Ann Thorac Surg 2006;81:1143-1145
© 2006 The Society of Thoracic Surgeons
How to do it
Pulmonary Artery Augmentation Using Autologous Vena Cava in Right Heart Bypass Operations
Takeshi Shinkawa, MD
*
,
Masaaki Yamagishi, MD,
Keisuke Shuntoh, MD,
Keitarou Koushi, MD,
Mitsugu Ogawa, MD,
Hitoshi Yaku, MD
Department of Pediatric Cardiovascular Surgery, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
Accepted for publication December 23, 2004.
* Address correspondence to Dr Shinkawa, Department of Pediatric Cardiovascular Surgery, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamigyo-ku, Kyoto, 602-8566 Japan (Email: newriver{at}koto.kpu-m.ac.jp).
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Abstract
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We obtained good results in the right heart bypass operation concomitant with the pulmonary arterial augmentation using the vena cava in 7 patients. We report the techniques used in 2 representative patients. The techniques used were a hemi-Fontan procedure with large superior vena caval patches and a bidirectional cavopulmonary shunt with superior vena caval interposition. These techniques have advantages in that the augmented pulmonary arteries have growth potential and low thrombogenicity because the procedures can be performed without the use of prosthetic materials or xenografts, especially in cases in which it is impossible to use the autologous pericardium.
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Technique
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Patient 1
An 8-month-old boy weighing 6.1 kg underwent central pulmonary arterial augmentation with large superior vena caval patches and a hemi-Fontan procedure. He was diagnosed as having right isomerism, single right ventricle, bilateral superior vena cavae, and infracardiac type total anomalous pulmonary venous return just after birth. He underwent total anomalous pulmonary venous return repair and pulmonary artery banding at 6 days of age. Preoperative angiogram showed severe central pulmonary artery stenosis (Fig 1A, 1B).
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Fig 1. Angiography of patient 1. (A) Preoperative pulmonary arteriogram showing severe central pulmonary stenosis. (B) Preoperative left superior vena cavogram showing its route close to the pulmonary stenotic portion. (C) Postoperative right superior vena cavogram showing smooth flow in hemi-Fontan circulation. (D) Postoperative left superior vena cavogram showing widely augmented central pulmonary artery.
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Through a median sternotomy, a cardiopulmonary bypass was established. The left superior vena cava was divided obliquely to enlarge the openings. A longitudinal incision was made on the roof of the stenotic central pulmonary artery as large as possible. The roof of the incised stenotic central pulmonary artery was patched with the distal opening of the divided left superior vena cava in a side-to-end fashion. A longitudinal incision was made in the floor of the stenotic central pulmonary artery, just opposite the wall of the anastomotic site. After aortic cross-clamping, the proximal opening of the left superior vena cava and the roof of the left atrium were incised toward the origin of the right superior vena cava to widen the opening. This enlarged opening and the floor of the incised central pulmonary artery were anastomosed in a side-to-side fashion. An expanded polytetrafluoroethylene patch was anastomosed in the right atrium to complete hemi-Fontan circulation (Fig 2). Postoperative angiogram showed a widely patent central pulmonary artery and smooth blood flow in the hemi-Fontan circulation (Fig 1C, 1D). He underwent a lateral tunnel Fontan operation at 2 years of age.
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Fig 2. Operative procedures showing (A) longitudinal incision on the roof of the stenotic central pulmonary artery and oblique incision of the left superior vena cava (dashed lines), (B) longitudinal incision in the floor of the stenotic pulmonary artery (dashed line) and the making of large caval patches, (C) anastomosis of large caval patches and incisions of central pulmonary artery, and (D) completion of hemi-Fontan circulation with an intraatrial patch.
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Patient 2
A 19-month-old girl weighing 7.9 kg underwent central pulmonary arterial augmentation with superior vena caval interposition and a bidirectional cavopulmonary shunt operation. She was diagnosed as having right isomerism, single right ventricle, double outlet right ventricle, and pulmonary valve stenosis just after birth. She received a left Blalock-Taussig shunt at 10 months of age. Preoperative angiogram showed severe central pulmonary artery stenosis just proximal to the left Blalock-Taussig shunt and the left superior vena cava (Fig 3A, 3B).
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Fig 3. Angiography of patient 2. (A) Preoperative injection of the Blalock-Taussig shunt showing severe central pulmonary arterial stenosis. (B) Preoperative superior vena cavogram showing its route close to the pulmonary stenotic portion. (C) Postoperative superior vena cavogram showing widely augmented central pulmonary artery.
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Through a median sternotomy, a cardiopulmonary bypass was established. The left Blalock-Taussig shunt was divided and the stenotic part of the central pulmonary artery was completely removed. The pulmonary valve was oversewn and closed with pledgetted sutures. The length of the stenotic part prevented direct anastomosis of the right and left stumps of the pulmonary artery. After division of the superior vena cava at the atrial connection, the superior vena cava was anastomosed directly to the right pulmonary artery in an end-to-end fashion. The left pulmonary artery was anastomosed to the hole made on the left side of the superior vena cava in an end-to-side fashion (Fig 4). Postoperative angiogram showed a widely patent central pulmonary artery and smooth blood flow in the cavopulmonary connection (Fig 3C, 3D). She underwent an extracardiac conduit Fontan operation at 2 years, 4 months of age.
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Fig 4. Operative procedures showing (A) division of the left Blalock-Taussig shunt and resection of the stenotic part of the central pulmonary artery (dashed line), (B) division of the superior vena cava and closure of the pulmonary valve, (C) direct anastomosis of the superior vena cava and the right pulmonary artery in an end-to-end fashion and making a hole on the left side of superior vena cava, (D) anastomosis of the left pulmonary artery and the superior vena cava in an end-to-side fashion and completion of the bidirectional cavopulmonary shunt.
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Comment
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Fontan candidates with pulmonary arterial stenosis require augmentation of the stenotic pulmonary artery at the right heart bypass operations to obtain smooth blood flow and balanced pulmonary growth [1]. In augmentation of the pulmonary artery, it is necessary to avoid using prosthetic materials or xenografts because they have no growth potential and thrombogenicity [2–4]. We prefer to use autologous materials for the patch, such as autologous pericardium [5]. In some patients, it is impossible to use the autologous pericardium because of adhesion resulting from multi-stage operation, and it is necessary to find an alternative material or an alternative technique.
We performed right heart bypass operations concomitant with the pulmonary arterial augmentation using the vena cava. These techniques have advantages in that the augmented pulmonary arteries have growth potential and low thrombogenicity, because the procedures can be performed without the use of prosthetic materials or xenografts, especially in cases in which it is impossible to use the autologous pericardium. For the same reason, these techniques presumably have a low possibility of pulmonary distortion. These techniques are available when the superior vena cava and the stenotic part of the pulmonary artery are located in close proximity. To achieve tension-free anastomosis and ideal anastomotic form, it is necessary to widely dissect the vena cava and the pulmonary arteries. Oblique division of the superior vena cava is useful as it gives a large caval opening for use as a large patch.
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References
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