Ann Thorac Surg 1996;62:1843-1845
© 1996 The Society of Thoracic Surgeons
Case Report
Repair of Aortopulmonary Window in an Infant With Extremely Low Birth Weight
Hiroaki Kawata, MD,
Hidefumi Kishimoto, MD,
Takayoshi Ueno, MD,
Tohru Nakajima, MD,
Noboru Inamura, MD,
Takeshi Nakada, MD
Departments of Cardiovascular Surgery and Pediatric Cardiology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
Accepted for publication June 14, 1996.
 |
Abstract
|
|---|
Although transaortic patch repair under cardiopulmonary bypass is a suitable procedure for aortopulmonary window, another method without cardiopulmonary bypass may be the only one for an infant with extremely low birth weight. We describe a successful repair of an infant with extremely low birth weight (758 g) by closing the window with a clip through a left thoracotomy. Cardiac catheterization 7 months after the operation showed no residual shunt and no stenosis of ascending aorta, pulmonary artery, or coronary arteries in the patient, whom we believe to be one of the smallest with successful repair.
|
Introduction
|
|---|
Aortopulmonary window is hemodynamically similar to large patent ductus arteriosus (PDA) or persistent truncus arteriosus. It may require surgical repair as an emergency in the first week of life. The incidence is much less than that of PDA (0.2% of clinical cases [1]). We closed the window of an infant with extremely low birth weight (birth weight 
1,000 g) by using a surgical clip through a left thoracotomy without cardiopulmonary bypass (CPB).
A 758-g female infant was born by cesarean section for bradycardia at a gestational age of 30 weeks 5 days. She was intubated 2 minutes after birth for apnea. When a systolic heart murmur was noted 24 hours later, cardiomegaly (cardiothoracic ratio = 61%) was also noted on chest roentgenography. Congestive heart failure was detected. Retrograde diastolic flow in the abdominal aorta by ultrasonic echocardiography suggested left-to-right shunt at great vessel level. However, ultrasonic echocardiography did not show PDA or any defect in the wall between the ascending aorta and the pulmonary trunk. The counter-current aortogram through the right radial artery demonstrated a right aortic arch, and the contrast medium appeared to enter the pulmonary trunk through a vessel from the origin of the innominate artery. We diagnosed left PDA originating from the left innominate artery with right aortic arch. No other associated cardiac defect was detected by ultrasonic echocardiography. A harsh grade 4 systolic murmur was detected at the third left intercostal space. Although systemic blood pressure was kept around 60/25 mm Hg with infusion of dopamine and dobutamine (5 µg•kg-1•min-1 each), urinary output decreased. An attempt to close a suspected PDA with indomethacin failed.
She underwent the surgical closure at 5 days of life. The body weight was 678 g. Left posterolateral thoracotomy was performed through the fourth intercostal space. The left pulmonary artery and a persistent left superior caval vein were identified. There was no PDA. After the pericardium was opened, the ascending aorta and bilateral pulmonary arteries were identified. The pulmonary trunk appeared to be originating from the ventricle and combining with the aorta, like in persistent truncus arteriosus. However, careful dissection between the ascending aorta and the pulmonary trunk just above the sinus of Valsalva exposed the large aortopulmonary window. The diameter of the orifice was about 8 mm. The coronary artery was not detected accurately. The window was closed with a medium-large (9 mm) titanium Hemoclip (Edward Weck Inc, NC). Her postoperative course was uneventful. Cardiac catheterization 7 months after the operation showed no residual shunt and no stenosis of ascending aorta, pulmonary artery, or coronary arteries (Fig 1
).
View larger version (91K):
[in this window]
[in a new window]
|
Fig 1. . Pulmonary arteriogram (A) and left ventriculogram (B) 7 months after the operation. There was no residual shunt and no stenosis of ascending aorta, pulmonary artery, or coronary arteries.
|
|
|
Comment
|
|---|
Although surgical repair for aortopulmonary window seems to have been established as a technique using CPB [2,3], the other approach without CPB may be useful for particular patients such as a very young infant [4] or a patient mistakenly diagnosed as having PDA [5]. Even though an early reparative cardiac operation with CPB has been undertaken for neonates recently, the lowest weight at successful repair was 1.24 kg [6]. For a patient with extremely low birth weight, the window closure without CPB may be the procedure of choice using a surgical clip. Successful closure without CPB depends on the anatomic localization of the window and the size. Doty and associates [7] described that the ligation method was possible for a window with a diameter of less than 1.2 cm when the window was a typical one connecting the ascending aorta and pulmonary trunk. However, in a patient with extremely low birth weight, like our patient, the window was large relative to the size and lengths of the ascending aorta and pulmonary artery trunk. The surgical clip appeared to us to be a more appropriate solution than ligation, in that the large aortopulmonary window would be compressed only from front to back and not circumferentially as in ligation. There were no complications and closure has remained complete, without the coronary artery or great vessel distortion reported with window ligation [7, 8]. Our patient seems to be one of the smallest infants who has undergone a successful surgical repair.
|
Footnotes
|
|---|
Address reprint requests to Dr Kawata, Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi City, Osaka 590-02, Japan.
|
References
|
|---|
- Kutsche LM, Van Mierop LHS. Anatomy and pathogenesis of aorticopulmonary septal defect. Am J Cardiol 1987;59:443–7.[Medline]
- Clarke CP, Richardson JP. The management of aortopulmonary window: advantages of transaortic closure with a Dacron patch. J Thorac Cardiovasc Surg1976;72:48–51.[Abstract]
- Kirklin JW. Aortopulmonary window. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. 2nd ed. New York: Churchill Livingstone, 1993:1153–l7.
- Schmid F-X, Hake U, Iversen S, Schranz D, Oelert H. Surgical closure of aorto-pulmonary window without cardiopulmonary bypass. Pediatr Cardiol 1989;10:166–9.[Medline]
- Berry BE, Jayasinghe M. Repair of aortopulmonary window at left thoracotomy for patent ductus arteriosus. Chest 1983;83:581–2.[Abstract/Free Full Text]
- Pawade A, Waterson K, Laussen P, Karl TR, Mee RBB. Cardiopulmonary bypass in neonates weighing less than 2.5 kg: analysis of the risk factors for early and late mortality. J Card Surg 1993;8:1–8.[Medline]
- Doty DB, Richardson JV, Falkovsky GE, Gordonova MI, Burakovsky VI. Aortopulmonary septal defect: hemodynamics, angiography, and operation. Ann Thorac Surg 1981;32:244–50.[Abstract]
- Doty DB. Safe closure of aortopulmonary window. Chest 1983;83:443–4.[Free Full Text]
Top
Abstract
Introduction
