Reoperative Techniques for Complications After Arterial Switch

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Presentation transcript:

Reoperative Techniques for Complications After Arterial Switch Constantine Mavroudis, MD, Robert D. Stewart, MD, Carl L. Backer, MD, Harish Rudra, DO, Patrick Vargo, BS, Marshall L. Jacobs, MD The Annals of Thoracic Surgery Volume 92, Issue 5, Pages 1747-1755 (November 2011) DOI: 10.1016/j.athoracsur.2011.04.102 Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Internal thoracic artery to left anterior descending coronary artery (LAD) bypass in a patient who had arterial switch operation and Lecompte maneuver. The bypass graft is placed in the proximal third of the LAD, where the luminal diameter of the artery is most likely to be larger. The Annals of Thoracic Surgery 2011 92, 1747-1755DOI: (10.1016/j.athoracsur.2011.04.102) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) Aortic root exposure by right pulmonary artery transection and proximal neopulmonary artery retraction in a patient who had transfer of an intramural coronary artery and presented 18 years postoperatively with acute myocardial infarction and cardiac arrest. The dotted line represents the intramural course. (B) After antegrade and retrograde cardioplegic arrest, the neoaorta is transected and the intramural coronary artery is visualized. (C) A scalpel unroofs the intramural coronary artery and individual sutures are placed to reapproximate the coronary and neoaortic intimal layers. (D) The operation is completed with a Gore-Tex interposition tube graft to reconstruct the right pulmonary artery, thereby avoiding proximal neoaortic constriction and right pulmonary artery tension. The Annals of Thoracic Surgery 2011 92, 1747-1755DOI: (10.1016/j.athoracsur.2011.04.102) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Neoaortic valve-sparing operation as modified after the David procedure. (A) Neoaortic exposure after right pulmonary artery transection, main neopulmonary artery retraction, cardioplegic arrest, and neoaortic transection. The dotted lines represent incisions that allow dissection of the coronary artery buttons and the noncoronary sinus of Valsalva neoaortic wall. (B) Pledgeted sutures placed at the neoaortic annulus equidistant between the commissures and passed through the Dacron graft, which allow seating over the neoaorta. Coronary artery buttons are liberally dissected for later implantation. (C) The seated Dacron graft. Hemostatic sutures within the graft are used to complete the reconstruction. (D) The creation of orifices in the Dacron graft with coronary artery reimplantation. (E) The operation is completed with a Gore-Tex interposition tube graft to reconstruct the right pulmonary artery. The Annals of Thoracic Surgery 2011 92, 1747-1755DOI: (10.1016/j.athoracsur.2011.04.102) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Neoaortic root exposure after right pulmonary artery transection, main neopulmonary artery retraction, cardioplegic arrest, and neoaortic root resection. Pledgeted sutures are placed in the neoaortic annulus, then through the suture ring of the prosthetic valved conduit. (B) The seated prosthetic valved conduit with reimplantation of the coronary arteries. (C) The completed operation with a Gore-Tex interposition tube graft to reconstruct the right pulmonary artery. The Annals of Thoracic Surgery 2011 92, 1747-1755DOI: (10.1016/j.athoracsur.2011.04.102) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Computed tomographic scan showing postoperative unroofing of the previously transferred intramural coronary artery of an 18-year-old patient. The Annals of Thoracic Surgery 2011 92, 1747-1755DOI: (10.1016/j.athoracsur.2011.04.102) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions