Ann Thorac Surg 1995;59:1469-1470
© 1995 The Society of Thoracic Surgeons
INVITED COMMENTARY
Christo I. Tchervenkov, MD
Cardiovascular Surgery, McGill University, The Montreal Children's Hospital, 2300 Tupper, C-827, Montreal, Quebec, Canada H3H 1P3
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Introduction
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 Introduction
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See also page 1464.
Uemura and associates are presenting a surgical solution for a most difficult group of patients with complex congenital heart disease that previously was overlooked. These are the patients with severe hypoplasia of a long segment of intrapericardial pulmonary arteries extending into the hilum of the lung precluding definitive repair. In 9 of their 14 patients, the hilar pulmonary stenosis and distal pulmonary artery hypoplasia was iatrogenic secondary to previous shunts.
Their technique involves the construction of a new pulmonary artery by a roll of heterologous pericardium and using it to enlarge the intrapulmonary segment of the pulmonary artery by exposing it through the intralobar fissure. To some extent they have dared to venture in what was previously considered no man's land. It is clear that they have benefited from their extensive experience with another difficult lesion, namely pulmonary atresia and ventricular septal defect associated with major aortopulmonary collateral arteries. Eleven of their 14 patients subsequently underwent biventricular repairs, which in themselves were quite complex, with no operative mortality. It was not clear whether the late death due to esophageal bleeding was due to erosion of the newly created pulmonary artery into the esophagus. Nevertheless, their results are quite spectacular in repairing a large number of patients who would have been considered, by most surgeons, unrepairable. The intermediate-term follow-up is extremely encouraging especially because calcification and obstruction of the conduit have not been found to be a problem.
Although these results are extremely encouraging, they were achieved by a very experienced group of surgeons with a large experience in dealing with extensive pulmonary reconstructions. This technique should be approached cautiously by those who do not possess such extensive experience. Even though the pulmonary artery hypoplasia appeared to have been corrected in the 3 patients with single-ventricle complexes, those patients have not undergone a Fontan operation yet, presumably because of concern for the somewhat elevated pulmonary artery pressure. It remains to be established whether this technique would be useful in salvaging patients with single-ventricle complexes who have severe hypoplasia of the intrapulmonary arteries.
In more general terms, perhaps one of the important lessons comes from the fact that in two thirds of the patients in these series, the hilar pulmonary artery stenosis was caused by palliative shunt procedures. This fact reinforces the notion that palliative operations are to be avoided, especially in patients with two-ventricle hearts, by performing early primary repairs. In our own institution, we have not seen such iatrogenic lesions in our patients in the last 8 years. This coincides with our change in philosophy in favor of primary repair of all complex lesions in two-ventricle hearts in early life. However, from time to time we see such iatrogenic stenoses in patients palliated elsewhere and referred to us for definitive repair. This article is therefore an important contribution because it offers a new surgical option for this difficult group of patients. The article clearly describes the surgical technique and will be an important source of information for the surgeons who encounter this difficult problem.
