 1959;58:407–13.[Medline]
- Nakae S, Kawada M, Shingo K, Lin ZB, Hiraishi S, Yoshimura H. Truncus areteriosus with interrupted aortic arch: a successful correction using autologous flap. Ann Thorac Surg 1995;60:697–8.
- Rawllat UF, Rimoldi HJA, Lev M. The quantitative anatomy of the normal child's heart. Pediatr Clin North Am 1963;10:499–587.
- Kirklin JW, Blackstone EH, Maehara T, et al. Intermediate-term fate of cryopreserved allograft and xenograft valved conduits. Ann Thorac Surg 1987;44:598–606.[Abstract]
- Jonas RA, Freed MD, Mayer JE Jr, Castañeda AR. Long term follow up of patients with synthetic right heart conduits. Am J Cardiol 1985;72(Suppl 2):77–83.
- Albert JD, Bishop DA, Fullerton DA, Campbell DN, Clarke DR. Conduit reconstruction of the right ventricular outflow tract: lessons learned in a twelve-year experience. J Thorac Cardiovasc Surg 1993;106:228–36.[Abstract]
- Viet TT, Bical O, Leca F, Neveux JY. Reconstruction plastique de la voie pulmonaire dans le truncus areteriosus communis. Presse Med 1984;28:13–8.
- 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 AK, Pilato M, Otto DA. Surgical repair of type II truncus arteriosus without a conduit. Ann Thorac Surg 1990;50:479–81.[Abstract]
- Peetz DJ, Spicer RL, Crowley DC, Sloan H, Behrendt DM. Correction of truncus arteriosus in the neonate using a nonvalved conduit. J Thorac Cardiovasc Surg 1982;83:743–6.[Abstract]
Related Article
-
Invited Commentary
- Frank L. Hanley
Ann. Thorac. Surg. 1996 62: 129.
[Extract]
[Full Text]
This article has been cited by other articles:
|
|
|
|
 
C. S. Park, W.-K. Jhang, J.-K. Ko, Y.-H. Kim, and T.-J. Yun
Lecompte operation: Is it still a viable option for truncus arteriosus?
J. Thorac. Cardiovasc. Surg.,
November 1, 2008;
136(5):
1384 - 1386.e2.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
