William M. DeCampli, MD, PhD, Craig E. Fleishman, MD, David G

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Presentation transcript:

Hybrid approach to the comprehensive stage II operation in a subset of single-ventricle variants William M. DeCampli, MD, PhD, Craig E. Fleishman, MD, David G. Nykanen, MD The Journal of Thoracic and Cardiovascular Surgery Volume 149, Issue 4, Pages 1095-1100 (April 2015) DOI: 10.1016/j.jtcvs.2014.11.081 Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 After commencing cardiopulmonary bypass with 1 or 2 arterial cannulas and a right atrium cannula, the branch pulmonary arteries are debanded. A, Under selective cerebral perfusion, an incision is made into the RPA at the proposed site of superior vena cava connection, usually at or just distal to the site of prior banding. Then, a longitudinal incision is made into the large main pulmonary artery. The location of the branch pulmonary artery and ductal orifices are noted. B, A protruding end of the original ductal stent is trimmed back. C, The ductal stent is then dilated under direct vision, and a second stent placed as needed and position determined by videoscope. RPA, Right pulmonary artery. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1095-1100DOI: (10.1016/j.jtcvs.2014.11.081) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, A guide wire and pulmonary artery stent catheter are advanced through the right pulmonary artery incision into the left lower lobe artery using videoscopic guidance. B, A pulmonary artery homograft baffle is partially sewn in place from the left to the right pulmonary artery orifice (intra-MPA baffle). The intimal side of the graft is oriented to lie within the pulmonary pathway because the flow there is of relatively low velocity and less pulsatile than that of the systemic pathway. MPA, Main pulmonary artery; LPA, left pulmonary artery. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1095-1100DOI: (10.1016/j.jtcvs.2014.11.081) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, The PA stent is first deployed. It should extend into each PA orifice by about 5 mm. B, C, The baffle suture line is completed, coming up over each PA orifice and back down to the floor of the PA bifurcation. The baffle is trimmed to fit snugly around the stent. The stent is anchored near each PA orifice using a 5-0 Prolene (polypropylene; Ethicon) stitch to prevent migration. D, The incision in the PA is closed and the heart and vasculature de-aired. The PA arterial cannula is replaced and reperfusion and warming begun. A superior vena cava cannula is placed and the cavo-pulmonary anastomosis is then performed with homograft augmentation as needed. MPA, Main pulmonary artery; PA, pulmonary artery. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1095-1100DOI: (10.1016/j.jtcvs.2014.11.081) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 An “exit angiogram” is performed to confirm bilateral pulmonary artery flow without pulmonary or systemic obstruction and no baffle leak (left to right shunt). Anteroposterior (A) and lateral (B) views of pulmonary root injection, showing no systemic obstruction or shunt into the branch pulmonary arteries. C, Cavo-pulmonary injection showing unobstructed baffle and left pulmonary artery flow and absence of wash-in from the systemic circulation. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1095-1100DOI: (10.1016/j.jtcvs.2014.11.081) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Echocardiographic images shown for case 2 at 10 months postoperation, age 15 months. A, Subcostal view shows that the anteriorly deviated conal septum crowds the subaortic area somewhat but is not obstructive to “upper body” (native aortic) flow. B, Parasternal view shows anatomic relationship between the main PA and the intra-PA baffle and LPA. Color Doppler shows flow from PA into stented PDA with no shunt (ie, baffle leak) into the LPA. C, Suprasternal view shows separate AAo, PDA, and LPA flows. Ao, Aorta root; PA, pulmonary artery; RV, right ventricle; R, right; S, superior; LPA, left pulmonary artery; PDA, patent ductus arteriosus; AAo, ascending aorta. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1095-1100DOI: (10.1016/j.jtcvs.2014.11.081) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions

Intramain pulmonary artery baffle in hybrid comprehensive stage II procedure. The Journal of Thoracic and Cardiovascular Surgery 2015 149, 1095-1100DOI: (10.1016/j.jtcvs.2014.11.081) Copyright © 2015 The American Association for Thoracic Surgery Terms and Conditions