- Email: [email protected]
A good chimney requires a good sweep
Accepted Manuscript Good Chimney Requires a Good Sweep Viktor Hraska, MD, PhD, Ronald K. Woods, MD, PhD. PII:
S0022-5223(17)31117-0
DOI:
10.1016/j.jtcvs.2017.05.064
Reference:
YMTC 11619
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 16 May 2017 Accepted Date: 18 May 2017
Please cite this article as: Hraska V, Woods RK, Good Chimney Requires a Good Sweep, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/j.jtcvs.2017.05.064. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Good Chimney Requires a Good Sweep.
2
Viktor Hraska, MD, PhD; Ronald K. Woods, MD, PhD.
4
Division of Congenital Heart Surgery; Department of Surgery, Medical College of Wisconsin,
5
Milwaukee, WI
6
RI PT
3
Conflict of Interest Statement and Sources of Funding:
8
The authors have nothing to disclose with regards to commercial support
M AN U
9
SC
7
Corresponding author:
11
Viktor Hraska, MD, PhD;
12
Division of Congenital Heart Surgery; Department of Surgery, Medical College of Wisconsin,
13
9000 W. Wisconsin Avenue, B730, Milwaukee, WI 53226
14
Email: [email protected]
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18 19 20
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Word count: 492
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ACCEPTED MANUSCRIPT
24
Central message
25
Tapering of the proximal neo-ascending aorta might provide a reconstructed aortic arch with
26
lower energy loss.
RI PT
27
Text
29
Asada and colleagues describe an innovative variation of autologous reconstruction of the aortic
30
arch in the Norwood procedure [1]. They describe this procedure for a patient with hypoplastic
31
left heart syndrome (HLHS) who had undergone newborn branch pulmonary artery (PA) banding
32
(as well as other repairs) followed by the Norwood procedure at approximately 2 months of age.
33
The key element of their “chimney reconstruction” is division of the main PA very distally for
34
the anterior 240 degrees, extending the division line proximally into the posterior pulmonary
35
sinus to create a U-shaped patch. This sets up the following important technical maneuvers: 1)
36
with primary closure of the posterior defect in the main PA, the main PA is reduced in diameter
37
while maintaining adequate length; and 2) the harvested U-shaped flap is used to create a patent
38
pulmonary bifurcation without the need for prosthetic material. The gradual tapering of the neo-
39
ascending aorta is purported to offer the dual advantage of 1) more space under the arch to
40
prevent compression of the left pulmonary artery and/or bronchus; and 2) a smoother caliber
41
transition of the ascending aorta into the aortic arch which might provide less energy loss.
42
This case report raises several technical issues. While the posterior U-shaped flap permits a more
43
distal PA incision anteriorly, the distal limit of this incision is inherent to each patient’s anatomy.
44
It is very likely that Asada’s patient had a very large and long pulmonary artery trunk, as is
45
typical after an extended period of branch PA banding. It is unclear whether this technique would
46
be uniformly effective for all primary Norwood procedures. The second issue is that the
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28
2
ACCEPTED MANUSCRIPT
reconstructed ascending aorta, aortic arch, and descending aorta lie in different planes.
48
Anteroposterior movement of these planes is more pronounced in the context of a long distal
49
transverse arch. Under these circumstances the risk of compression of the branch PA or bronchus
50
might be higher because the pulmonary trunk is either “pulled” more posteriorly to reach the
51
descending aorta, and/or the reconstructed descending aorta is “pulled” more superiorly and
52
anteriorly. A third issue is that this technique will be prone to result in a more gothic-shaped
53
arch, an anatomic characteristic that has been associated with greater energy loss and risk for
54
recurrent stenosis [2]. An excellent result in one patient and a reassuring CFD study are
55
inadequate to negate this concern. A final issue is that it would be difficult to use this technique
56
in certain variants of single ventricle anatomy with either transposed great vessels or an
57
interrupted aortic arch.
58
Given the limited availability of native tissues in patients with HLHS and the excellent results of
59
arch reconstruction obtained by interdigitated repair with patch augmentation [3,4], it is not
60
surprising that many surgeons continue to rely on patch augmentation for arch reconstruction
61
instead of autologous arch reconstruction.
62
We commend Asada and colleagues for introducing yet another technique of arch reconstruction
63
and await further data to verify its effectiveness.
65
66 67 68
SC
M AN U
TE D
EP
AC C
64
RI PT
47
References
1. Asada S, Yamagishi M, Itatani K, Yaku H. Chimney reconstruction of the aortic arch in the Norwood procedure. JTCVS in press 2. Voges I, Jerosch-Herold M, Hedderich J,Westphal C, Hart C, Helle M, et al. Maladaptive 3
ACCEPTED MANUSCRIPT
69
aortic properties in children after palliation of hypoplastic left heart syndrome assessed
70
by cardiovascular magnetic resonance imaging. Circulation. 2010;122:1068-76. 3. Burkhart H, Ashburn D, Konstanitinov I, et al. Interdigitating arch reconstruction
RI PT
71 72
eliminates recurrent coarctation after the Norwood procedure. J Thorac Cardiovasc Surg.
73
2005;130:61-5.
4. Lamers L, Frommelt P, Mussatto, K, Jaquiss R, Mitchell M, Tweddell, J. Coarctectomy
SC
74
combined with an interdigitating arch reconstruction results in a lower incidence of
76
recurrent arch obstruction after the Norwood procedure than coarctectomy alone. J
77
Thorac Cardiovasc Surg. 2012;143:1098-1102.
AC C
EP
TE D
M AN U
75
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0022-5223(17)31117-0
DOI:
10.1016/j.jtcvs.2017.05.064
Reference:
YMTC 11619
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 16 May 2017 Accepted Date: 18 May 2017
Please cite this article as: Hraska V, Woods RK, Good Chimney Requires a Good Sweep, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/j.jtcvs.2017.05.064. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Good Chimney Requires a Good Sweep.
2
Viktor Hraska, MD, PhD; Ronald K. Woods, MD, PhD.
4
Division of Congenital Heart Surgery; Department of Surgery, Medical College of Wisconsin,
5
Milwaukee, WI
6
RI PT
3
Conflict of Interest Statement and Sources of Funding:
8
The authors have nothing to disclose with regards to commercial support
M AN U
9
SC
7
Corresponding author:
11
Viktor Hraska, MD, PhD;
12
Division of Congenital Heart Surgery; Department of Surgery, Medical College of Wisconsin,
13
9000 W. Wisconsin Avenue, B730, Milwaukee, WI 53226
14
Email: [email protected]
15
18 19 20
EP
17
Word count: 492
AC C
16
TE D
10
21 22 23
1
ACCEPTED MANUSCRIPT
24
Central message
25
Tapering of the proximal neo-ascending aorta might provide a reconstructed aortic arch with
26
lower energy loss.
RI PT
27
Text
29
Asada and colleagues describe an innovative variation of autologous reconstruction of the aortic
30
arch in the Norwood procedure [1]. They describe this procedure for a patient with hypoplastic
31
left heart syndrome (HLHS) who had undergone newborn branch pulmonary artery (PA) banding
32
(as well as other repairs) followed by the Norwood procedure at approximately 2 months of age.
33
The key element of their “chimney reconstruction” is division of the main PA very distally for
34
the anterior 240 degrees, extending the division line proximally into the posterior pulmonary
35
sinus to create a U-shaped patch. This sets up the following important technical maneuvers: 1)
36
with primary closure of the posterior defect in the main PA, the main PA is reduced in diameter
37
while maintaining adequate length; and 2) the harvested U-shaped flap is used to create a patent
38
pulmonary bifurcation without the need for prosthetic material. The gradual tapering of the neo-
39
ascending aorta is purported to offer the dual advantage of 1) more space under the arch to
40
prevent compression of the left pulmonary artery and/or bronchus; and 2) a smoother caliber
41
transition of the ascending aorta into the aortic arch which might provide less energy loss.
42
This case report raises several technical issues. While the posterior U-shaped flap permits a more
43
distal PA incision anteriorly, the distal limit of this incision is inherent to each patient’s anatomy.
44
It is very likely that Asada’s patient had a very large and long pulmonary artery trunk, as is
45
typical after an extended period of branch PA banding. It is unclear whether this technique would
46
be uniformly effective for all primary Norwood procedures. The second issue is that the
AC C
EP
TE D
M AN U
SC
28
2
ACCEPTED MANUSCRIPT
reconstructed ascending aorta, aortic arch, and descending aorta lie in different planes.
48
Anteroposterior movement of these planes is more pronounced in the context of a long distal
49
transverse arch. Under these circumstances the risk of compression of the branch PA or bronchus
50
might be higher because the pulmonary trunk is either “pulled” more posteriorly to reach the
51
descending aorta, and/or the reconstructed descending aorta is “pulled” more superiorly and
52
anteriorly. A third issue is that this technique will be prone to result in a more gothic-shaped
53
arch, an anatomic characteristic that has been associated with greater energy loss and risk for
54
recurrent stenosis [2]. An excellent result in one patient and a reassuring CFD study are
55
inadequate to negate this concern. A final issue is that it would be difficult to use this technique
56
in certain variants of single ventricle anatomy with either transposed great vessels or an
57
interrupted aortic arch.
58
Given the limited availability of native tissues in patients with HLHS and the excellent results of
59
arch reconstruction obtained by interdigitated repair with patch augmentation [3,4], it is not
60
surprising that many surgeons continue to rely on patch augmentation for arch reconstruction
61
instead of autologous arch reconstruction.
62
We commend Asada and colleagues for introducing yet another technique of arch reconstruction
63
and await further data to verify its effectiveness.
65
66 67 68
SC
M AN U
TE D
EP
AC C
64
RI PT
47
References
1. Asada S, Yamagishi M, Itatani K, Yaku H. Chimney reconstruction of the aortic arch in the Norwood procedure. JTCVS in press 2. Voges I, Jerosch-Herold M, Hedderich J,Westphal C, Hart C, Helle M, et al. Maladaptive 3
ACCEPTED MANUSCRIPT
69
aortic properties in children after palliation of hypoplastic left heart syndrome assessed
70
by cardiovascular magnetic resonance imaging. Circulation. 2010;122:1068-76. 3. Burkhart H, Ashburn D, Konstanitinov I, et al. Interdigitating arch reconstruction
RI PT
71 72
eliminates recurrent coarctation after the Norwood procedure. J Thorac Cardiovasc Surg.
73
2005;130:61-5.
4. Lamers L, Frommelt P, Mussatto, K, Jaquiss R, Mitchell M, Tweddell, J. Coarctectomy
SC
74
combined with an interdigitating arch reconstruction results in a lower incidence of
76
recurrent arch obstruction after the Norwood procedure than coarctectomy alone. J
77
Thorac Cardiovasc Surg. 2012;143:1098-1102.
AC C
EP
TE D
M AN U
75
4
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT