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Ann Thorac Surg 1998;65:829-831
© 1998 The Society of Thoracic Surgeons
Second Department of Surgery, Nihon University, Tokyo, Japan
Department of Pediatrics, Nihon University, Tokyo, Japan
Accepted for publication September 29, 1997.
Dr Hata, The Second Department of Surgery, Nihon University School of Medicine, 30-1, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173, Japan.
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Abstract |
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Introduction |
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A 12-day-old boy (3,159 g) was referred to Nihon University Itabashi Hospital because of hemodynamic and metabolic deterioration. He was intubated immediately and his condition was diagnosed as IAA type A, intact ventricular septum, and APW.
One-stage repair was then performed through a median sternotomy. The ascending aorta was 7.7 mm and the pulmonary trunk was 6.0 mm in diameter. Aortopulmonary window formed a large aortic sac measuring 6.0 mm in diameter. Fig 1 shows an 8F arterial cannula placed distally in the ascending aorta to confirm aortic clamping between the arterial cannula and the aortopulmonary window, and connected in a Y fashion to the other 8F arterial cannula. Bicaval 14F venous return lines were introduced and bypass was instituted. Both the pulmonary arteries were dissected and occluded with rubber tapes to prevent pulmonary flooding. While the patient was being cooled to a rectal temperature of 24°C, with a pump flow rate of 130 to 110 ml · kg-1 · min-1, the ductus and the descending aorta were dissected free down to the second intercostal branches without division. While the heart was beating, lower body perfusion through the ductus arteriosus was satisfactory. The aortic sac was successfully encircled and clamped at a rectal temperature of 26°C to prevent dilatation of the right ventricle. The ascending aorta was cross-clamped between the arterial cannula and the aortopulmonary window. Cold crystalloid cardioplegic solution was infused into the aortic root. The clamp on the aortic sac was removed and the sac was opened longitudinally. The large aortopulmonary septal defect involved the entire length of the pulmonary trunk. This was separated from the right pulmonary artery. A polytetrafluoroethylene patch was sewn into the window using a 5-0 polypropylene continuous suture, the so-called anterior sandwich patch closure technique [3][4]. After declamping of the aorta, another arterial cannula was inserted into the mid-ascending aorta, and then the first arterial cannula was removed. The ductus was divided and oversewn on its pulmonary artery end with a 6-0 polypropylene suture. All ductal tissue was excised on the aortic side down to the healthy aorta. When the rectal temperature reached 24°C, the aortic arch was clamped between the innominate and left carotid arteries and the flow rate was decreased to 65 ml · kg-1 · min-1. An incision was made on the underside of the aortic arch and extended onto the left subclavian artery and then the distal aorta was anastomosed directly using continuous 6-0 polydioxanone suture on the posterior wall and interrupted 6-0 polydioxanone suture on the anterior wall.
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Circulatory Maintenance
One-stage repair of IAA and APW through a median sternotomy is usually performed under circulatory arrest [1]. Although a great advantage of hypothermic circulatory arrest is the absence of perfusion cannulas and blood in the surgical field, strategies consisting predominantly of circulatory arrest are associated with greater central nervous system perturbation in infants [5]. Therefore, to prevent organ damage, particularly to the brain, circulatory arrest time should be shortened by every possible method [2]. In this case, circulatory arrest was avoided by continuously perfusing the innominate artery.
Establishing Cardiopulmonary Bypass
Establishing bypass by single arterial cannulation of the ascending aorta or by an additional separate perfusion line to the descending aorta was reported previously [1][2]. These methods provide excellent exposure of the arch anastomosis, but neither procedure avoids cerebral circulatory arrest during direct anastomosis. Ingram and Ott [6] reported successful primary repair using the subclavian turn-down technique without circulatory arrest in a neonate with IAA type A and APW. They indicated that if direct anastomosis is preferable, circulatory arrest will be required and APW closure should be best performed after the completion of arch repair. This means that the cardiac ischemic time involves the duration of both arch repair and APW closure. In this case, the APW was repaired first, with use of continuous hypothermic cardiopulmonary bypass, aortic cross-clamping, and cardioplegic myocardial arrest (21 minutes). The aortic arch interruption was repaired second without circulatory arrest, with use of continuous hypothermic perfusion of the heart and innominate artery with repositioning of the aortic cannula from the distal to mid-ascending aorta and placement of a clamp across the proximal aortic arch. The cardiac ischemic time was shortened by perfusing the heart during aortic arch repair. Fifty-eight minutes of lower body ischemic time from clamping of the APW until declamping of the aortic arch may be allowed because lower body organs are more tolerant of ischemia than the brain.
Surgical Technique
The defect was closed as reported by Johansson and associates [3] with a polytetrafluoroethylene patch, which has several advantages: the procedure can be performed more quickly and allows better visualization of the inner structure [3][4]. Regarding aortic arch reconstruction, repositioning of the arterial cannula allowed adequate mobilization and exposure for the completion of direct anastomosis. If the ascending aorta is too small to allow cannulation and clamp placement as in other complex IAAs, this approach is not suitable because of the high risk of damaging the ascending aorta at the cannulation site [2]. However, IAA type A, which occurs more commonly in this combination [7], involves usually a large ascending aorta. This technique offers great advantages in shortening cardiac ischemic time without circulatory arrest, especially in a patient with type A IAA and type II APW.
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