Repair of Truncus Arteriosus With Interrupted Aortic Arch

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Repair of Truncus Arteriosus With Interrupted Aortic Arch Ralph S. Mosca, MD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 15, Issue 3, Pages 223-230 (September 2010) DOI: 10.1053/j.optechstcvs.2010.07.002 Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 1 Collett and Edwards classification scheme for truncus arteriosus. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 223-230DOI: (10.1053/j.optechstcvs.2010.07.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 2 Classification of interrupted aortic arch as described by Celoria and Patton. Type A, at aortic isthmus; type B, between left common carotid artery and left subclavian artery; type C, between inominate artery and left common carotid artery. Asc. ao. = ascending aorta; Desc. ao. = descending aorta; IA = innominate artery; LCC = left common carotid artery; LSCA = left subclavian artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 223-230DOI: (10.1053/j.optechstcvs.2010.07.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 3 (A) Appearance of truncus arteriosus type 2. Cannulation of the ascending aorta and the proximal ductus arteriosus are shown. Pulmonary artery snares are tightened on commencing CPB and cooling is begun. (B) The truncus, brachiocephalic vessels, PDA, and descending aorta are widely mobilized. This can be facilitated by removal of the arterial cannula in the PDA after sufficient cooling. (C) The arterial cannula is removed; the head vessels snares are tightened and antegrade cardioplegia is given. The proximal tie on the PDA and the LPA snare are retained and can be used to improve exposure to the aortic arch and descending aorta. (C-E) A transverse incision is made anteriorly over the pulmonary arteries and extended both superiorly and inferiorly, removing the pulmonary artery branches from the truncus. Care must be taken to avoid injury to the coronary ostia and the aortic valve commissures. Ao. = aorta; LSCA = left subclavian artery; RA = right artery; RV = right ventricle; SVC = superior vena cava. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 223-230DOI: (10.1053/j.optechstcvs.2010.07.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 4 (A) Anatomy is shown after division of the truncal root and removal of the pulmonary artery branches. The dotted lines indicate arteriotomies for repair of the ascending aorta and arch. (B) Exposure to the descending aorta can be facilitated by the use of a “Spoon Potts” type clamp. The back wall is repaired after excising all residual ductal tissue. A portion of pulmonary allograft tissue is thawed and trimmed to augment the aorta. (C) The reconstructed ascending aorta is reanastomosed to the proximal aortic root. (D) The VSD is exposed via a right ventriculotomy. It is directed to the left of the aorta. The truncal valve extends somewhat inferiorly and care must be taken to avoid injuring it at the superior end of the incision. Silk stay sutures improve the exposure. MPA = main pulmonary artery; PA = pulmonary artery; PDA = patent ductus arteriosus; RV = right ventricle. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 223-230DOI: (10.1053/j.optechstcvs.2010.07.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 5 (A) View of the outlet VSD via the right ventriculotomy. Here the VSD is shown as outlet muscular in nature; thus, the conduction system is remote from the defect. (B) Closure of the VSD with a PTFE patch. Superomedially the patch is sutured close to the aortic valve annulus to prevent residual VSDs through trabeculations. Superiorly the patch is sewn to the edge of the right ventriculotomy. (C) Distal homograft to PA bifurcation anastomosis. Segments of running polypropylene are used to prevent a “purse-string” distortion. (D) The posterior aspect of the proximal homograft to RV anastomosis. Approximately one third of the circumference of the homograft is sutured to the superior aspect of the RV incision. (E) The repair is completed with a hood of glutaraldehyde-treated pericardium or PTFE. The dimensions for the patch are shown in (D). VSD = ventricular septal defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 223-230DOI: (10.1053/j.optechstcvs.2010.07.002) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 5 (A) View of the outlet VSD via the right ventriculotomy. Here the VSD is shown as outlet muscular in nature; thus, the conduction system is remote from the defect. (B) Closure of the VSD with a PTFE patch. Superomedially the patch is sutured close to the aortic valve annulus to prevent residual VSDs through trabeculations. Superiorly the patch is sewn to the edge of the right ventriculotomy. (C) Distal homograft to PA bifurcation anastomosis. Segments of running polypropylene are used to prevent a “purse-string” distortion. (D) The posterior aspect of the proximal homograft to RV anastomosis. Approximately one third of the circumference of the homograft is sutured to the superior aspect of the RV incision. (E) The repair is completed with a hood of glutaraldehyde-treated pericardium or PTFE. The dimensions for the patch are shown in (D). VSD = ventricular septal defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 223-230DOI: (10.1053/j.optechstcvs.2010.07.002) Copyright © 2010 Elsevier Inc. Terms and Conditions