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Ann Thorac Surg 1997;64:1132
© 1997 The Society of Thoracic Surgeons
DR BABULAL SETHIA (Birmingham, England):
I enjoyed your paper very much, and we have had similar experience with these types of patients, but I have two questions. You said that you cannulate the pulmonary artery electively. However, in most of these patients, the ascending aorta is of good size and can be cannulated to undertake the operation, reducing some of the circulatory arrest time. Do you have any comments on that?
DR MOSCA:
The vast majority of these patients have small ascending aortas and concomitant aortic arch hypoplasia or coarctation. Thus, it can be difficult to cannulate the ascending aorta directly. Cannulation of the main pulmonary artery in a sinus just above the pulmonary valve is simple, safe, and reliable. Manipulation of the arterial cannulas is reduced greatly during mobilization of the head vessels and proximal descending thoracic aorta. In our experience, the circulatory arrest times have averaged approximately 50 minutes, which is well tolerated as long as uniform cooling has been performed for more than 20 minutes before the arrest portion of the procedure and the cardiac output after the repair is good. If the circulatory arrest time becomes an issue, the distal ascending aorta can be cannulated after repair of the aortic arch and reinstitution of low-flow cardiopulmonary bypass. In a patient with a larger aorta (
6 mm), the option of direct aortic cannulation also is feasible.
DR SETHIA:
I think one can save a little bit of clamp or arrest time in that way.
I have a second question. I note that you still use a pulmonary or other type of homograft to reconstruct the aortic arch. In our series of more than 100 Norwood procedures, we had had to use a homograft in only about 5 patients. Do you think that it is really necessary to continue to use a homograft or some form of augmentation of the transverse aortic arch?
DR MOSCA:
Are you referring to the technique where you bring the pulmonary artery right up under the aortic arch?
DR SETHIA:
You do not have to bring the pulmonary valve right up under the aortic arch, but you have to mobilize the aortic arch quite extensively with the head and neck vessels and the descending aorta. And you can undertake a primary anastomosis.
DR MOSCA:
This technique, popularized by you and Dr Brahm, also is applicable. However, in our opinion, the technique you described does not relieve the aortic arch obstruction as reliably, and it may produce tension at the arch anastomosis by virtue of bringing the divided pulmonary artery up under the aortic arch. We believe that the incidence of neocoronary obstruction and neoaortic valve insufficiency is less using our technique, which eliminates any tension on the aorta or distortion of the pulmonary valve.
DR SETHIA:
So you have used the other technique?
DR MOSCA:
We used it before 1987, but have switched to the technique I just presented, and our results have improved.
DR SETHIA:
Thank you.
Related Article
Ann. Thorac. Surg. 1997 64: 1126-1132.
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