Ann Thorac Surg 2002;74:569-571
© 2002 The Society of Thoracic Surgeons
Case report
Anterior translocation of the right pulmonary artery for airway obstruction caused by pulmonary hypertension
Masaaki Yamagishi, MD*a,
Keisuke Shuntoh, MDa,
Akiyuki Takahashi, MDa,
Takeshi Shinkawa, MDa,
Takako Miyazaki, MDa,
Nobuo Kitamura, MDa
a Department of Pediatric Cardiovascular Surgery, Children’s Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Yamagishi, Department of Pediatric Cardiovascular Surgery, Children’s Research Hospital, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan
e-mail: myama{at}koto.kpu-m.ac.jp
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Abstract
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Both the bronchi are often severely squeezed by the dilated pulmonary artery in infants with ventricular septal defect and pulmonary hypertension. To relieve the considerable residual airway obstruction, the right pulmonary artery is translocated anteriorly to the ascending aorta concomitantly with the intracardiac repair. This technique is a useful procedure for infants with intractable respiratory failure caused by a dilated pulmonary artery.
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Introduction
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In patients with a ventricular septal defect (VSD) with increased pulmonary blood flow and severe pulmonary hypertension (PH), the bronchi are often squeezed under the pressure of the dilated pulmonary artery (PA). Because the airway obstruction and subsequent respiratory distress often remain after intracardiac surgical repair, postoperative respiratory management is rather complicated [1]. To relieve the considerable residual airway obstruction, we adopted concomitant anterior translocation of the right PA to the ascending aorta in an infant suffering from VSD with PH and a markedly dilated PA.
A male infant weighing 5,200 g was referred to our hospital with respiratory distress. Cardiac catheterization revealed that the systolic pulmonary arterial pressure was equal to the systolic systemic pressure: the left-to-right shunt ratio was 58% whereas the right-to-left shunt ratio was 21%; and the pulmonary arterial resistance was 7.4 Wood units. The pulmonary artery was remarkably dilated with a pulmonary artery index of 783 mm2/m2.
Preoperative three-dimensional computed tomography revealed that both the right and the left bronchi were severely squeezed by the dilated pulmonary artery. Particularly, the right bronchus was interrupted at the carina (Fig 1).
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Fig 1. Anterior view of preoperative three-dimensional computed tomography revealed that the right bronchus (RB) was squeezed (a) and the left bronchus (LB) was interrupted at the carina (b). (Tr = trachea.)
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Surgical repair was performed at 9 months of age. Through a median sternotomy, a moderate hypothermic cardiopulmonary bypass was established. After aortic cross-clamping and administration of cold crystalloid cardioplegia, the perimembranous VSD was closed by a usual technique. Then the ascending aorta was transected at the level of the right PA. Both the right and left PA branches were thoroughly dissected to the pulmonary hilus. The right PA was translocated anteriorly to the ascending aorta. After resection of a triangular segment of the anterior wall of the distal stump, the ascending aorta was reconstructed by a direct end-to-end anastomosis using a running 6-0 polydioxanone suture (Ethicon, Somerville, NJ). Because a part of the anterior wall of the ascending aorta was resected, the distance of the anterior wall shortens and the reconstructed ascending aorta was rather concave dorsally to make way for the anteriorly translocated right PA.
Postoperative three-dimensional computed tomography confirmed that the right bronchial stenosis was completely relieved (Fig 2A). Neither of the translocated great arteries was distorted (Fig 2B). Doppler echocardiography confirmed that the blood flow was not turbulent in the pulmonary bifurcation or in the reconstructed ascending aorta.
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Fig 2. (A) Superioposterior view of postoperative three-dimensional computed tomography. Squeezing of the right bronchus was completely ameliorated (arrow). (B) Superioanterior view of postoperative three-dimensional computed tomography. The right pulmonary artery (RPA) was translocated anteriorly to the ascending aorta (Ao). Neither of the translocated great arteries was distorted. (DAo = descending aorta; LPA = left pulmonary artery; MPA = main pulmonary artery; Tr = trachea.)
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Comment
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In patients with heart defects with massive left-to-right shunts and severe PH, the PA is often uniformly dilated. Bronchial compression by the dilated PA causes air trapping and subsequent pulmonary emphysema. In spite of the operation for the intracardiac anomalies, PH in varying degrees often remains, and the dilated PA is not promptly reduced in size. Therefore, residual bronchial stenosis prevents recovery from respiratory failure. Although additional surgical intervention is indicated, relief of the bronchial compression is insufficient only by dissection of the fibrous bands between the bronchi and the PA. A more serious condition is noted in patients with absent pulmonary valve syndrome [2]. Resection and plication of the aneurysmally dilated PA is a conventional surgical strategy for the absent pulmonary valve syndrome. However, the same procedure is not applicable to the dilated PA with VSD and PH, because there is no enormous aneurysmal lesion.
Hraska [3] reported an innovative pulmonary translocation technique for absent pulmonary valve syndrome. This translocation technique is applicable to VSD with PH. As demonstrated in preoperative three-dimensional computed tomography (Fig 1), the carina and both the left and right bronchi were pressed by the dilated right PA. Therefore, anterior translocation of the right PA is very effective in relieving the bronchial squeezing. This technique is technically simple and does not create any hemodynamic problems. Nonturbulent smooth blood flow and adequate growth of the reconstructed great arteries have already been proven by long-term follow-up of the arterial switch operation for complete transposition of the great arteries [4]. It would be far better to reconstruct the ascending aorta with retroflexion to make way for the right PA. Otherwise, the anteriorly translocated PA may be pushed up and flattened by the posterior ascending aorta.
Anterior translocation of the right PA should be adopted for infants suffering from VSD with PH and markedly dilated PA, and intractable respiratory failure. Severe bronchial squeezing confirmed by preoperative CT is an appropriate criterion for this technique.
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References
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- Hordof A.J., Mellins R.B., Gersony W.M., Steeg C.N. Reversibility of chronic obstructive lung disease in infants following repair of ventricular septal defect. J Pediatr 1977;90:187-191.[Medline]
- Watterson K.G., Malm T.K., Karl T.R., Mee R.B. Absent pulmonary valve syndrome: operation in infants with airway obstruction. Ann Thorac Surg 1992;54:1116-1119.[Abstract]
- Hraska V. A new approach to correction of tetralogy of Fallot with absent pulmonary valve. Ann Thorac Surg 2000;69:1601-1603.[Abstract/Free Full Text]
- Losay J., Touchot A., Serraf A., et al. Late outcome after arterial switch operation for transposition of the great arteries. Circulation 2001;104(Suppl 1):I121-1126.
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Abstract
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