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eComment: The anastomosis between aorta and extension conduit of the pulmonary artery

Istanbul University Istanbul Medical Faculty, Department of Cardiovascular Surgery, Capa 34390, Turkey

Systemic venous segments interposition for pulmonary artery to aorta connection

We read with interest the manuscript by Napoleone et al. [1] in which they present their two case experiences for the early palliation of VSD-PA cases. Actually the authors created a kind of central shunt, in other words, an aortopulmonary window [2] but with the aid of elongation graft material [3]. They also state in their manuscript that their technique permits a tension free anastomosis. However, the method also has advantages from other points of view as well as containing some surgical points to be stressed.

In very small caliber pulmonary arteries (e.g <3 mm) technical difficulties of performing shunt operations on the pulmonary branches and limited potential of these shunts on the pulmonary arterial growth have already been well documented. Thus, many authors recommend connection of the pulmonary artery to the ascending aorta or the aortic arch [4]. However, direct anastomosis of the pulmonary artery to the aorta has increased risks of acute pulmonary edema, early pulmonary vascular disease occurrence, and congestive cardiac failure. On the other hand, interposition of a graft, due to the resistance of the tissue itself to the blood flow passing through it, may attenuate these complications to a certain degree.

The other issue during creation of aortopulmonary window is a concern for the proximal anastomosis. The proximal anastomosis requires special precautions otherwise distortion in the pulmonary artery and its branches which can further cause unbalanced pulmonary blood flow and inhomogenous pulmonary arterial growth may be inevitable [5]. And such risks are increased even more when the main pulmonary artery or the extension conduit of the pulmonary artery is anastomosed to the lateral surface of the ascending aorta. In order to overcome those problems, as described above, some authors prefer to perform the proximal anastomosis to the aortic arch or to the posterolateral aspect of the ascending aorta. However, the difficulty in this case is that the technique requires cardiopulmonary bypass in certain cases.

Thus, rather than end to side anastomosis to the lateral surface of the aorta, we believe side to side anastomosis between the ascending aorta and the main pulmonary artery or extension conduit of the pulmonary artery is an easier alternative to avoid cardiopulmonary bypass and may provide better configuration as well as optimal pulmonary vasculature growth.

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1. Napoleone CP, Oppido G, Angeli E, Gargiulo GD. Systemic venous segments interposition for pulmonary artery to aorta connection. Interact CardioVasc Thorac Surg 2008;7:192–194.[Abstract/Free Full Text]
2. Duncan BW, Mee BBR, Prieto RL, Rosenthal LG, Mesia CI, Qureshi A, Tucker OP, Rhodes JF, Latson LA. Staged repair of tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. J Thorac Cardiovasc Surg 2003;126:694–702.[Abstract/Free Full Text]
3. Ugurlucan M, Sayin ÖA, Çinar T, Sürmen B, Aydogan Ü, Tireli E. Modified aortopulmonary window technique for the first stage treatment of patients with pulmonary atresia. Turk J Thorac Cardiovasc Surg 2007;15:41–44.
4. Batra AS, Starnes VA, Wells WJ. Does the site of insertion of a systemic-pulmonary shunt influence growth of the pulmonary arteries? Ann Thorac Surg 2005;79:636–640.[Abstract/Free Full Text]
5. Rodefeld MD, Reddy VM, Thompson LD, Suleman S, Moore PC, Teitel DF, Hanley FL. Surgical creation of aortopulmonary window in selected patients with pulmonary atresia with poorly developed aortopulmonary collaterals and hypoplastic pulmonary arteries. J Thorac Cardiovasc Surg 2002;123:1147–1154.[Abstract/Free Full Text]

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