Ann Thorac Surg 1997;64:228-230
© 1997 The Society of Thoracic Surgeons
Case Report
Atrially Based Pericardial Tunnel for Central Pulmonary Artery Construction
Richard A. Perryman, MD,
Robert D. B. Jaquiss, MD
Division of Cardiothoracic Surgery, University of Miami School of Medicine, Miami, Florida
Accepted for publication January 28, 1997.
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Abstract
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Discontinuity of central intrapericardial pulmonary arteries requires reconstruction of a pulmonary artery confluence before cavopulmonary connection, whether this connection be by bidirectional Glenn or Fontan procedure. Reconstruction of the central pulmonary arteries has previously been described using material of poor or no growth potential. A method is described for central pulmonary artery reconstruction that provides growth potential and is based on previous experience with Fontan lateral tunnel construction.
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Introduction
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The patient presented neonatally as one of triplets (2.5 kg) and presented echocardiographically with double-inlet single ventricle, nonconfluent pulmonary arteries, and pulmonary atresia. The neonate was maintained on a regimen of prostaglandin and, at 4 days of age, a right modified Blalock-Taussig shunt was performed using 4-mm polytetrafluoroethylene graft. Two days later, a left modified Blalock-Taussig shunt was similarly performed and the child was discharged after an uneventful postoperative course.
At 7 months of age, the child underwent his first cardiac catheterization with angiography to evaluate the pulmonary artery anatomy. Pulmonary artery angiograms obtained at that time are shown in Figure 1
. Discontinuous pulmonary arteries were supplied by their respective shunts with significant narrowing of the right shunt. Shortly after catheterization, the child was taken to the operating room. Through a median sternotomy, both pulmonary arteries were dissected to their respective lung hilae and shunts controlled. The child was then placed on cardiopulmonary bypass with moderate hypothermia. After ligation and excision of each of the shunts, the pulmonary arteries were transected at their maximum diameter. Each pulmonary artery was then connected to the roof of the left and right atria, respectively, over approximately one third of the inferior circumference of each pulmonary artery (Fig 2A). The confluent tunnel was then completed using autogenous fresh pericardium as depicted (Fig 2B). After completion of this tunnel, approximately one third of the circumference was made from atrial wall and two thirds from pericardium. The transected superior vena cava was then anastomosed to the roof of the tunnel as a standard bidirectional Glenn shunt (Figs 2C, 2D). The child's postoperative course was unremarkable.
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Fig 1. . (A) Right and (B) left pulmonary arteriograms of patient at age 7 months shows stenosis of right Blalock-Taussig shunt.
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Fig 2. . Surgical technique. (A) Transected distal pulmonary artery sutured to atrial "roof." (B) Pericardial tunnel partially constructed. (C) Completed pulmonary artery construction with bidirectional Glenn shunt completed. (D) Cross-section of construction showing atrial "floor."
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The child returned for pre-Fontan evaluation at age 18 months. An angiogram performed during that catheterization is shown in Figure 3. Mean pulmonary artery pressure was measured at 7 mm Hg. Shortly after this catheterization, the child was returned to the operating room and through a median sternotomy and on cardiopulmonary bypass, an inferior vena cava-to-right pulmonary artery connection was simply established. The right atrium was opened and the reconstructed pulmonary artery confluence accessed through the roof of the right atrium. A polytetrafluoroethylene lateral tunnel was then constructed from the inferior vena cava to this opening in the roof of the right atrium. The connection was fenestrated. The child recovered uneventfully and, after mild right pleural effusions, was discharged on the eighth postoperative day. The child has subsequently had an uncomplicated course and is doing well.
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Comment
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Restoration of intrapericardial pulmonary artery confluence should ideally be established by a technique that allows continued growth, particularly if performed in an infant or young child. Although initial reanastomosis in the neonate provides such an opportunity [1], many children present having had palliative shunts, and the mobilization required for direct reanastomosis is not readily attainable. A variety of conduits have been described to recreate continuity between discontinuous pulmonary arteries. These include autologous pericardium, equine or bovine heterogenous pericardium used as tube grafts, homograft aorta or pulmonary artery, and Dacron or polytetrafluoroethylene tube grafts [2–6]. Those conduits have no growth potential. Pedicled autogenous pericardial tubes have been described as having growth potential but are technically difficult to place in the transverse sinus [7].
Using experience established in the use of lateral tunnel cavopulmonary connection, where growth is preserved by using a portion of the atrial wall in the tube circumference, we reasoned a similar tunnel could be constructed in the superior mediastinum. The common atrial roof across the transverse sinus provides a convenient "floor" for the construction of a bridging tunnel between discontinuous pulmonary arteries. Growth potential is preserved by using a portion of atrial wall. Additionally, the completion Fontan operation is simplified by creating a connection through the atrial roof into the confluent tunnel allowing easy access for cavopulmonary connection. Although the atrial flap technique described for atriopulmonary Fontan operation does have similar growth potential [8], it is not readily applicable for cavopulmonary connection in those cases requiring staged progression to the Fontan procedure.
In summary, a technique is described for restoring intrapericardial pulmonary artery continuity in infants and children that allows conduit growth and is applicable to all stages of creation of cavopulmonary circulation.
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Footnotes
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Address reprint requests to Dr Perryman, Division of Thoracic and Cardiovascular Surgery, University of Miami School of Medicine, PO Box 016960 (R-114), Miami, FL 33101.
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References
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- Yasuharu I, Yoshinori T, Shuuichi H, Seisuke N. The equine pericardial valved conduit and current strategies for pulmonary reconstruction. Semin Thorac Cardiovasc Surg 1995;7:157–61.[Medline]
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Abstract
Introduction
