Ann Thorac Surg 2009;87:677-678. doi:10.1016/j.athoracsur.2008.07.091
© 2009 The Society of Thoracic Surgeons
Correspondence
Aortic Origin of the Right Pulmonary Artery: Surgical Techniques and Outcome
Edvin Prifti, MD, PhDa,
Albi Fagu, MDa,
Arben Baboci, MDa,
Massimo Bonacchi, MDb
a Division of Cardiac Surgery, University Hospital Center of Tirana, "Mother Teresa", Rruga e Dibres, Tirana, Albania
b Cattedra di Cardiochirurgia, University Hospital of Florence "Careggi", Viale Morgagni, 85, Firenze, 50134 Italy
(Email: edvinprifti{at}hotmail.com; mbonacchi{at}unifi.it).
To the Editor:
We read with interest the article by Kajihara and colleagues [1] reporting a series of 8 patients with anomalous origin of the right pulmonary artery (AORPA) from the ascending aorta undergoing surgical correction. An AORPA is a rare and hazardous congenital malformation due to the surgical difficulties of implanting the AORPA to the main pulmonary artery (MPA). All the reported patients [1] underwent direct implantation except 1 who required the interposition of a synthetic graft. During a follow-up of 8 years, the authors identified 3 patient reoperations in this series and 3 other patients required catheter balloon angioplasty due to anastomotic site stenosis.
Direct implantation of the AORPA is generally reserved when the AORPA originates in proximity to the MPA; however this technique is associated with a higher residual gradient through the anastomotic site [2] and with a high reoperation rate [1]. In our series of 10 patients (8 of them reported) [2, 3], we have had only one reoperation in a patient undergoing reimplantation of the AORPA using a synthetic graft. All the other patients underwent reimplantation using various techniques of the autologous tissue. Five of them underwent surgical repair by using two new surgical techniques, consisting in the use of aortic and pulmonary artery tissue for increasing the length of the AORPA and the mean gradient through the anastomotic site was 8 ± 4 mm Hg.
The single aortic flap technique was used in 3 patients (Fig 1A) [4]. The ascending aorta was transected just above and beneath the origin of AORPA. The resulting aortic ring was fashioned into an elongated tube for the pulmonary artery, and the far end was connected to the MPA side-to-end.
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Fig 1. (A) Single-aortic flap technique. The reimplantation of the anomalous right pulmonary artery to the main pulmonary trunk by using an aortic ring. (B) The double-flap technique uses the aortic and pulmonary flap preparation followed by the (C) anterior positioning of the aortic and pulmonary flaps and anastomosis. (D) Newly created communication between the anomalous right pulmonary artery and main pulmonary artery. (AO = aorta; AV = aortic valve; LPA = left pulmonary artery; MPA = main pulmonary artery; PV = pulmonary valve; RPA = right pulmonary artery.)
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In 2 other patients, we used the double flap technique (Fig 1B) [3]. The ascending aorta is transsected obliquely, above and beneath the AORPA origin, providing a symmetric large aortic ring. Then, an anterior vertical incision of MPA is performed extending superiorly and inferiorly to the MPA, providing a symmetric pulmonary flap with a similar width as the aortic flap. The aortic ring is cut transversely, leaving a small aortic flap posteriorly, and an anterior aortic flap is created to balance the posterior pulmonary flap. The pulmonary flap is sutured to the small posterior aortic flap, anterior to the ascending aorta (Fig 1C). Then, the anterior aortic flap is anastomosed to the pulmonary flap and MPA (Fig 1D).
The techniques using autologous tissues for enlarging and lengthening the AORPA seem to be associated with better results in terms of postoperative re-stenosis and reoperation rate, and we strongly recommend them.
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References
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- Kajihara N, Imoto Y, Sakamoto M, et al. Surgical results of anomalous origin of the right pulmonary artery from the ascending aorta including reoperation for infrequent complications Ann Thorac Surg 2008;85:1407-1411.[Abstract/Free Full Text]
- Prifti E, Crucean A, Bonacchi M, et al. Postoperative outcome in patients with anomalous origin of one pulmonary artery branch from the aorta Eur J Cardiothorac Surg 2003;24:21-27.[Abstract/Free Full Text]
- Prifti E, Frati G, Crucean A, Vanini V. A modified technique for repair of the anomalous origin of the right pulmonary artery from the ascending aorta Eur J Cardiothorac Surg 2002;22:148-150.[Abstract/Free Full Text]
- Gybels Y, Grapow MTR, Todorov A, Wagner G, Zerkowski H-R. Aberrant right pulmonary artery and double outlet ventricle: one stage repair Ann Thorac Surg 2000;69:630-632.[Abstract/Free Full Text]
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