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Ann Thorac Surg 1995;59:1464-1469
© 1995 The Society of Thoracic Surgeons

Intrapulmonary Reconstruction of Pulmonary Arteries Using a Heterologous Pericardial Roll

Hideki Uemura, MD, Toshikatsu Yagihara, MD, Yasunaru Kawashima, MD, Katsushi Yamashita, MD, Tetsuro Kamiya, MD

Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan

Accepted for publication January 30, 1995.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Pulmonary artery reconstruction using a handmade heterologous pericardial roll was achieved in 5 patients with severe hypoplasia of the intrapericardial pulmonary arteries and in 9 patients with critical hilar pulmonary stenosis occurring subsequent to previous construction of a systemic-pulmonary shunt. The pericardial roll was 12 to 16 mm in diameter and was anastomosed to the pulmonary arteries through divided interlobar fissures. At the opposite end, it was fixed anteriorly to the chest wall and connected to a prosthetic tube so as to obtain a blood supply from the systemic circulation. The flow through the roll measured intraoperatively was 95 ± 23 mL • kg-1 • min-1. Postoperative catheterization showed that the mean pressure in the roll was 31 ± 18 mm Hg. Eleven patients have subsequently undergone anatomic repair using an external conduit after 8 ± 4 months. There were no operative deaths, but 1 patient died of esophageal bleeding after the definitive intracardiac repair. We conclude that this technique is a feasible surgical option as a part of staged operations leading to biventricular repair.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Reconstruction or enlargement of obstructive or nonconfluent pulmonary arteries either by operation [1–3] or by interventional catheterization [4, 5] is an important step in the quest to achieve definitive repairs for patients with complex cardiac malformations associated with pulmonary atresia or stenosis. Regional stenoses in the intrapericardial pulmonary arteries are usually repaired at the time of definitive surgical intervention. Stenoses in more distal branches of the pulmonary arteries, however, are occasionally difficult to repair through a median sternotomy. Moreover, agenesis of the intrapericardial pulmonary arteries is well recognized as a hazard for successful definitive repair. In such circumstances, when it has not proved possible to use a patch to enlarge the pulmonary arteries, we have employed an alternative technique involving construction of a heterologous pericardial roll as the first step of a staged repair.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Since 1989, 14 patients without major systemic-pulmonary collateral arteries have undergone pulmonary artery reconstruction using a handmade heterologous pericardial roll at the National Cardiovascular Center in Osaka, Japan. In 5 patients, part or almost all of the intrapericardial pulmonary tree was severely hypoplastic or even aplastic. Two of these patients also had concomitant severe hypoplasia of the intrapulmonary pulmonary arteries. In the other 9 patients, severe pulmonary stenosis was seen at the hili of the lungs and was probably related to previous construction of systemic-pulmonary shunts (Fig 1Go).



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  		Fig 1. . Patterns of the pulmonary arterial trees. Numbers refer to numbers of patients with that configuration.

 
The major intracardiac malformations were discordant atrioventricular connections (with either double-outlet right ventricle or discordant ventriculoarterial connections) in 5 patients, tetralogy of Fallot with pulmonary atresia in 4, classic tricuspid atresia (absent right atrioventricular connection) in 3, complete transposition (concordant atrioventricular and discordant ventriculoarterial connections) with pulmonary stenosis in 1, and common arterial trunk in 1. The operation for the reconstruction of the pulmonary arteries was performed unilaterally on the right side of the thorax in 5 patients and on the left side in 7. In another 2 patients, the reconstructive procedure was carried out sequentially on both sides. The mean age of the patients was 6.3 ± 3.1 years (range, 1.8 to 13.6 years), and the mean body weight was 15.9 ± 4.1 kg (range, 8.2 to 24.6 kg).

All the stenoses were considered unsuitable for reconstruction through a median sternotomy concomitant with a planned definitive repair or for patch enlargement of the stenotic lesions. The previously constructed systemic-pulmonary shunts producing iatrogenic stenosis had been placed 59 ± 25 months before reconstruction of the pulmonary arteries. The initial palliation had been performed in 4 patients at our institution and in 5 at other hospitals.

A handmade heterologous pericardial roll, made of equine (13 rolls) or porcine (three rolls) pericardium, was prepared during the operation using 6-0 polypropylene sutures in mattress and continuous fashion, the mattress sutures producing a mildly curved figure (Fig 2Go). The diameters were designed to be 12 mm in two rolls, 14 mm in four, and 16 mm in 10. The open ends of the rolls were trimmed and anastomosed to the intrapulmonary pulmonary arteries through divided interlobar fissures using 6-0 or 7-0 polypropylene sutures. The pulmonary arteries were exposed extensively until we could clearly identify branches to every lobe. The length of the incision into the pulmonary arteries ranged from 24 to 45 mm (range, 32.6 ± 6.1 mm) and was not related to the diameter of the arteries (range, 2 to 10 mm; mean, 5.7 ± 2.5 mm).



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  		Fig 2. . Handmade heterologous pericardial roll. The mattress sutures produce a mildly curved figure.

 
An artificial tube graft was anastomosed between the opposite end of the pericardial roll and either the aorta or the subclavian artery, thus perfusing the pericardial channel from the systemic circulation (Fig 3Go). The artificial tubes were made of knitted Dacron, the diameters being 5 mm in 13 tubes, 4 mm in 2, and 6 mm in 1 tube. The ends of the pericardial rolls connected to the tubes were suspended from the anterior mediastinum, and all the prostheses were wrapped with a polytetrafluoroethylene sheet after reconstruction. The suspension and wrapping were carried out in the hope of making the subsequent construction of the pulmonary artery confluence easy at the time of the definitive future operation through a median sternotomy.



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  		Fig 3. . Reconstruction of the pulmonary arteries. The incision in the pulmonary arteries was made as large as possible, without considering their diameter, so as to create an adequate anastomosis. The mean length was 32.6 ± 6.1 mm.

 

   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
All patients successfully underwent reconstruction using the pericardial rolls with no deaths. The flow through the rolls measured during operation ranged from 58 to 130 mL • kg-1 • min-1 (mean, 94.6 ± 23.3 mL • kg-1 • min-1 (Fig 4Go). Mean pulmonary artery pressure at catheterization after reconstruction and after definitive repair was 30.6 ± 18.0 mm Hg and 20.6 ± 5.9 mm Hg, respectively (see Fig 4Go).



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  		Fig 4. . (A) Flow through and (B) mean pressure within pericardial roll.

 
All 11 patients without tricuspid atresia have subsequently undergone biventricular repair using an external conduit 3 to 15 months (mean time, 8 ± 4 months) after pulmonary artery reconstruction with a pericardial roll. Four of the 5 patients with discordant atrioventricular connections underwent the so-called double-switch operation [6–8]; the other patient had a ``crisscross heart'' and underwent functional biventricular repair using the morphologically right ventricle as the systemic ventricle. Other patients with cardiac morphology suitable for biventricular repair underwent anatomic repair. A confluence of the pulmonary arteries was constructed without difficulty through the median sternotomy using another heterologous pericardial roll (Fig 5Go). Figure 6Go shows preoperative and postoperative angiograms from a patient with tetralogy of Fallot with pulmonary atresia.



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  		Fig 5. . Construction of pulmonary artery confluence and right ventricular outflow tract at time of biventricular repair in a patient with previous pulmonary artery reconstruction on both sides.

 


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  		Fig 6. . Angiographic findings in a 9-year-old boy with tetralogy of Fallot with pulmonary atresia: (A) before pulmonary artery reconstruction, (B) after reconstruction, and (C) after definitive repair using external conduit. At the time of pulmonary artery reconstruction, the narrowest portions of the pulmonary arteries surgically exposed and to which the pericardial rolls were anastomosed proved to be 2 mm in diameter on both sides.

 
There have been no operative or late deaths after the definitive operation except one hospital death from esophageal bleeding. To date, no reoperations have been required, and no stenotic lesions have been recognized in the reconstructed pericardial rolls within the follow-up of 44 ± 13 months. Mild calcification of the prosthetic material has been observed on chest radiographs in 1 patient. Bacterial infection was diagnosed in another patient and was treated successfully with antibiotics.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
In patients with cardiac malformations accompanied with markedly reduced pulmonary flow, the development of the pulmonary artery tree is known to be hypoplastic [9]. When the diameter of the pulmonary arteries falls below the established values for successful definitive repair [10, 11], primary definitive surgical intervention is not justified. Some surgeons will opt to construct a systemic-pulmonary shunt in such circumstances [12, 13]. Postoperative distortion of the pulmonary arteries can, however, be among the undesirable sequelae of this palliative operation. If severe stenosis affects long segments of the peripheral pulmonary arteries, subsequent repair is often difficult to achieve through a median sternotomy at the time of the definitive procedure. Besides such iatrogenic obstructions, congenital agenesis of the intrapericardial pulmonary arteries is another lesion that can complicate subsequent surgical strategies. In these circumstances, we have opted to extensively reconstruct the pulmonary arteries using pericardial rolls, a method that is employed only when other options have been excluded as unsuitable.

There are, of course, other techniques available for repair of pulmonary artery stenoses. If the obstruction is limited within a short segment, resection of the stenosis along with direct anastomosis of the stumps can be employed. This method, particularly when used without any prosthetic gusset, could provide the potential for growth of the repaired portion but is clearly unsuitable for repair of a long segmental stenosis. Enlargement of the stenotic lumen using a patch is another option and is more flexible in its indications.

Severely obstructed pulmonary arteries over a markedly long segment or the presence of hypoplastic intrapulmonary pulmonary arteries contradicts these indications. This is because in such circumstances, the method itself is technically difficult, and recurrent obstruction at the site of repair occurs frequently owing to the lack of potential for growth of the prosthetic material used as the patch. Further, structures crossing the intrapulmonary pulmonary arteries, such as the right upper pulmonary vein in the setting of usually arranged thoracic organs, can produce major technical difficulties when enlargement is sought by means of a patch.

We, therefore, have tried to create artificial proximal pulmonary arteries as an alternative option. This built on the previous experience of Sawatari and associates [14] and our own experiences [15] of unifocalization of pulmonary artery supply in patients with major systemic-pulmonary collateral arteries using a heterologous pericardial roll.

Technical difficulties were encountered in our use of the pericardial rolls. The first was in dissecting severe adhesions, as the majority of our patients had previously undergone thoracotomies. The finding of abnormal or incomplete formation of the interlobar fissures, frequent in our series, made difficult the desired exposure of the intrapulmonary pulmonary arteries. To minimize the turbulence across the anastomosis between the roll and the pulmonary arteries as well as to avoid stenoses, we considered that extensive exposure of the intrapulmonary pulmonary artery as well as adequate size of the anastomosis was essential. Our extensive dissection provided the means to identify the major arterial branches to each lobe of the lung, and each incision could then be extended into the arteries supplying the lower lobes so as to achieve the desired anastomosis. The need of such extensive dissection, however, made us hesitant to proceed directly to anatomic repair of the cardiac malformations, as this would have entailed heparinization for cardiopulmonary bypass.

The construction of a nonobstructive anastomosis is also of technical importance, for it likely influences the outcome over the short term and the long term. Some pulmonary artery branches can be iatrogenically occluded after these reconstructive procedures. Postoperative obstructions in the reconstructed pulmonary arteries must be carefully evaluated. A segmental defect of pulmonary perfusion demonstrated by angiography does not necessarily represent occlusion of the arteries. As is often seen in the setting of major systemic-pulmonary collateral arteries, the various pulmonary resistances of each pulmonary segment can produce unbalanced pulmonary perfusion after reconstruction of the pulmonary arterial tree.

Severe stenotic lesions within the peripheral pulmonary arteries occasionally provide similar circumstances. Indeed, in the patient in Figure 6Go, the left upper lobar branch, which had been overperfused in the preoperative study, proved to be underperfused during the late phase of injection at the time of postoperative evaluations. During the reconstruction of the pulmonary arteries, a severe stenosis had been detected at the portion between the upper and lower lobar arteries. In this respect, it remains to be seen whether our technique for reconstructing pulmonary artery stenoses is suitable as preparation for a Fontan type of procedure. The postoperative finding of a mean pressure of 30 mm Hg within the pericardial roll is less than ideal for a successful subsequent total right heart bypass operation. The high pressure produced may partly be related to potential damage to the lung during the operation but could also reflect development of pulmonary vascular changes over the period of abnormal pulmonary circulation.

In contrast, although staged repair was the rule in this series, the technique has proved feasible as a preparation for subsequent biventricular repair. The wrapping with a polytetrafluoroethylene sheet was most helpful, the pericardial rolls being readily exposed through the median sternotomy at the time of definitive repair. The sheet was not removed. In another series of patients after similar use of a polytetrafluoroethylene sheet, postoperative hemorrhage was a hazard after removal of the sheet at the time of total cavopulmonary connection.

In terms of long-term outcome, calcification of a heterologous pericardium treated with glutaraldehyde and progression of stenotic lesions within the roll are clearly factors that will require careful follow-up. Calcification itself is not a major problem because the roll does not contain any valves in contrast to the situation found with external conduits used for reconstruction of the right ventricular outflow tract. If the pericardial roll is sufficiently large in diameter to endure the organic changes, calcification would not produce any obstructions. Nevertheless, we have not yet determined the appropriate diameter of the roll precisely.

Unlike calcification, the formation of thrombosis in the pericardial roll is an obvious cause of subsequent stenosis. Postoperative anticoagulation is likely to have an important role in avoiding this sequela. In our series, all patients were, have been, or will be administered warfarin sodium and a low-dose antiplatelet drug for at least 1 year after the definitive repair. No evidence of thrombosis has been detected to date. Nonetheless, our present study is based on the intermediate-term results. A longer follow-up is necessary to determine whether the reconstructed pulmonary arterial tree will be free from major obstructions with or without calcification in our patients.

As for materials used for construction of the pericardial roll, although further experimental investigations such as those reported by Planche and co-workers [16] are necessary, bovine pericardium treated with isopropyl alcohol could be an alternative and might lead to a lower incidence or degree of calcification. We have avoided use of autologous pericardium because it is usually difficult to obtain an adequate size for the roll we use, particularly in the setting of reentering the thoracic cavity with severe adhesions. In addition, the harvest of autologous pericardium necessarily means opening the pericardial cavity, and it might not have been opened previously. Pulmonary artery homografts, in contrast, could be available for this option, although we are unable to comment precisely on the suitability of the material because of lack of experience with homografts in congenital heart disease.

Bacterial infection is another possible problem in the intermediate and long terms. In our experience of unifocalization using a heterologous pericardial roll, 2 (6.7%) of 30 patients have required treatment, 1 by surgical means and the other by medication, for bacterial infection. This incidence is comparable to that found in this study (7.1%). As long as prosthetic materials are used for a pathway within the circulation of the right heart and located within a thoracic cavity, the risk of bacterial infection must always be considered.

Iatrogenic distortion of the pulmonary arteries is best avoided. If distortion is produced, the surgical procedure described here can rescue that situation, and it also is an option for salvaging pulmonary arteries with agenetic or severely hypoplastic intrapericardial portions. Our results show that pulmonary artery reconstruction using a heterologous pericardial roll is an acceptable option particularly as part of staged operations leading toward biventricular repair.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Uemura, Department of Cardiovascular Surgery, National Cardiovascular Surgery, 5-7-1 Fujishirodai, Suita, Osaka 565, Japan.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Barbero-Marcial M, Atik E, Baucia JA, Pradel HOV, Macruz R, Jatene AD. Reconstruction of stenotic or nonconfluent pulmonary arteries simultaneously with a Blalock-Taussig shunt. J Thorac Cardiovasc Surg 1988;95:82–9.[Abstract]
  2. Nakae S, Kawada M, Machii M, et al. Surgical treatments of nonconfluent pulmonary arteries with congenital cardiac defects. Kyobu Geka 1992;45:1146–51.[Medline]
  3. Shanley CJ, Lupinetti FM, Shah NL, Beekman RH, Crowley DC, Bove EL. Primary unifocalization for the absence of intrapericardial pulmonary arteries in the neonate. J Thorac Cardiovasc Surg 1993;106:237–47.[Abstract]
  4. Gentles TL, Lock JE, Perry SB. High pressure balloon angioplasty for branch pulmonary artery stenosis: early experience. J Am Coll Cardiol 1993;22:867–72.[Abstract]
  5. Hosking MCK, Thomaidis C, Hamilton R, Burrows PE, Freedom RM, Benson LN. Clinical impact of balloon angioplasty for branch pulmonary arterial stenosis. Am J Cardiol 1992;69:1467–70.[Medline]
  6. Yagihara T, Kishimoto H, Isobe F, et al. Double switch operation in cardiac anomalies with atrioventricular and ventriculoarterial discordance. J Thorac Cardiovasc Surg 1994;107:351–8.[Abstract/Free Full Text]
  7. Ilbawi MN, DeLeon SY, Backer CL, et al. An alternative approach to the surgical management of physiologically corrected transposition with ventricular septal defect and pulmonary stenosis or atresia. J Thorac Cardiovasc Surg 1990;100:410–5.[Abstract]
  8. Di Donato RM, Troconis CJ, Marino B, et al. Combined Mustard and Rastelli operations. An alternative approach for repair of associated anomalies in congenitally corrected transposition in situs inversus. J Thorac Cardiovasc Surg 1992;104:1246–8.[Abstract]
  9. Nakata S, Imai Y, Takanashi Y, et al. A new method for the quantitative standardization of cross-sectional areas of the pulmonary arteries in congenital heart disease with decreased pulmonary blood flow. J Thorac Cardiovasc Surg 1984;88:610–9.[Abstract]
  10. Naito Y, Fujita T, Tomino T, et al. Total correction of tetralogy of Fallot: operative results, surgical indication, operative procedure and postoperative management. Nippon Kyobu Geka Gakkai Zasshi 1982;30:200–6.[Medline]
  11. Fontan F, Fernandez G, Costa F, et al. The size of the pulmonary arteries and the results of the Fontan operation. J Thorac Cardiovasc Surg 1989;98:711–24.[Abstract]
  12. Kirklin JW, Bargeron LM Jr, Pacifico AD. The enlargement of small pulmonary arteries by preliminary palliative operations. Circulation 1977;56:612–7.[Abstract/Free Full Text]
  13. Watterson KG, Wilkinson JL, Karl TR, Mee RBB. Very small pulmonary arteries: central end-to-side shunt. Ann Thorac Surg 1991;52:1132–7.[Abstract]
  14. Sawatari K, Imai Y, Kurosawa H, Isomatsu Y, Momma K. Staged operation for pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries. New technique for complete unifocalization. J Thorac Cardiovasc Surg 1989;98:738–50.[Abstract]
  15. Yagihara T, Yamamoto F, Nishigaki K, et al. Unifocalization for pulmonary atresia with ventricular septal defect and major aorto-pulmonary collateral arteries. J Thorac Cardiovasc Surg (in press).
  16. Planche CL, Fichelle JM, Paul J, Lethias CL, Elroy R, Weiss M. Long-term evaluation of five biomaterials for angioplastic enlargement of the pulmonary artery in a young dog model. J Biomed Mater Res 1987;21:509–23.[Medline]



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