Interactive Cardiovascular and Thoracic Surgery 3:145-147(2004)
© 2004 European Association of Cardio-Thoracic Surgery
The use of pulmonary autograft patch for type A aortic interruption and Swiss-cheese ventricular septal defect (VSD)
Gürkan Çetina,
Emin Tirelia,*,
Ahmet Özkaraa and
Funda Öztunçb
a Department of Cardiovascular Surgery, Institute of Cardiology, Istanbul University, 81070 Istanbul, Turkey
b Department of Paediatric Cardiology, Medical Faculty of Cerrahpa a, 81070 Istanbul, Turkey
* Corresponding author. Tel.: +90-542-234-2865; fax: +90-212-529-1188
emintireli{at}yahoo.com
Received August 22, 2003;
received in revised form October 17, 2003;
accepted November 10, 2003
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Abstract
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The surgical management of the aortic arch pathologies is controversial. Primary anastomosis and patch aortoplasties combined with end-to-end anastomosis have some complications like recurrence and aneurysm formation. Surgical repair of apical muscular (Swiss-cheese) defects is also still under debate. A 6-year-old patient with diagnosis of type A aortic arch interruption and Swiss-cheese ventricular septal defect (VSD) underwent successful intracardiac repair and aortic arch reconstruction. Aortic arch reconstruction was done by end-to-side anastomosis of distal aortic archus and thoracic aorta without cardiopulmonary bypass. The anterior side of the anastomosis was augmented by using pulmonary autograft patch and this patch was extended to the inferior surface of the archus aorta. Swiss-cheese VSD was repaired with a single patch using septal obliteration technique via transatrial approach. Pulmonary autograft patch aortoplasty and end-to-side anastomosis may be an alternative surgical management for surgical repair and it may be done without the need for cardiopulmonary bypass. In these patients associated multiple apical muscular VSDs can be repaired with a single patch, septal obliteration technique.
Key Words: Pulmonary autograft; Aortic arch interruption; Swiss-cheese ventricular septal defect
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1. Introduction
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Aortic arch interruption with ventricular septal defect (VSD) is a common congenital heart disease. Surgical correction has to be performed in the neonatal period because serious and irreversible respiratory problems may appear within the first few months. Swiss-cheese VSD is very rarely seen with aortic arch interruption. Surgical managements of such cases are controversial.
In this case report we describe the rare presentation of this anomaly. Our patient is 6 years old with diagnosis of type A aortic interruption with multiple trabecular VSDs. She underwent a successful aortic arch repair with pulmonary autograft patch without using CPB and intracardiac repair with a single patch, septal obliteration technique.
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2. Case report
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A 6-year-old child presented with New York Heart Association (NYHA) Class-III, dyspnoea on exertion for the last 4 years. There was cyanosis at the lower extremities. On examination, the only positive finding was the presence of grade 1-2/6 systolic murmur at base. Arterial saturation was measured 98% at the upper extremity and 85% at the lower extremity on pulse oximetry.
Transthoracic two-dimensional echocardiography revealed normally related great arteries, multiple VSDs (Swiss-cheese VSD), and large pulmonary artery. There were multiple left–right shunts through VSDs.
On cardiac catheterisation, type A aortic interruption and multiple VSDs were determined. Catheter was passed from pulmonary artery to descending aorta through ductus arteriosus (Fig. 1a). Apically located multiple VSDs were seen on left ventriculography (Fig. 1b). Saturation of the right atrium, the right ventricle, the pulmonary artery, the ascending and descending aorta were 76, 86, 90, 97 and 90%, respectively. Systolic pressure of the left ventricle, the right ventricle and pulmonary artery were measured 100, 100 and 100/55 mmHg, respectively.
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Fig. 1 Preoperatively cardiac catheterisation of the patient (PDA, patent ductus arteriosus; PA, pulmonary artery; Ao. d, descending aorta; LV, left ventricle; Ao. Int, aortic interruption). (a) Ductus-dependent lower body circulation is seen. Catheter was passed from pulmonary artery to descending aorta through large ductus arteriosus. (b) Apical located multiple ventricular septal defects (Swiss-cheese) and aortic interruption type A were seen on left ventriculography.
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Following median sternotomy, aortic arch, descending aorta, pulmonary artery and ductus arteriosus were prepared. Pulmonary artery was approximately 2.5 times larger than the ascending aorta. Ascending aorta and proximal archus aorta were normal in calibre. There was progressive narrowing of archus aorta starting from origin of left carotis artery. Large PDA was continued with descending aorta. We thought that direct anastomosis of the distal archus aorta to the descending thoracic aorta might cause gradient through the anastomosis so we augmented the anastomosis and distal archus aorta by using a piece of pulmonary autograft patch. We did this procedure without using CPB. Since the main pulmonary artery was large enough, adequate sized pulmonary autograft patch was resected by clamping the main pulmonary artery just above the pulmonary valves and till to the origin of PDA with a side clamp. Pulmonary artery was repaired primarily. Proximal aortic arch including the half of the origin of the truncus brachiocephalicus was clamped. PDA was ligated and descending thoracic aorta was also clamped. All the ductal tissues were resected. Inferior surface of distal archus aorta was incised beginning from the origin of subclavian artery to the proximal clamp. Lateral and posterior end of descending aorta was sutured primarily to the posterior end of the previously incised distal archus aorta by using 6–0 polypropylene suture. Anterior surface of narrow distal archus aorta was enlarged and remaining part of anastomosis was completed by using pulmonary artery autograft patch. Aortic clamp time was 25 min. Than the patient was cooled down to 32 °C, after cardiopulmonary bypass was initiated by using aortic and bicaval cannulation. Following cross-clamp, right atriotomy was done. Apical trabecular VSDs were exposed during saline injection through left ventricular vent. Trabecular septum was closed with single patch, septal obliteration technique without division of the moderator band by using 15 separate teflon pledgetted, 5–0 polypropylene sutures and gluteraldehyde fixated pericardial patch. Three fixation sutures were placed to prevent bulging of the patch into the right ventricle. Aortic cross-clamp time was 60 min. Cardiopulmonary bypass was finished by using inotropic agents in low doses without any problem. Arterial saturation difference between right atrium and pulmonary artery was not significant. Systemic and pulmonary arterial pressures were 110/50 and 50/20 mmHg, respectively.
The patient was extubated at 12th hour postoperatively. Cardiac catheterisation was done 1 month postoperation. Aortagraphy and left ventriculography are seen in Fig. 2a and b. A minimal residual VSD is also revealed in Fig. 2a.
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Fig. 2 Cardiac catheterisation on postoperative first month (LV, left ventricle; res. VSD, residual ventricular septal defect). (a) A minimal residual VSD is revealed on left ventriculography. (b) Normal anatomical continuity of the arcus and descending aorta is seen after correction of interruption with pulmonary autograft patch.
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3. Discussion
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Aortic arch interruption with VSD is a congenital defect, which usually manifests itself in the neonatal period. Therefore most of the reports have concentrated on the management of this anomaly in the neonates [1].
The case that we have described is an unusual presentation of this anomaly. Our 6-year-old patient had a relatively asymptomatic childhood, with normal physical growth. Many authors prefer single stage repair in the neonatal period [2] using hypothermic circulatory arrest or regional cerebral perfusion [3]. In rare adult patients extraanatomical repair is preferred [4]. Strength of anastomosis and left main bronchial compression are complications of direct anastomosis in aortic archus reconstruction. Roussin and colleagues [5] reported pulmonary autograft patch aortaplasty in 20 patients. We used the technique pulmonary autograft patch aortaplasty and end-to-side anastomosis to reduce the tension on the anastomosis and to maintain growth potential. Surgical management of apical muscular (Swiss-cheese) defects is controversial. Surgical technique of ‘single patch repair with intermediate fixing’ through the right atrium is described to avoid right or left ventriculotomy. We used the septal obliteration technique on cardiopulmonary bypass following aortic arch reconstruction.
In conclusion, pulmonary autograft patch aortoplasty without CPB may be an alternative surgical management of the patients with diagnosis of aortic arch interruption. In these patients concomitant multiple apical muscular VSDs can be repaired with single patch, septal obliteration technique, successfully.
doi:10.1016/S1569-9293(03)00260-3
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References
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- Sandhu SK, Beekman RH, Mosca RS, Bove EL. Single-stage repair of aortic arch obstruction and associated intracardiac defects in the neonate. Am J Cardiol. 1995;75:370–373[CrossRef][Medline]
- Tchervenkov CT, Tahta SA, Jutras L, Beland MJ. Single stage repair of aortic arch obstruction and associated intracardiac defects with pulmonary homograft patch aortoplasty. J Thorac Cardiovasc Surg. 1998;116:897–904[Abstract/Free Full Text]
- Lacour-Gayet F, Serraf A, Galletti L, Bruniaux J, Belli E, Piot D, Touchot A, Petit J, Houyel L, Planche C. Biventricular repair of conotruncal anomalies associated with aortic arch obstruction. Circulation. 1997;96:II328–II334
- Messner G, Reul GS, Flamm SD, Gregoric ID, Opfermann UT. Interrupted aortic arch in a adult single stage extraanatomic repair. Tex Heart J. 2002;29:118–121
- Roussin R, Belli E, Lacour-Gayet F, Godart F, Rey C, Bruniaux J, Planche C, Serraf A. Aortic arch reconstruction with pulmonary autograft patch aortoplasty. J Thorac Cardiovasc Surg. 2002;123:443–450[Abstract/Free Full Text]
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Abstract
1. Introduction