Ann Thorac Surg 2000;69:1887-1892
© 2000 The Society of Thoracic Surgeons
Original articles: Cardiovascular
Modified arterial switch operation by spiral reconstruction of the great arteries in transposition
Ing-Sh Chiu, MD, PhDa,
Shye-Jao Wu, MDa,
Ming-Ren Chen, MDa,
Meng-Luen Lee, MDa,
Mei-Hwan Wu, MD, PhDa,
Jou-Kou Wang, MD, PhDa,
Hung-Chi Lue, MDa
a Departments of Surgery and Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
Address reprint requests to Dr Chiu, Department of Surgery, National Taiwan University Hospital, No. 7 Chung-Shan S. Rd, Taipei 100, Taiwan
e-mail: ingsh{at}ha.mc.ntu.edu.tw
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Abstract
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Background. Spiral relationship of the normally related great arteries (SRGA) has never been reconstructed in an arterial switch operation.
Methods. From March 1998 to April 1999, 9 consecutive cases of transposition of the great arteries (TGA) family (from 2 days to 1.6 years old) underwent arterial switch operations with SRGA at our hospital. Two had a congenitally corrected TGA (plus atrial redirection). Lecompte maneuver was not used in all. The posterior wall of pulmonary trunk was not divided but three were reattached, two of whom had had previous pulmonary trunk banding. Thus the wall was shared between the great arteries facing each other.
Results. All survived the operation. Supraaortic stenosis was balloon-dilated in 2 cases of early series, but technical modifications later were able to avoid it. Angiogram showed smooth flow into SRGA without upward and anterior tilting of the pulmonary bifurcation. All great and coronary arteries were patent. All were doing well on follow-up (16.5 ± 4.2 months).
Conclusions. We concluded that the techniques to relocate the coronary arteries using common wall and in situ switch could also be applied to pulmonary arterial reconstruction, so that SRGA can be resumed in TGA.
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Introduction
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That the normal spiral relationship of the great arteries did not exist in transposition of the great arteries (TGA) has not been well appreciated, and has thus never been reconstructed in arterial switch operations (ASO). In the present era, suprapulmonary stenosis remains one of the most worrisome problems after ASO [1, 2]. Even in the most capable hands, the late occurrence of coronary arterial obstruction has been as high as 3% to 7.8% [3, 4]. Here, a technique is reported which can avoid coronary kinking, and also provide spiral reconstruction of the great arteries, although outflow stenosis was noted in the early experiences.
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Patients and methods
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From March 1998 to April 1999, 9 consecutive cases of TGA family underwent ASO with the following technique at National Taiwan University Hospital. Their ages ranged from 2 days to 1.6 years (mean ± SD; neonate: 7.5 ± 11.3 days; child: 1.5 ± 0.2 years); there were 4 females and 5 males. Demography for these 9 cases is listed in Table 1. Among them, 6 had simple TGA, one had TGA with a ventricular septal defect (Case 5) and two had congenitally corrected TGA (Cases 2 and 9). Both children underwent pulmonary trunk (PT) banding previously. All had situs solitus except Case 9 who had situs inversus and apicocaval juxtaposition. Coronary artery patterns are shown in Figure 1 and Table 1 following a modified nomenclature of Shaher and Puddu [5, 6]. Five of them had juxtacommissural origin of coronary arteries (JOCA). Case 6 had left-sided juxtaposed atrial appendages.
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Fig 1. Types of coronary arteries in 9 patients, 5 of them had juxtacommissural origin of the coronary arteries. (j, j', j'' = juxtafacing commissure; jn, j'n = juxta-nonfacing commissure. See Chiu and associates [6, 11] for details.)
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Surgical techniques
All neonatal operations were done with a single venous cannula (USCI, straight type) in the right atrium, at 22°C nasopharygeal temperature with multiple doses of blood cardioplegia [7]. A period of total circulatory arrest at 16°C was used to repair, through the right atrium, the atrial septal defect and the ventricular septal defect as well, when present. Bicaval cannulation was used in 2 children (Cases 2 and 9) without circulatory arrest. Both were debanded. Senning was performed before ASO in Case 2, and Mustard in Case 9 because of apicocaval juxtaposition. Phenoxybenzamine was used in all cases. The coronary transfer sites were marked on the PT. Then the arterial duct was ligated without division. The PT and its branches were dissected. Bilateral hilar dissection was not as distal as those that adopted a Lecompte maneuver, which was not used in all cases. The dissection around both pulmonary arteries was not performed at all in the last 2 cases.
Figure 2 illustrates the cases with the original aorta left anterior (Cases 2, 4, and 5), directly anterior (Case 1), or slightly right anterior (Cases 7 and 8) to the PT. The end of cutback on the right pulmonary artery (arrow in Fig 2F) and its opposite point at the posterior part of the aorta were decided and marked before the cardiopulmonary bypass, except in Cases 1 and 2. The aorta was transected after cross-clamping about 1 cm distal to the coronary artery. The aortopulmonary junction was further dissected. Then the nonfacing aortic sinus wall was cut open down to its annulus to facilitate exposure (Fig 2A). A J-shaped incision was made on each facing sinus down to the margin of the coronary artery orifice to develop a semi-flap (Fig 2A). Then the half circumference of PT that faced the aorta was incised transversely proximal to its branching site and distal to the coronary artery marking suture. The anterior wall of the distal PT was cut back along the right anterior border toward the right pulmonary artery and along the dashed line (Fig 2A). Another two J-shaped incisions were made in the proximal PT with the curve towards the cut end of the coronary semi-flap (Fig 2A). Starting from the end of the incision, the cut end of each J-incision on the aorta and PT facing each other were sutured together with 7-0 prolene double arms and ligated (Fig 2B). Using one arm and keeping the medial edge of the pulmonary semi-flap in between the aortic incision, the lateral edge of aortic semi-flap was sutured to the lateral edge of the PT incision (depicted by X-stitches in Fig 2B,C). With the other arm of 7-0 prolene, the medial edge of the pulmonary semi-flap was sutured to the annulus of aortic sinus 1 (depicted by l-stitches in Fig 2B) around and away from the coronary ostium to act as a common wall between the aortic and pulmonary pathways [8]. Using the same arm, the cephalic edge of pulmonary semi-flap was sutured to the inner wall of sinus 1 to cover the coronary orifice (depicted by heavy l-stitches in Fig 2C), or to the cephalic edge of sinus 1 [9] with a higher take-off of coronary artery, thus redirecting the blood from the PT into the almost in situ coronary artery [10]. The same maneuver was done again for the coronary artery in sinus 2, except for the coronary orifice-covering suture. For those with a left anterior neoPT in the future (Fig 2), this covering suture was not performed in sinus 2 (left-handed sinus for right coronary artery) (Fig 2C), so that the neoaortic orifice could take a more right anterior location (Fig 2D) to give way to the right pulmonary artery behind the aorta.
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Fig 2. Techniques of modified arterial switch operation with the neopulmonary trunk in a left anterior portion (Cases 4, 5, 7, and 8). The semilunar valves were all omitted for clear illustration. (A) The aorta was amputated. The posterior wall of the pulmonary trunk (PT) was not divided. Four J-shaped incisions were made on facing part of the great arteries. The anterior wall of the PT will be cutback along the dashed line to augment the pulmonary pathway. The nonfacing aortic sinus was incised to facilitate exposure. (B) The lateral edges of two J-shaped incisions facing each other were sutured together (depicted by X-stitches) to form the aortopulmonary window. Then, the semi-flap of the PT was placed into the opposite aortic sinus and sutured (depicted by l-stitches) in such a way that it acted as the posterior wall of neoPT and as the anterior wall of the neoaorta. The suture for the other two semi-flaps in sinus 2 was not yet finished. (C) The cephalic edge of the pulmonary semi-flap was sutured to the inner wall of sinus 1 (depicted by heavy l-stitches) cephalic to the coronary orifice to cover it. The distal aorta was sutured to the posterior wall of the PT along the light dashed line. (D) The neoaortic anastomosis was finished. The flap of the facing commissure in the old aorta was fixed to the anterior wall of the PT (depicted by Y-stitches). The anterior lip of the cutback PT was everted to the left, and attached to the cephalic cut edge of the aortic sinus 1 (depicted by X-stitches) to form the floor of the pulmonary pathway. The cut edge of PT was attached to the posterior aorta. (E) The cut edges of right pulmonary artery were attached to the posterior outer wall of the aorta along the dotted line to enlarge the orifice. Cutback on the left pulmonary artery was done as needed. (F) Finally, the anterior defect of the pulmonary pathway was patched with an untanned pericardium.
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The distal aorta was anastomosed to the posterior inner wall of PT above the commissure (light dashed line in Fig 2C) with 7-0 maxon (polyconate, Cyanamid Ltd, Hampshire, UK), and then the rest of the distal aorta was sutured to the orifice of the neoaortic root anteriorly (Fig 2D). The blood cardioplegic solution was then infused through the original cardioplegic needle to confirm the coronary arterial filling and check the bleeder. The posterior wall of PT or aortic anastomosis had to be dry at this stage with no drip of blood cardioplegia. The flap of the facing commissure in the aorta was attached to the anterior wall of the proximal PT by interrupted stitches with 7-0 prolene (depicted by Y-stitches in Fig 2D,E). Then, the aortic cross-clamp was released; the myocardial color, coronary arterial filling, and no arterial bleeder were secured again. The anterior lip of the PT was everted to the left (Fig 2B,C), then its caudal edge was attached to the PT and cephalic edge of the aortic sinus 1 (depicted by X-stitches in Fig 2D,E) to act as the floor for the pulmonary pathway. The neoaortic adventitia inside the pulmonary pathway was cleaned at this stage. With the heart beating, the edge of cutback on the PT and right pulmonary artery was sutured to the posterior aorta using double arm 7-0 maxon (Fig 2D,E). In this way, the posterior wall of the aorta augmented the orifice of right pulmonary artery. Cutback on the left pulmonary artery was done if necessary. After a strong heartbeat was resumed, the patient was cooled further to 16°C. The aorta was cross-clamped again and septal defects, if present, were closed. During rewarming, a fresh pericardium was used to repair the anterior defect of the neopulmonary pathway down to the cutback nonfacing aortic sinus. In Case 2, the PT was amputated at the previous banding site and reattached, otherwise similar to Figure 2. In Case 1 with JOCA near the facing commissure (Fig 1), a superior trapdoor [11] was used to reconstruct the coronary artery after unroofing the intramural part [9] without tailoring a J-shaped semi-flap. The posterior part of the PT was not divided as in Figure 1, but the left lateral part of the neoaortic orifice was covered with a free flap of PT as the ceiling of the neoaorta to match the size of the smaller ascending aorta.
Figure 3 depicts the cases with a right anterior aorta of more than 30° (Cases 3, 6, and 9). The end of cutback on the left pulmonary artery (arrow in Fig 3F) and its opposite point at the posterior part of the aorta were decided, and marked before the cardiopulmonary bypass, except Case 3. The PT was cut back along the left anterior portion toward the left pulmonary artery and along the dashed line (Fig 3A). The cephalic edge of pulmonary semi-flap was run to cover the coronary orifice in sinus 2, but not in sinus 1 (Fig 3C). So that this semi-flap acted as the floor of the pulmonary pathway (Fig 3D), and the neoaortic orifice took a more left anterior location. The anterior lip of the PT was everted to the right and attached to the cephalic edge of aortic sinus 2 (depicted by X-stitches in Fig 3D,E). The PT was amputated in Cases 3 and 9, and then the distal aorta was anastomosed to the neoaortic stump as usual ASO after coronary rerouting by swinging the semi-flaps as shown in Figure 3. The caudal edges of cut open PT (Fig 3D) and left pulmonary artery (Fig 3E) in these 2 cases were attached proximal to or just on the posterior neoaortic suture line, that was thus included in the neopulmonary pathway.
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Fig 3. Techniques of modified arterial switch operation with the neopulmonary trunk in a right anterior portion (Case 6). The semilunar valves were all omitted for clear illustration. The main differences from Figure 2 are described below. The PT was divided right anteriorly, then along the left anterior portion (A); cut back along the dashed line (B); everted to the right (C); attached to the cephalic cut edge of aortic sinus 2 (D); to its wall, the cephalic edge of the pulmonary semi-flap was sutured to cover the coronary orifice (C), in this way to form the floor of the pulmonary pathway (E). The cutback left pulmonary artery was attached to the posterior wall of the aorta (D,E). Finally, its roof was patched (F).
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Two chest tubes, two pericardial drains, one peritoneal dialysis catheter, and two temporary pacing wires were inserted. With the vigorous heartbeat and bloodless pericardial cavity, the sternum was kept open by a 2.5 cc syringe [12], the wound was sutured with silicone sheeting (Perthese, LP500-3, LPI, Bornel, France) and then draped with a antimicrobial film (Ioban, 3M Company, St. Paul, MN). The sternum was closed in the operating theatre on Case 9, the rest in the intensive care unit 3 to 6 (mean 4.6) days later after a remarkable diuretic stage.
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Results
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The mean cross-clamp duration was 115 ± 18 minutes, and perfusion time was 288 ± 52 minutes. All patients were weaned from bypass smoothly with minimal inotropic support. Peritoneal dialysis was not required absolutely in all cases but, in 4 cases, it was used transiently to facilitate negative fluid balance. ST-segment monitoring throughout the postoperative period was normal. There was no significant cardiac enzyme elevation. All survived after the operation. Follow-up electrocardiography showed right bundle branch block in only 1 case; all others were within normal limits.
The gradient across the suprapulmonary region is listed in Table 2. The pressure gradient across the supraaortic region by echocardiography was often contaminated by the turbulence inside the nearby pulmonary arteries. Three patients underwent recatheterization. The gradient on pullback was much lower than those measured by Doppler echocardiography (Table 2). Percutaneous transluminal angioplasty (PTA) was done in 2 cases. In Case 1, the supraaortic stenosis was the result of patching (ceiling) of the left-sided orifice of the neoaortic root (also as the floor of the neopulmonary pathway). Although it was balloon-dilated successfully, this free-flap covering technique was abandoned. In Case 2 with previous PT banding, the PT had to be amputated. There was no pressure gradient at the supraaortic site. Therefore, in Case 3, although PT was not banded previously, it was amputated and the cutback branch pulmonary artery was used to cover the posterior neoaortic anastomosis. That case had severe supraaortic stenosis. PTA in the aorta was performed 5 weeks after ASO. The gradient dropped from 110 to 20 mmHg after PTA. The residual aortopulmonary window became a large shunt 2 days after PTA, thus a redo was necessary to repair the aortopulmonary window with an equine pericardial patch. The follow-up study showed no gradient across this region. After Case 4, it was decided not to divide the posterior PT (as in Case 1), if PT banding was not performed. Technical modifications, including non-division of the posterior PT, marking of the branch pulmonary artery cutback end point and its corresponding point on the posterior aorta, and avoidance of the purse-string effect, had decreased the incidence of significant supraaortic stenosis from Cases 4 to 9 (Table 2). Minimal to mild aortic insufficiency was seen by echocardiography in 2 cases; in 1 of them, pulmonary regurgitation had been present since before ASO. All patients were doing well on follow-up at 16.5 ± 4.2 months after ASO. Follow-up angiocardiogram of Case 5 (Fig 4) showed good flow to coronary and both great arteries without anterior and upward tilting of the pulmonary bifurcation by the Lecompte maneuver (Fig 4D). The lowest panel of Figure 4 at levophase of the pulmonary arterial angiogram clearly demonstrates the resumption of the spiral relationship of the great arteries. The PT, with a catheter (arrowhead) in its lumen, is located left and anterior to the ascending aorta.
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Fig 4. Follow-up angiocardiogram of Case 5 shows good curvature of aorta and patent coronary arteries (arrows) (upper panels). Right ventriculogram in the middle panels shows that the pulmonary trunk was filled smoothly, and the right pulmonary artery coursed behind the aorta (C); there was no anterior and upward tilting of the pulmonary bifurcation by the usual Lecompte maneuver (D). The levophase of the left pulmonary arterial injection in the lowest panels showed the resumption of the spiral relationship of the great arteries. The pulmonary trunk, with a catheter (arrowheads) in its lumen, located left (E) and anterior (F) to the ascending aorta. (A,C,E) Frontal projection; (B,D,F) lateral projection.
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Comment
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No-fault transfer of the coronary artery is the cornerstone of a successful ASO. Various techniques [8–11, 13–18] have been proposed to achieve this goal: de Leval and colleagues [10] pointed out that the key point is to take the aorta away from the coronary arteries and the PT is brought to them, rather than moving the coronaries from the aorta and transferring the coronary scallops to the PT or neoaorta. To implement this concept, the in situ transfer techniques proposed by Aubert and coworkers [17] and Takeuchi and Katogi [18] was further developed by Murthy and Cherian [8]. In case of JOCA of both coronary arteries near the facing commissure, a superior common wall (Case 1) is recommended, like a superior trapdoor [11] instead of a medial common wall. In cases without an intramural segment, or one with the coronary artery away from the commissure, the lateral funnel technique [11] can still be used in addition to the medial common wall. For JOCA near the nonfacing commissure (Cases 4 and 9), the medial common wall should be sutured away from the coronary orifice. The absence of anatomic coronary abnormalities on aortography before discharge may not guarantee that the patient will be free from late coronary arterial obstruction [19]. Even in the hands of experts, coronary arterial obstruction can occur [3–4] and thus it is recommended that coronary transfer should follow the above-mentioned principle.
Our technique is different from Murthy and Cherian’s technique [8], not only in special management for JOCA, but also in sharing the common wall for the pulmonary arteries. The spiral relationship of the normal great arteries was not well appreciated in reconstructing TGA. TGA was considered to be an anterioposterior reversal of the great arteries [20, 21], so that in ASO the posterior PT was simply brought to the anterior, and the aorta to posterior position, thus, an unnatural suprapulmonary stenosis resulted [1, 2]. With the frequently adopted Lecompte maneuver, the bifurcation of PT was even mobilized to an anteaortic site, which resulted in suprapulmonary stenosis after ASO [22], even though a huge patch was repaired [23]. Although there might be no pressure gradient across this anterior and upward tilting region initially, the flow inside the anteaortic pulmonary pathway is not streamlined. The cross-section of the PT became oval after the Lecompte maneuver [24]. It is circular provided that the compression from the posterior aorta is not present by spiral reconstruction, as created naturally by nature. We therefore advocate resumption of the normal spiral relationship of the great arteries in TGA by sharing the common wall between branch pulmonary artery and the posterior aorta, and also between the PT and the ascending aorta. By our method, if the aorta was slightly right anterior to the PT (< 30°, Cases 7 and 8), the neoPT can still be reconstructed at the left anterior portion.
However, the spiral relationship of the great arteries as reconstructed in the fashion recommended might aggravate the branch pulmonary artery stenosis that is posterior to the neoaorta (right pulmonary artery in Cases 1 and 5, left pulmonary artery in Case 3; Table 2). Three technical modifications as described above have reduced the incidence of supraaortic stenosis and branch pulmonary artery stenosis afterwards. The gradient, if any, did not increase at short-term follow-up by echocardiography, and it did reveal decrease of the gradient (Table 2) as a result of potentially growable common wall. But, longer follow-up is mandatory, to see if any torsion or twisting of the pulmonary artery occurs later because it is sutured to the aorta. By our method of reconstruction, the neoaortic bleeding after operation or catheter intervention, if any, is recirculated into the lung via the common wall, it will not result in tamponade, and can be left alone or managed electively. In Case 3, who had PTA for supraaortic stenosis, the redo for the leakage through the aortopulmonary window could be delayed for 2 days after balloon dilatation. The gradient decreased after PTA, and the surgeon could follow the size of the window to do patch aortoplasty. If the common wall technique was not used and tamponade developed in the catheterization room, a disaster could ensue. Finally, intraluminal fibrous formation from the adventitia of the neoaorta inside the pulmonary pathway had contributed to the development of suprapulmonary stenosis. Therefore, we recommend cleaning all neoaortic adventitia inside the pulmonary pathway.
In conclusion, the common wall concept and in situ switch technique, which are applied not only for coronary arteries but also for pulmonary arteries, can provide a safe and reproducible technique for an arterial switch operation. The resumption of the spiral relationship of the great arteries can be achieved in the family of transposed great arteries, with or without previous PT banding.
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Addendum
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After submitting this paper, 3 more babies with complete TGA underwent successful spiral reconstruction of the great arteries as presented above.
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Acknowledgments
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The authors express their respectful appreciation to Professor Chi-Ren Hung for his inspiration to create the new idea. We thank the talented Miss Chang-Ying Lin, Dr Chih-Hsiang Chan, and Dr Shyh-Jye Chen for their artistic drawings.
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References
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Accepted for publication March 3, 2000.
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Top
Abstract
Introduction
