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Closure of aortopulmonary septal defect
Volume 93
Brief communications
Number 5 May 1987
the unfinished upper and middle lobe branches. After restoration of blood flow to the left lower lobe, immediate hemodynamic improvement was obtained and the patient was quite stable during the rest of the procedure. A second patch arterioplasty for the contralateral pulmonary artery is usually performed very safely as enough blood flow is maintained to the opposite lung during the procedure. Final definitive intracardiac repair for supravalvular aortic stenosis with cardiopulmonary bypass should be performed safely without any additional risks when scheduled after the patient's full recovery from the bilateral thoracotomies. Both of our patients were doing well on follow-up (2 years 4 months and 1 year 9 months after the initial operation) without any x-ray signs of decreased pulmonary vascularity or electrocardiographic signs of right ventricular overload. In Case 1, cardiac catheterization performed 1 month after the extended aortoplasty (10 months after the initial pulmonary patch arterioplasty) revealed pressure gradients of 8 and 10 mm Hg between the main pulmonary artery and the right distal and left distal pulmonary arteries, respectively. REFERENCES Doty DB, Polansky DB,Jenson CB.Supravalvular aortic stenosis: repair by extended aortoplasty. J THORAC CARD10VASC SURG 1977;74:362-71. 2. Bernhard WF, Keane JF, Fellows KE, Litwin SB, Gross RE.Progress and problems inthe surgical management of congenital aortic stenosis. J THORAC CARDIOVASC SURG 1973;66:404-19. 3. Weisz D, Hartmann AF Jr, Weldon CS. Results of surgery for congenital supravalvular aortic stenosis. Am J Cardiol 1976;37:73~ 7. 4. Landes RG, Zavoral JH, Emery RW, Moller JH, Lindsay WG, Nicoloff OM. The surgical management of vascular abnormalities associated with supravalvular aortic stenosis. J THORAC CARDIOVASC SURG 1978;75:80-6. 5. Ring JC, Bass JL, Marvin W, et al. Management of congenital stenosis of a branch pulmonary artery with balloon dilation angioplasty. J THORAC CARDIOVASC SURG 1985;90:35-44. 6. Rocchini AP, Kveselis D, Dich M, Crowley 0, SniderR, Rosenthal A. Use of balloon angioplasty to treat peripheral pulmonary stenosis. Am J Cardiol 1984;54:106973. 7. McCue CM, Robertson LW, Lester RG, Mauck HP Jr. Pulmonary artery coarctations: a report of 20 cases with review of 319 cases from the literature. J Pediatr 1965;67:222-38. 8. D'Cruz lA, Agustsson MH, Bicoff JP, Weinberg M Jr, Argilla RA. Stenotic lesions of the pulmonary arteries: clinical and hemodynamic findings in 84 cases. Am J CardioI1964;13:441-50. I.
789
9. Weinberg M Jr, Agustsson MH, D'Cruz lA, et al. Stenosis of the branches of the pulmonary artery. J THORAC CARDIOVASC SURG 1964;47:40-9. 10. Smith GW, Thompson WM, Muller WHo Surgical treatment of pulmonary hypertension secondary to multiple bilateral pulmonary arterial stenosis. Circulation 1964;29 (Suppl): 152-6.
Closure of aortopulmonary septal defect P. Shatapathy, M.Ch.,
K. Madhusudhana Rao, M.Ch., and K. V. Krishnan, M.Ch., Manipal, India From the Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College and Hospital, Manipal, India. An alternative technique for closure of an aortopuImonary septal defect is presented.
Faulty embryogenesis of septation of the aortopulmonary trunk results in a defect between the ascending aorta and the main pulmonary artery, referred to as an aortopulmonary window."! Typically, in a heart with normally related great arteries, the defect is located in the proximal portion of the ascending aorta on the medial wall just above the right and left sinuses of Valsalva of the aortic valve. This has previously been designated as type I aortopulmonary septal defect. The type II defect is located more distally on the ascending aorta and opens into the main pulmonary artery near its bifurcation.v' In 1952 Gross' successfullyclosed an aortopulmonary septal defect for the first time. Since then, a variety of techniques have been employed, all of which are associated with significant technical problems.?" A simple, safe, and effective method of repair, applicable to all types of aortopulmonary septal defects, was initially attempted on an animal model and later was used successfully in one subject with a type II anomaly. Method. The heart is exposed via a median sternotomy with the pericardium marsupialized. The extent and location of the aortopulmonary septal defect is readily gauged. The ascending aorta is usually cannulated, as
Address for correspondence: P. Shatapathy, M.S., M.Ch., F.A.C.S., Professor and Head, Department ofCardiovascular and Thoracic Surgery, Kasturba Medical College and Hospital, Manipal, India-576 119.
790
The Journal of Thoracic and Cardiovascular Surgery
Brief communications
Fig. 1. Operative technique for aortopulmonary window.
indeed was done in our subject, for the return of blood from the pump-oxygenator. However, if the length of the ascending aorta distal to the defect is considered insufficient for cannulation as well as for application of the cross-clamp, then there should be no hesitation in directing the arterial inflow into the femoral artery, the groin having been prepared and draped earlier. As soon as cardiopulmonary bypass is instituted, the aortopulmonary connection is occluded by digital pressure applied on the pulmonary artery side of the defect, until the core temperature is lowered to between 30° and 32° C and the aorta is cross-clamped. Once the aorta is cross-clamped, the aortopulmonary connection is detached by incising the pulmonary artery adjacent to the defect. This procedure borrows tissue from the latter (Figs. 1, A and 2, A) while avoiding any possible injury to the pulmonary valve or the left main coronary artery, which traverses close by. The aortic defect is sutured vertically with two layers of running
4-0 Prolene suture (Fig. 1, B). This part of the operation is comfortably completed in 10 to 15 minutes, a length of time that is considered safe for ischemic arrest of the heart. The aortic cross-clamp is now released, with care taken to aspirate air from the aortic root before coronary perfusion is reestablished. At this stage the cardioplegic solution of choice may be conveniently administered if so desired. The aortic end of the anomaly having been closed by "borrowing" from the pulmonary artery, there is now a resultant defect in the latter that may extend into the right pulmonary artery, as was the case in our subject. This defect is reconstituted with either a polytetrafluoroethylene graft or autogenous pericardium (Figs. 1, C and 2, B). Advantages of the method. 1. Dissection is totally avoided around the "fistula" between the aorta and the pulmonary artery, which has virtually no length, is usually thin-walled and under high
Volume 93
Brief communications 7 9 1
Number 5 May 1987
o
(!)
BEFORE REPAIR
AFtER REPAIR
Fig. 2. Cross-sectional view. PA, Pulmonary artery. A, Aorta. W. Aortopulmonary window. Open outlined area, Wall of pulmonary artery. Dotted outlined area, Wall of aorta. Lined outlined area, Patch on pulmonary artery. Arrows, Line of incision on the pulmonary artery to "borrow" tissue.
pressure, and does not allow adequate access because of its peculiar location. 2. Because the aortopulmonary connection is completely disconnected, there is no question of leaving any residual defect. 3. The aortic closure is accomplished in such a short time that the period of interruption of the coronary circulation should be of no material consequence. 4. Bleeding from the suture lines comes under direct view and can be controlled easily. 5. All types of aortopulmonary septal defects can be closed by means of this technique. Because the basic defect in this anomaly is a failure in the development of aortopulmonary septal tissue (the spiral bulbar septum), it is to be expected that direct suturing of the ends of the divided communication may be accomplished only by producing significant narrowing of one or both great arteries. The aorta is therefore closed by "borrowing" from the pulmonary artery and the latter is reconstructed with a patch graft. Our clinical experience with this new method of repair is limited to an 18-year-old male subject who had
a type II defect. He underwent operation on Dec. 12, 1983, had an uneventful postoperative recovery, and was reinvestigated on April 2, 1984. The pulmonary artery pressure had dropped from a preoperative value of 105/68 to 38/8 mm Hg at follow-up, and the aortogram showed no distortion or narrowing of the ascending aorta. REFERENCES I. Eliotson J. Case of malformation of the pulmonary artery and aorta. Lancet 1830;1:247. 2. Cucci CE, Doyle EF, Lewis EW. Absence of a primary division of the pulmonary trunk: an autogenetic theory. Circulation 1964;29:1964. 3. Mori K, Ando M, Takao A, Ishikawa S, Imai Y. Distal type of aortopulmonary window: report of 4 cases. Br Heart J 1978;40:681. 4. Richardson JV, Doty DB, Rose NP, Ehrenhaft JL. The spectrum of anomalies of aortopulmonary septation. J THORAC CARDIOVASC SURG 1979;78:21. 5. Gross RE. Surgical closure of an aortic septal defect. Circulation 1952;5:858. 6. Cooley DA, McNamara DG, Latson JR. Aorticopulmonary septal defect: diagnosis and surgical treatment. • Surgery 1957;42:101. 7. Putnam TC, Gross RE. Surgical management of aortopulmonary fenestration. Surgery 1966;59:727. 8. Wright JS, Freeman R, Johnston JB. Aorto-pulmonary fenestration: a technique of surgical management. J. THORAC CARDIOVASC SURG 1968;55:280. 9. Doty DB, Richardson JV, Falkovsky GE, Gordonova MI, Burakovsky VI. Aortopulmonary septal defect: hemodynamics, angiography, and operation. Ann Thorac Surg 1981;32:244. 10. Scott HW Jr, Sabiston DC Jr. Surgical treatment for congenital aorticopulmonary fistula: experimental and clinical aspects. J THORAC SURG 1953;25:26. 11. Neufield HN, Lester RG, Adams P Jr, Anderson RC, Lillehei CW, Edwards JE. Aorticopulmonary septal defect. Am J Cardiol 1962;9:12. 12. Meissner H, Schmit Habelman P, Schonning F, KIener W. Surgical correction of aorto-pulmonary septal defect: a review of literature and report of 8 cases. Chest 1968;53:750. 13. Deverall PB, Lincoln JCR, Aberdeen E, Bonham Carter RE, Watson OJ. Aortopulmonary window. J THORAC CARDIOVASC SURG 1969;57:479. 14. Bleiden LC, MoUer JH. Aortico-pulmonary septal defect: an experience with 17 patients. Br Heart J 1974;36: 630. 15. Clarke CP, Richardson JP. The management of aortopulmonary window: advantages of transaortic closure with a Dacron patch. J THORAC CARDIOVASC SURG 1976; 72:48.
Brief communications
Number 5 May 1987
the unfinished upper and middle lobe branches. After restoration of blood flow to the left lower lobe, immediate hemodynamic improvement was obtained and the patient was quite stable during the rest of the procedure. A second patch arterioplasty for the contralateral pulmonary artery is usually performed very safely as enough blood flow is maintained to the opposite lung during the procedure. Final definitive intracardiac repair for supravalvular aortic stenosis with cardiopulmonary bypass should be performed safely without any additional risks when scheduled after the patient's full recovery from the bilateral thoracotomies. Both of our patients were doing well on follow-up (2 years 4 months and 1 year 9 months after the initial operation) without any x-ray signs of decreased pulmonary vascularity or electrocardiographic signs of right ventricular overload. In Case 1, cardiac catheterization performed 1 month after the extended aortoplasty (10 months after the initial pulmonary patch arterioplasty) revealed pressure gradients of 8 and 10 mm Hg between the main pulmonary artery and the right distal and left distal pulmonary arteries, respectively. REFERENCES Doty DB, Polansky DB,Jenson CB.Supravalvular aortic stenosis: repair by extended aortoplasty. J THORAC CARD10VASC SURG 1977;74:362-71. 2. Bernhard WF, Keane JF, Fellows KE, Litwin SB, Gross RE.Progress and problems inthe surgical management of congenital aortic stenosis. J THORAC CARDIOVASC SURG 1973;66:404-19. 3. Weisz D, Hartmann AF Jr, Weldon CS. Results of surgery for congenital supravalvular aortic stenosis. Am J Cardiol 1976;37:73~ 7. 4. Landes RG, Zavoral JH, Emery RW, Moller JH, Lindsay WG, Nicoloff OM. The surgical management of vascular abnormalities associated with supravalvular aortic stenosis. J THORAC CARDIOVASC SURG 1978;75:80-6. 5. Ring JC, Bass JL, Marvin W, et al. Management of congenital stenosis of a branch pulmonary artery with balloon dilation angioplasty. J THORAC CARDIOVASC SURG 1985;90:35-44. 6. Rocchini AP, Kveselis D, Dich M, Crowley 0, SniderR, Rosenthal A. Use of balloon angioplasty to treat peripheral pulmonary stenosis. Am J Cardiol 1984;54:106973. 7. McCue CM, Robertson LW, Lester RG, Mauck HP Jr. Pulmonary artery coarctations: a report of 20 cases with review of 319 cases from the literature. J Pediatr 1965;67:222-38. 8. D'Cruz lA, Agustsson MH, Bicoff JP, Weinberg M Jr, Argilla RA. Stenotic lesions of the pulmonary arteries: clinical and hemodynamic findings in 84 cases. Am J CardioI1964;13:441-50. I.
789
9. Weinberg M Jr, Agustsson MH, D'Cruz lA, et al. Stenosis of the branches of the pulmonary artery. J THORAC CARDIOVASC SURG 1964;47:40-9. 10. Smith GW, Thompson WM, Muller WHo Surgical treatment of pulmonary hypertension secondary to multiple bilateral pulmonary arterial stenosis. Circulation 1964;29 (Suppl): 152-6.
Closure of aortopulmonary septal defect P. Shatapathy, M.Ch.,
K. Madhusudhana Rao, M.Ch., and K. V. Krishnan, M.Ch., Manipal, India From the Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College and Hospital, Manipal, India. An alternative technique for closure of an aortopuImonary septal defect is presented.
Faulty embryogenesis of septation of the aortopulmonary trunk results in a defect between the ascending aorta and the main pulmonary artery, referred to as an aortopulmonary window."! Typically, in a heart with normally related great arteries, the defect is located in the proximal portion of the ascending aorta on the medial wall just above the right and left sinuses of Valsalva of the aortic valve. This has previously been designated as type I aortopulmonary septal defect. The type II defect is located more distally on the ascending aorta and opens into the main pulmonary artery near its bifurcation.v' In 1952 Gross' successfullyclosed an aortopulmonary septal defect for the first time. Since then, a variety of techniques have been employed, all of which are associated with significant technical problems.?" A simple, safe, and effective method of repair, applicable to all types of aortopulmonary septal defects, was initially attempted on an animal model and later was used successfully in one subject with a type II anomaly. Method. The heart is exposed via a median sternotomy with the pericardium marsupialized. The extent and location of the aortopulmonary septal defect is readily gauged. The ascending aorta is usually cannulated, as
Address for correspondence: P. Shatapathy, M.S., M.Ch., F.A.C.S., Professor and Head, Department ofCardiovascular and Thoracic Surgery, Kasturba Medical College and Hospital, Manipal, India-576 119.
790
The Journal of Thoracic and Cardiovascular Surgery
Brief communications
Fig. 1. Operative technique for aortopulmonary window.
indeed was done in our subject, for the return of blood from the pump-oxygenator. However, if the length of the ascending aorta distal to the defect is considered insufficient for cannulation as well as for application of the cross-clamp, then there should be no hesitation in directing the arterial inflow into the femoral artery, the groin having been prepared and draped earlier. As soon as cardiopulmonary bypass is instituted, the aortopulmonary connection is occluded by digital pressure applied on the pulmonary artery side of the defect, until the core temperature is lowered to between 30° and 32° C and the aorta is cross-clamped. Once the aorta is cross-clamped, the aortopulmonary connection is detached by incising the pulmonary artery adjacent to the defect. This procedure borrows tissue from the latter (Figs. 1, A and 2, A) while avoiding any possible injury to the pulmonary valve or the left main coronary artery, which traverses close by. The aortic defect is sutured vertically with two layers of running
4-0 Prolene suture (Fig. 1, B). This part of the operation is comfortably completed in 10 to 15 minutes, a length of time that is considered safe for ischemic arrest of the heart. The aortic cross-clamp is now released, with care taken to aspirate air from the aortic root before coronary perfusion is reestablished. At this stage the cardioplegic solution of choice may be conveniently administered if so desired. The aortic end of the anomaly having been closed by "borrowing" from the pulmonary artery, there is now a resultant defect in the latter that may extend into the right pulmonary artery, as was the case in our subject. This defect is reconstituted with either a polytetrafluoroethylene graft or autogenous pericardium (Figs. 1, C and 2, B). Advantages of the method. 1. Dissection is totally avoided around the "fistula" between the aorta and the pulmonary artery, which has virtually no length, is usually thin-walled and under high
Volume 93
Brief communications 7 9 1
Number 5 May 1987
o
(!)
BEFORE REPAIR
AFtER REPAIR
Fig. 2. Cross-sectional view. PA, Pulmonary artery. A, Aorta. W. Aortopulmonary window. Open outlined area, Wall of pulmonary artery. Dotted outlined area, Wall of aorta. Lined outlined area, Patch on pulmonary artery. Arrows, Line of incision on the pulmonary artery to "borrow" tissue.
pressure, and does not allow adequate access because of its peculiar location. 2. Because the aortopulmonary connection is completely disconnected, there is no question of leaving any residual defect. 3. The aortic closure is accomplished in such a short time that the period of interruption of the coronary circulation should be of no material consequence. 4. Bleeding from the suture lines comes under direct view and can be controlled easily. 5. All types of aortopulmonary septal defects can be closed by means of this technique. Because the basic defect in this anomaly is a failure in the development of aortopulmonary septal tissue (the spiral bulbar septum), it is to be expected that direct suturing of the ends of the divided communication may be accomplished only by producing significant narrowing of one or both great arteries. The aorta is therefore closed by "borrowing" from the pulmonary artery and the latter is reconstructed with a patch graft. Our clinical experience with this new method of repair is limited to an 18-year-old male subject who had
a type II defect. He underwent operation on Dec. 12, 1983, had an uneventful postoperative recovery, and was reinvestigated on April 2, 1984. The pulmonary artery pressure had dropped from a preoperative value of 105/68 to 38/8 mm Hg at follow-up, and the aortogram showed no distortion or narrowing of the ascending aorta. REFERENCES I. Eliotson J. Case of malformation of the pulmonary artery and aorta. Lancet 1830;1:247. 2. Cucci CE, Doyle EF, Lewis EW. Absence of a primary division of the pulmonary trunk: an autogenetic theory. Circulation 1964;29:1964. 3. Mori K, Ando M, Takao A, Ishikawa S, Imai Y. Distal type of aortopulmonary window: report of 4 cases. Br Heart J 1978;40:681. 4. Richardson JV, Doty DB, Rose NP, Ehrenhaft JL. The spectrum of anomalies of aortopulmonary septation. J THORAC CARDIOVASC SURG 1979;78:21. 5. Gross RE. Surgical closure of an aortic septal defect. Circulation 1952;5:858. 6. Cooley DA, McNamara DG, Latson JR. Aorticopulmonary septal defect: diagnosis and surgical treatment. • Surgery 1957;42:101. 7. Putnam TC, Gross RE. Surgical management of aortopulmonary fenestration. Surgery 1966;59:727. 8. Wright JS, Freeman R, Johnston JB. Aorto-pulmonary fenestration: a technique of surgical management. J. THORAC CARDIOVASC SURG 1968;55:280. 9. Doty DB, Richardson JV, Falkovsky GE, Gordonova MI, Burakovsky VI. Aortopulmonary septal defect: hemodynamics, angiography, and operation. Ann Thorac Surg 1981;32:244. 10. Scott HW Jr, Sabiston DC Jr. Surgical treatment for congenital aorticopulmonary fistula: experimental and clinical aspects. J THORAC SURG 1953;25:26. 11. Neufield HN, Lester RG, Adams P Jr, Anderson RC, Lillehei CW, Edwards JE. Aorticopulmonary septal defect. Am J Cardiol 1962;9:12. 12. Meissner H, Schmit Habelman P, Schonning F, KIener W. Surgical correction of aorto-pulmonary septal defect: a review of literature and report of 8 cases. Chest 1968;53:750. 13. Deverall PB, Lincoln JCR, Aberdeen E, Bonham Carter RE, Watson OJ. Aortopulmonary window. J THORAC CARDIOVASC SURG 1969;57:479. 14. Bleiden LC, MoUer JH. Aortico-pulmonary septal defect: an experience with 17 patients. Br Heart J 1974;36: 630. 15. Clarke CP, Richardson JP. The management of aortopulmonary window: advantages of transaortic closure with a Dacron patch. J THORAC CARDIOVASC SURG 1976; 72:48.