Ann Thorac Surg 2000;70:674-675
© 2000 The Society of Thoracic Surgeons
How to do it
Anatomical reconstruction of aorta and pulmonary trunk in patients with an aortopulmonary window
Jacques A.M. van Son, MD, PhDa,
Jörg Hambsch, MDa,
Friedrich W. Mohr, MD, PhDa
a Herzzentrum, University of Leipzig, Leipzig, Germany
Address reprint requests to Dr van Son, Herzzentrum, University of Leipzig, Russenstrasse 19, D-04289 Leipzig, Germany
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Abstract
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We report a modified technique for repair of aortopulmonary window in which a native pulmonary artery flap is created and the aortopulmonary window is completely divided. The pulmonary artery flap is used to reconstruct the ascending aorta, and the defect in the pulmonary trunk is closed with an autologous pericardial patch. This repair avoids the use of a fabric patch with its inherent disadvantages and allows anatomical reconstruction of both the ascending aorta and the pulmonary trunk with low risk of early or late distortion of the aortic and pulmonary root structures.
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Introduction
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Aortopulmonary window (APW) is an uncommon cardiac anomaly in which a communication exists between the ascending aorta and the pulmonary trunk in hearts that have normal separation of the aortic and pulmonary valves. This communication can be variable both in size and in location, occurring either close to the semilunar valves or closer to the right pulmonary artery; aortic origin of the right pulmonary artery can also be associated with this defect [1]. In approximately 25% of cases, usually in those with a distal communication, APW is associated with interrupted aortic arch or coarctation of the aorta [2–4]. As with other conotruncal malformations, 22q11 chromosomal deletion can be associated with this defect [5]. Because the natural history of patients with APW is characterized by early manifestation of congestive heart failure, gradual development of irreversible pulmonary hypertension occurring as early as several months of life, and death, early surgical treatment is mandatory [6]. The widely applied technique of repair of APW through patch closure, although a major improvement over suture closure, may lead to distortion of the aortic and pulmonary root structures [7]. With the objective of avoiding such distortion and completely separating the ascending aorta from the pulmonary trunk, we have a devised a modified technique of APW repair.
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Technique
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Cardiopulmonary bypass is instituted through a median sternotomy. Depending on the size and location of the APW, either the APW itself, the pulmonary trunk, or both branch pulmonary arteries are clamped or snared, followed by aortic cross-clamping and administration of cold cardioplegic solution. A semicircular flap of native pulmonary artery wall is created by incising the pulmonary trunk several millimeters to the left of the APW. The incision is extended to opposite points at the superior and inferior margins of the defect and subsequently the back wall of the APW is divided slightly toward the pulmonary trunk (Fig 1). Utmost attention is directed to the location of the coronary artery ostia. The flap is then used to reconstruct the ascending aorta. Starting at the midpoint of the flap, it is sutured to the posterior margin of the aortic defect, using a continuous 6-0 Maxon suture (Davis & Geck, Danbury, CT) (Fig 2). After removal of air from the aorta, the aortic cross-clamp is removed and the defect in the pulmonary trunk is closed with an autologous pericardial patch (Fig 3).
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Fig 1. Line of incision on the anterior pulmonary trunk (PT) resulting in the creation of a native pulmonary artery flap (left). The back wall of the aortopulmonary window is divided slightly toward the pulmonary trunk (arrows, right). (Ao = ascending aorta.)
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Fig 2. The native pulmonary artery flap is sutured to the posterior margin of the ascending aorta (Ao). (PT = pulmonary trunk.)
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Fig 3. The defect in the pulmonary trunk (PT) is closed with an autologous pericardial patch, indicated in white. Dashed line represents the pulmonary artery flap used for reconstruction of the ascending aorta (Ao).
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Case reports
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We have successfully performed this technique in 2 male patients aged 5 and 9 weeks with respective body weights of 3.5 and 3.9 kg who had APWs with respective maximum diameters of 10 and 12 mm but normal origin of the right pulmonary artery. Both had symptoms of severe congestive heart failure caused by the APW. In one patient the right coronary artery arose very close to the inferior border of the APW. The pulmonary artery flap was consequently created in such a fashion that the origin of the right coronary artery was not compromised. At follow-up 48 and 17 months after the procedure, both patients were clinically well. In both, echocardiography demonstrated an anatomically normal aortic root with patent coronary ostia and a competent aortic valve, a normal ascending aorta, and a normal pulmonary trunk.
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Comment
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The surgical treatment of APW represents a continuous evolution of technique. Since 1948, when Gross [8] first successfully ligated an APW, several surgical techniques for closure of the APW with a patch have been reported; these use either a transpulmonary or transaortic approach or else an approach through the APW itself [9–11]. Most surgeons currently use the latter technique, originally reported by Johansson and coworkers [11], which involves opening the APW anteriorly, sewing a fabric patch around the rim of the defect posteriorly, and then including the patch in a so-called sandwich closure of the anterior incision. In our experience, application of this technique in one patient led to both slight distortion of the right cusp of the aortic valve and moderate pulmonary regurgitation. With the objectives of preserving growth potential of the ascending aorta and the pulmonary trunk and of limiting the potential for microembolic events during the early postoperative stage, Messmer [12] and Di Bella and Gladstone [4] have devised pulmonary artery flap techniques for closure of APW. In neither of these techniques, however, is the posterior wall of the APW divided. Growth of the ascending aorta and the adherent pulmonary trunk may therefore potentially produce distortion of the aortic and pulmonary root structures—that is, the aortic and pulmonary valves and coronary ostia [7]. Complete division and separate reconstruction of the ascending aorta and the pulmonary trunk may result in less risk of distortion of the aortic and pulmonary valves and the coronary ostia. In addition, such anatomical reconstruction may also be advantageous in case a reoperation is needed, such as coronary artery bypass grafting or an aortic valve procedure. The operation that we report is technically easy, can be performed in small infants and neonates, and allows for normal growth of both the ascending aorta and the pulmonary trunk.
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References
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Richardson J.V., Doty D.B., Rossi N.P., Ehrenhaft J.L. The spectrum of anomalies of aortopulmonary septation. J Thorac Cardiovasc Surg 1979;78:21-27.[Abstract]
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Di Bella I., Gladstone D.J. Surgical management of aortopulmonary window. Ann Thorac Surg 1998;65:768-770.[Abstract/Free Full Text]
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Takahashi K., Kido S., Hoshino K., et al. Frequency of 22q11 deletion in patients with conotruncal cardiac malformations. Eur J Pediatr 1995;154:878-881.[Medline]
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Van Son J.A.M., Puga F.J., Danielson G.K., et al. Aortopulmonary window. Mayo Clin Proc 1993;68:128-133.[Medline]
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Accepted for publication January 19, 2000.
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Abstract
Introduction
