Midline one-stage complete unifocalization and repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals V.Mohan.

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Presentation transcript:

Midline one-stage complete unifocalization and repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals V.Mohan Reddy, MD (by invitation), John R. Liddicoat, MD (by invitation), Frank L. Hanley, MD (by invitation) The Journal of Thoracic and Cardiovascular Surgery Volume 109, Issue 5, Pages 832-845 (May 1995) DOI: 10.1016/S0022-5223(95)70305-5 Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 1 Angiogram of a 3.5-year-old patient showing multiple major AP collaterals arising from the descending aorta. True pulmonary arteries were absent. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 2 Diagram of the transverse sinus approach for the dissection, rerouting, and unifocalization of the major AP collaterals. Ac, Aortic cannula; Ao, ascending aorta; D.Ao, descending aorta; IC, venous cannula in the inferior vena cava; L, true left pulmonary artery; LA, left atrium; LV, left ventricle; PA, long-segment pulmonary atresia; R, true right pulmonary artery; RA, right atrium; RV, right ventricle; SC, venous cannula in the superior vena cava (SVC); T, trachea; 1, 2, and 3, major AP collaterals. In this diagrammatic representation the major AP collaterals are all shown anterior to the tracheobronchial tree. However, these collaterals often have variable relation to the tracheobronchial tree and the esophagus. Therefore unifocalization should be individualized to achieve the best lie of the major AP collateral. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 3 Diagrams of the anatomy of the major AP collaterals and true pulmonary arteries and the techniques of unifocalization in a 3.5-month-old infant weighing 3.5 kg. A, Schematic representation of the major AP collaterals and true Pulmonary Arteries. AO, Aorta; COR, coronary collateral; IA, innominate artery; LPA, left pulmonary artery; RPA, right pulmonary artery, 1, large and tortuous major AP collateral arising from the carotid artery; 2 and 3, major AP collaterals arising from the descending aorta. *Site of ligation and division of the major AP collaterals. B, A-A′, D-D′, E-E′, the major AP collaterals are filleted open along the broken lines; B-B′, the true right and left pulmonary arteries are filleted open from hilum to hilum. C, A-A′ to B-B′, major AP collateral 1 is filleted open along its length all the way to the hilum and is anastamosed to the true pulmonary arteries, thereby augmenting the pulmonary arteries from hilum to hilum; C-C′ to D-D′ and F-F′ to E-E′, major AP collaterals 2 and 3 are anastomosed to the augmented true pulmonary arteries in an end-to-side fashion. Unifocalization and central pulmonary artery reconstruction are thus achieved without the need for non-native material. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 3 Diagrams of the anatomy of the major AP collaterals and true pulmonary arteries and the techniques of unifocalization in a 3.5-month-old infant weighing 3.5 kg. A, Schematic representation of the major AP collaterals and true Pulmonary Arteries. AO, Aorta; COR, coronary collateral; IA, innominate artery; LPA, left pulmonary artery; RPA, right pulmonary artery, 1, large and tortuous major AP collateral arising from the carotid artery; 2 and 3, major AP collaterals arising from the descending aorta. *Site of ligation and division of the major AP collaterals. B, A-A′, D-D′, E-E′, the major AP collaterals are filleted open along the broken lines; B-B′, the true right and left pulmonary arteries are filleted open from hilum to hilum. C, A-A′ to B-B′, major AP collateral 1 is filleted open along its length all the way to the hilum and is anastamosed to the true pulmonary arteries, thereby augmenting the pulmonary arteries from hilum to hilum; C-C′ to D-D′ and F-F′ to E-E′, major AP collaterals 2 and 3 are anastomosed to the augmented true pulmonary arteries in an end-to-side fashion. Unifocalization and central pulmonary artery reconstruction are thus achieved without the need for non-native material. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 3 Diagrams of the anatomy of the major AP collaterals and true pulmonary arteries and the techniques of unifocalization in a 3.5-month-old infant weighing 3.5 kg. A, Schematic representation of the major AP collaterals and true Pulmonary Arteries. AO, Aorta; COR, coronary collateral; IA, innominate artery; LPA, left pulmonary artery; RPA, right pulmonary artery, 1, large and tortuous major AP collateral arising from the carotid artery; 2 and 3, major AP collaterals arising from the descending aorta. *Site of ligation and division of the major AP collaterals. B, A-A′, D-D′, E-E′, the major AP collaterals are filleted open along the broken lines; B-B′, the true right and left pulmonary arteries are filleted open from hilum to hilum. C, A-A′ to B-B′, major AP collateral 1 is filleted open along its length all the way to the hilum and is anastamosed to the true pulmonary arteries, thereby augmenting the pulmonary arteries from hilum to hilum; C-C′ to D-D′ and F-F′ to E-E′, major AP collaterals 2 and 3 are anastomosed to the augmented true pulmonary arteries in an end-to-side fashion. Unifocalization and central pulmonary artery reconstruction are thus achieved without the need for non-native material. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 4 Diagrams of the anatomy of the major AP collaterals and true pulmonary arteries and the technique of unifocalization in a 9.2-month-old infant. A, Schematic representation of the anatomy of major AP collaterals and true pulmonary arteries. COR, coronary collateral; LPA, left pulmonary artery; RPA, right pulmonary artery; 1, 2, 3 and 4, major AP collaterals. B, B, Button of aortic wall with all the major AP collaterals is anastomosed to the right pulmonary artery, thereby achieving complete unifocalization. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 4 Diagrams of the anatomy of the major AP collaterals and true pulmonary arteries and the technique of unifocalization in a 9.2-month-old infant. A, Schematic representation of the anatomy of major AP collaterals and true pulmonary arteries. COR, coronary collateral; LPA, left pulmonary artery; RPA, right pulmonary artery; 1, 2, 3 and 4, major AP collaterals. B, B, Button of aortic wall with all the major AP collaterals is anastomosed to the right pulmonary artery, thereby achieving complete unifocalization. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 5 Schematic representations of the anatomy of the major AP collaterals and the technique of unifocalization. A, 1, 2, 3, and 4, major AP collaterals arising from a short segment of the descending aorta are stenotic at their origins. AO, Aorta. B, Each of the major AP collaterals (1, 2, 3, and 4) is anastomosed to an allograft conduit (HC), which is now the central pulmonary artery. A 6 mm ePTFE tube graft (G) is interposed to anastomose collateral 1 (which was posterior to the right bronchus is translocated anteriorly) to the allograft conduit. Non-native material was used in this 37.34-year-old patient, in whom growth was not an issue. T, Trachea. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 5 Schematic representations of the anatomy of the major AP collaterals and the technique of unifocalization. A, 1, 2, 3, and 4, major AP collaterals arising from a short segment of the descending aorta are stenotic at their origins. AO, Aorta. B, Each of the major AP collaterals (1, 2, 3, and 4) is anastomosed to an allograft conduit (HC), which is now the central pulmonary artery. A 6 mm ePTFE tube graft (G) is interposed to anastomose collateral 1 (which was posterior to the right bronchus is translocated anteriorly) to the allograft conduit. Non-native material was used in this 37.34-year-old patient, in whom growth was not an issue. T, Trachea. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 6 The trend of the pRV/pLV. Mean pRV/pLV 24 to 48 hours after repair was significantly (p < 0.02) lower than that measured in the operating room. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions

Fig. 7 Schematic representation of unifocalization in a 2.6-month-old infant who subsequently required reintervention. 1, A large major AP collateral supplying the entire right lower and middle lobes. *Site of communication of the large collateral 1 with the true right pulmonary artery. This communication later required balloon dilation. 2, Major AP collateral supplying the right upper lobe. 3, Major AP collateral supplying the left lower lobe. The large collateral (1) was ligated flush with the aorta. Collateral 3 was disconnected from the aorta and anastomosed end to side to collateral 1. Unifocalization was thus achieved. •, Site of occlusion of collateral 3 at its anastomosis with collateral 1. The Journal of Thoracic and Cardiovascular Surgery 1995 109, 832-845DOI: (10.1016/S0022-5223(95)70305-5) Copyright © 1995 Mosby, Inc. Terms and Conditions