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Repair of pulmonary arterial stenosis after Waterston-Cooley anastomosis
Repair of pulmonary arterial stenosis after Waterston-Cooley anastomosis Within the spectrum of neonatal congenital cyanotic heart disease. emergent surgery is often necessary to correct profound pulmonary hypoperfusion . An ascending aorto-to-pulmonary artery anastomosis (Waterston-Cooley ) has proved to be the preferred procedure in selected patients. A new technique to correct the occasional resultant pulmonary arterial deformity is presented which is performed concomitantly with definitive intracardiac correction.
Denton A. Cooley, M.D., and J. Marvin Smith, M.D., Houston, Texas
DeSPite an increasing emphasis upon definitive intracardiac repair during infancy in patients with tetralogy of Fallot and other anomalies causing cyanosis, palliative procedures which provide a systemic-pulmonary arterial shunt maintain a place in the cardiac surgeon's armamentarium. The Blalock-Taussig! operation consisting of subclavian-pulmonary artery anastomosis was the first to be applied clinically. The Potts-Smith" shunt, which created a side-to-side anastomosis between the proximal descending thoracic aorta and adjacent pulmonary artery, was introduced several years later. Both of these techniques were widely used, but subsequently they proved to have disadvantages that were partially eliminated with the introduction of side-to-side anastomosis between the ascending aorta and the right main pulmonary artery. Waterston" first described, in the Czechoslovakian literature, the technique using an extrapericardial posterior approach. Later, unaware of his report, we" described a transpericardial technique through an anterolateral approach. Thus the Waterston-Cooley anastomosis soon became the procedure of choice in many centers. The advantages cited for this technique were numerous, but most important was the relative ease of surgical closure when intracardiac repair was performed. Reports from our center by Reitman and associates," and more recently from other centers, 6-10 have deFrom the Division of Surgery, the Texas Heart Institute, St. Luke's Episcopal and Texas Children's Hospitals, Houston, Texas. Received for publication Aug. 23, 1978. Accepted for publication Oct. 10, 1978. Address for reprints: Dr. Denton A. Cooley, Texas Heart Institute, P.O. Box 20345, Houston, Texas 77025.
474
scribed the results. The operation introduced technical difficulties, since the diameter of the anastomosis was critical. Also, critical relationships between the large aorta and the small right pulmonary artery led to kinking, stenosis, and obstruction of the pulmonary artery. Repair of such iatrogenic deformities of the pulmonary artery becomes necessary if integrity of pulmonary circulation to the right lung is to be restored after intracardiac repair. In the usual situation, when no deformity of the right pulmonary artery is noted on the preoperative angiograms, the anastomosis can be closed readily by a transaortic approach. I I When kinking and stenosis of the artery exist, separation of the delicate pulmonary artery from the aorta by a tedious dissection has been used. Usually, this involves a patch graft angioplasty on the pulmonary artery, which may be fragmented because of its friability and surrounding fibrosis. Postoperative bleeding from the artery has occurred in some patients, and distortion of the pulmonary artery often results. In a previous report, we" described a somewhat radical surgical technique for repair of the stenotic underlying pulmonary artery, particularly in patients with pulmonary branch stenosis. Transection of the ascending aorta provides access to the right and left pulmonary arteries and allows extensive patch graft angioplasty of the entire intrapericardial segment. That method should be reserved for only the most difficult problems. Recently, we have employed a method which accomplishes the desired result for less severe arterial deformities with simple arterial stenosis or kinking, namely, restoration of normal continuity and luminal size of the pulmonary artery. The repair is technically simpler and not associated with extensive mediastinal dissection.
0022-5223/79/030474+04$00.40/0 © 1979 The C. V. Mosby Co.
Volume 77 Number 3 March,1979
Repair of pulmonary arterial stenosis
475
,hunt
Fig. I. A to F , Drawing showing steps in aorti copulmonary ang ioplasty using a woven Dacron patch . £ and E ' , In placin g the sutures into the patch graft . the suture should incorporate the ed ge of the aorta and the underlying pulmonary artery .
Technique
The usual midline sternotomy approach is used and cannulation is performed for temporary total cardiopulmonary bypass. Cannulation of the aorta should be made more cephalad than usual to allow cross-
clamping of the aorta distal to the aorticopulmonary j unction. After caval inflow is instituted. the aorta is cross-clamped at the highest possible level without occlud ing the aortic cannula . Cold cardioplegic solution containing potassium ion and other ingredients is
476
The Joumal of 1lloracic and Cardiovascular Surgery
Cooley and Smith
CD Fig. 2. Pulmonary arteriograms made before and 2 month s following patch graft repa ir. A. Almost complete obstruction of a deformed right pulmonary artery is evident. The catheter tip was inserted direct ly into the ana stomosi s from the ascending aorta. B. After operation. the stenosi s has been relieved without residual pressure gradient across this area. although the artery remain s irregular in configuration .
injected into the proximal aorta until cardiac arrest is obtained. A sump suction drain is inserted into the left atrium through the right superior pulmonary vein. With the quiet blood-free field attained, a transverse aortotomy incision is made and the anastomotic open ing is identified (Fig. I). A short incision is made laterally in the distal right pulmonary artery, all from within the overlying artery. A longer incision is then made medially toward the main pulmonary artery until the uninvolved part of the artery is identified. A patch of low porosity Dacron fabric * is tailored to fit the new opening. A disposable hot cautery (AccuTempt) has proved useful for cutting the woven fabric to prevent fraying during the subsequent suturing. The patch is then sutured with 4-0 suture , either braided or monofilament , to cover and widen the underlying pulmonary artery. Care should be taken to include the walls of both the aorta and pulmonary artery to prevent leakage and obtain a secure repair (Fig. I, E'). After the pulmonary arterioplasty has been performed, the original aortotomy is closed with a continuous suture and the standard repair of the cardiac anomaly is performed. The remainder of the operation is completed in the usual manner.
Comment This technique has been used succe ssfull y in four patients without complications . Angiography in one *Meadox Medicals, Inc.. Oakland. N. J. t Concepl. Inc.• Clearwater . Fla.
patient several months later confirmed the adequacy of the repair (Fig. 2). Long-term follow-up is not yet available; however, we believe the higher pressure in the aorta tends to hold the patch graft open and to prevent collapse and steno sis of the pulmonary artery . Whether the higher pressure in the aorta causes bulging of the patch and obstruction of the underlying low pressure artery will be determined later. Since the technique is not difficult, it probably should be applied in most patients following the Waterston-Cooley anastomosis to prevent complications early in the postoperative course. Recently, Rao and Ellison" have speculated that discrepancy in growth of the ascending aorta and the underlying adherent pulmonary artery may be responsible for the obstruction of the pulmonary artery. Our technique , therefore, would be useful to prevent late onset of stenosis after the definitive cardiac repair was accomplished . Availability of a safe and simple method of repair of the Waterston-Cooley anastomosis dispels some major objections to its selection as the procedure of choice for palliative treatment of cyanotic anomalies . REFERENCES Blalock A, Tau ssig HB : Surgical treatment of malform ations of the heart in which there is pulmon ary stenosis or atresia. lAMA 132:189-202. 1945 2 Potts Wl , Smith S. Bigson Sl : Anastomosis of aorta to pulmonary artery . Certain types in congenital heart disease . lAMA 132:627-631. 1946
Volume
n
Number 3 March,1979
3 Waterston OJ: The treatment of Fallot's tetralogy in infants under the age of one year. Rozhl Chir 41: 181-183, 1962 4 Cooley DA, Hallman GL: Intrapericardial aortic-right pulmonary arterial anastomosis. Surg Gynecol Obstet 122:1084-1086, 1966 5 Reitman MJ, Galioto FM, EI-Said GM, Cooley DA, Hallman GL, McNamara DG: Ascending aorta to right pulmonary artery anastomosis. Circulation 49:952-957, 1974 6 Vetter VL, Rashkind WJ, Waldhausen JA: Ascending aorta-right pulmonary artery anastomosis. Long-term results in 137 patients with cyanotic congenital heart disease. J THORAC CARDIOVASC SURG 76:115-125, 1978 7 Stewart S, Harris P, Manning J: Current results with construction and interruption of the Waterston anastomosis. Ann Thorac Surg 25:431-437, 1978
Repair of pulmonary arterial stenosis
47 7
8 Rao PS, Ellison RG: The cause of kinking of the right pulmonary artery in the Waterston anastomosis. A growth phenomenon. J THoRAc CARDIOVASC SURG 76:126-129, 1978 9 Sade RM, Sloss L, Treves S, Bernhard WF, Castaneda AR: Repair of tetralogy of Fallot after aortopulmonary anastomosis. Ann Thorac Surg 23:32-38, 1977 10 Tay OJ, Engle MA, Ehlers KH, Levin AR: Early results and late developments of the Waterston anastomosis. Circulation 50:220-229, 1974 II Cooley DA, Norman JC: Techniques in Cardiac Surgery. Houston, Texas, 1975, Texas Medical Press, Inc., pp 36-39 12 Yamamoto N, Reul GJ Jr, Kidd JN, Cooley DA, Hallman GL: A new approach to repair of pulmonary branch stenosis following ascending aorta-right pulmonary artery anastomosis. Ann Thorac Surg 21:237-242, 1976
Denton A. Cooley, M.D., and J. Marvin Smith, M.D., Houston, Texas
DeSPite an increasing emphasis upon definitive intracardiac repair during infancy in patients with tetralogy of Fallot and other anomalies causing cyanosis, palliative procedures which provide a systemic-pulmonary arterial shunt maintain a place in the cardiac surgeon's armamentarium. The Blalock-Taussig! operation consisting of subclavian-pulmonary artery anastomosis was the first to be applied clinically. The Potts-Smith" shunt, which created a side-to-side anastomosis between the proximal descending thoracic aorta and adjacent pulmonary artery, was introduced several years later. Both of these techniques were widely used, but subsequently they proved to have disadvantages that were partially eliminated with the introduction of side-to-side anastomosis between the ascending aorta and the right main pulmonary artery. Waterston" first described, in the Czechoslovakian literature, the technique using an extrapericardial posterior approach. Later, unaware of his report, we" described a transpericardial technique through an anterolateral approach. Thus the Waterston-Cooley anastomosis soon became the procedure of choice in many centers. The advantages cited for this technique were numerous, but most important was the relative ease of surgical closure when intracardiac repair was performed. Reports from our center by Reitman and associates," and more recently from other centers, 6-10 have deFrom the Division of Surgery, the Texas Heart Institute, St. Luke's Episcopal and Texas Children's Hospitals, Houston, Texas. Received for publication Aug. 23, 1978. Accepted for publication Oct. 10, 1978. Address for reprints: Dr. Denton A. Cooley, Texas Heart Institute, P.O. Box 20345, Houston, Texas 77025.
474
scribed the results. The operation introduced technical difficulties, since the diameter of the anastomosis was critical. Also, critical relationships between the large aorta and the small right pulmonary artery led to kinking, stenosis, and obstruction of the pulmonary artery. Repair of such iatrogenic deformities of the pulmonary artery becomes necessary if integrity of pulmonary circulation to the right lung is to be restored after intracardiac repair. In the usual situation, when no deformity of the right pulmonary artery is noted on the preoperative angiograms, the anastomosis can be closed readily by a transaortic approach. I I When kinking and stenosis of the artery exist, separation of the delicate pulmonary artery from the aorta by a tedious dissection has been used. Usually, this involves a patch graft angioplasty on the pulmonary artery, which may be fragmented because of its friability and surrounding fibrosis. Postoperative bleeding from the artery has occurred in some patients, and distortion of the pulmonary artery often results. In a previous report, we" described a somewhat radical surgical technique for repair of the stenotic underlying pulmonary artery, particularly in patients with pulmonary branch stenosis. Transection of the ascending aorta provides access to the right and left pulmonary arteries and allows extensive patch graft angioplasty of the entire intrapericardial segment. That method should be reserved for only the most difficult problems. Recently, we have employed a method which accomplishes the desired result for less severe arterial deformities with simple arterial stenosis or kinking, namely, restoration of normal continuity and luminal size of the pulmonary artery. The repair is technically simpler and not associated with extensive mediastinal dissection.
0022-5223/79/030474+04$00.40/0 © 1979 The C. V. Mosby Co.
Volume 77 Number 3 March,1979
Repair of pulmonary arterial stenosis
475
,hunt
Fig. I. A to F , Drawing showing steps in aorti copulmonary ang ioplasty using a woven Dacron patch . £ and E ' , In placin g the sutures into the patch graft . the suture should incorporate the ed ge of the aorta and the underlying pulmonary artery .
Technique
The usual midline sternotomy approach is used and cannulation is performed for temporary total cardiopulmonary bypass. Cannulation of the aorta should be made more cephalad than usual to allow cross-
clamping of the aorta distal to the aorticopulmonary j unction. After caval inflow is instituted. the aorta is cross-clamped at the highest possible level without occlud ing the aortic cannula . Cold cardioplegic solution containing potassium ion and other ingredients is
476
The Joumal of 1lloracic and Cardiovascular Surgery
Cooley and Smith
CD Fig. 2. Pulmonary arteriograms made before and 2 month s following patch graft repa ir. A. Almost complete obstruction of a deformed right pulmonary artery is evident. The catheter tip was inserted direct ly into the ana stomosi s from the ascending aorta. B. After operation. the stenosi s has been relieved without residual pressure gradient across this area. although the artery remain s irregular in configuration .
injected into the proximal aorta until cardiac arrest is obtained. A sump suction drain is inserted into the left atrium through the right superior pulmonary vein. With the quiet blood-free field attained, a transverse aortotomy incision is made and the anastomotic open ing is identified (Fig. I). A short incision is made laterally in the distal right pulmonary artery, all from within the overlying artery. A longer incision is then made medially toward the main pulmonary artery until the uninvolved part of the artery is identified. A patch of low porosity Dacron fabric * is tailored to fit the new opening. A disposable hot cautery (AccuTempt) has proved useful for cutting the woven fabric to prevent fraying during the subsequent suturing. The patch is then sutured with 4-0 suture , either braided or monofilament , to cover and widen the underlying pulmonary artery. Care should be taken to include the walls of both the aorta and pulmonary artery to prevent leakage and obtain a secure repair (Fig. I, E'). After the pulmonary arterioplasty has been performed, the original aortotomy is closed with a continuous suture and the standard repair of the cardiac anomaly is performed. The remainder of the operation is completed in the usual manner.
Comment This technique has been used succe ssfull y in four patients without complications . Angiography in one *Meadox Medicals, Inc.. Oakland. N. J. t Concepl. Inc.• Clearwater . Fla.
patient several months later confirmed the adequacy of the repair (Fig. 2). Long-term follow-up is not yet available; however, we believe the higher pressure in the aorta tends to hold the patch graft open and to prevent collapse and steno sis of the pulmonary artery . Whether the higher pressure in the aorta causes bulging of the patch and obstruction of the underlying low pressure artery will be determined later. Since the technique is not difficult, it probably should be applied in most patients following the Waterston-Cooley anastomosis to prevent complications early in the postoperative course. Recently, Rao and Ellison" have speculated that discrepancy in growth of the ascending aorta and the underlying adherent pulmonary artery may be responsible for the obstruction of the pulmonary artery. Our technique , therefore, would be useful to prevent late onset of stenosis after the definitive cardiac repair was accomplished . Availability of a safe and simple method of repair of the Waterston-Cooley anastomosis dispels some major objections to its selection as the procedure of choice for palliative treatment of cyanotic anomalies . REFERENCES Blalock A, Tau ssig HB : Surgical treatment of malform ations of the heart in which there is pulmon ary stenosis or atresia. lAMA 132:189-202. 1945 2 Potts Wl , Smith S. Bigson Sl : Anastomosis of aorta to pulmonary artery . Certain types in congenital heart disease . lAMA 132:627-631. 1946
Volume
n
Number 3 March,1979
3 Waterston OJ: The treatment of Fallot's tetralogy in infants under the age of one year. Rozhl Chir 41: 181-183, 1962 4 Cooley DA, Hallman GL: Intrapericardial aortic-right pulmonary arterial anastomosis. Surg Gynecol Obstet 122:1084-1086, 1966 5 Reitman MJ, Galioto FM, EI-Said GM, Cooley DA, Hallman GL, McNamara DG: Ascending aorta to right pulmonary artery anastomosis. Circulation 49:952-957, 1974 6 Vetter VL, Rashkind WJ, Waldhausen JA: Ascending aorta-right pulmonary artery anastomosis. Long-term results in 137 patients with cyanotic congenital heart disease. J THORAC CARDIOVASC SURG 76:115-125, 1978 7 Stewart S, Harris P, Manning J: Current results with construction and interruption of the Waterston anastomosis. Ann Thorac Surg 25:431-437, 1978
Repair of pulmonary arterial stenosis
47 7
8 Rao PS, Ellison RG: The cause of kinking of the right pulmonary artery in the Waterston anastomosis. A growth phenomenon. J THoRAc CARDIOVASC SURG 76:126-129, 1978 9 Sade RM, Sloss L, Treves S, Bernhard WF, Castaneda AR: Repair of tetralogy of Fallot after aortopulmonary anastomosis. Ann Thorac Surg 23:32-38, 1977 10 Tay OJ, Engle MA, Ehlers KH, Levin AR: Early results and late developments of the Waterston anastomosis. Circulation 50:220-229, 1974 II Cooley DA, Norman JC: Techniques in Cardiac Surgery. Houston, Texas, 1975, Texas Medical Press, Inc., pp 36-39 12 Yamamoto N, Reul GJ Jr, Kidd JN, Cooley DA, Hallman GL: A new approach to repair of pulmonary branch stenosis following ascending aorta-right pulmonary artery anastomosis. Ann Thorac Surg 21:237-242, 1976