Ann Thorac Surg 2005;79:1066-1067
© 2005 The Society of Thoracic Surgeons
How to do it
D-Transposition of the Great Arteries With an Aortopulmonary Window: A New Corrective Technique
Krishna Adluri, MS, FRCSa,
David J. Barron, MD, MRCP, FRCS(CT)a,
William J. Brawn, FRCS, FRACS*,a
a Department of Pediatric Cardiac Surgery, Diana Princess of Wales Children's Hospital, Birmingham, United Kingdom
Accepted for publication November 25, 2003.
* Address reprint requests to Dr Brawn, Diana Princess of Wales Children's Hospital, Steele House Ln, Birmingham B4 6NH, UK
sec.brawn{at}bch.nhs.uk
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Abstract
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D-transposition of the great arteries with an aortopulmonary window is rare. Five cases have been previously reported. Arterial switch is the procedure of choice. We describe a new method of transferring coronaries making use of the aortopulmonary window and a pericardial patch to form a pouch.
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Introduction
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D-transposition of the great arteries is commonly associated with other cardiac anomalies. However, association with an aortopulmonary (AP) window is rare and only five cases have been reported in the literature [1–5]; 3 of these patients survived and 2 died in the immediate postoperative period. The occurrence of postoperative pulmonary hypertensive crises was the cause of death in 2 of these patients [1, 4]. This emphasizes the need for early repair.
Four patients had arterial switch and 1 had atrial switch. The coronary artery pattern was usual in these cases with sinus 1, giving origin to the left circumflex and the left anterior descending arteries and the right coronary originating from sinus 2 [6, 7]. We describe an alternative method of repair incorporating the AP window into the repair.
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Technique
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An 8-day male (weight, 2.7 kg), who was one of twins born at term, was diagnosed on an echocardiogram to have transposition of the great arteries with an aortopulmonary window and an intact interventricular septum associated with pulmonary hypertension. He had a balloon atrial septostomy performed in the referring hospital, which did not improve his clinical condition; therefore he had urgent surgical intervention. At the time of transfer his oxygen saturation was 80% on room air, and he was not on any inotropic support.
Intraoperatively the aorta was found to be anterior to the pulmonary artery with a large AP window between them. The left coronary artery originated from sinus 1 and divided into the left circumflex and left anterior descending artery. The right coronary artery originated from sinus 2.
The two coronary orifices were close together in the posterior wall of the aorta, such that it would be difficult to develop an adequate sized button for each coronary separately. There was a large created ASD, and the duct was closed.
An arterial switch operation was performed with a modification to deal with the coronaries. The great vessels were transected at the level of the AP window, which was included in the line of transection (Fig 1). The commissure of the aortic valve between the coronaries was taken down, and both coronaries were mobilized on a single button in continuity with the window. The aortopulmonary window and the shelf with the coronaries were now included into the neo-aorta by creating a pouch with a bovine pericardial patch (Fig 2). The defect in the pulmonary artery was closed using autologous pericardium and the commissure was re-suspended. The Lécompte maneuver was performed and the great vessels were reconstructed. The pulmonary artery was reconstructed to position its bifurcation on the ascending aorta distal to the coronary artery pouch. The patient was weaned off bypass on minimal doses of ionotropes. He was transferred to the intensive care unit in stable condition. The sternotomy was closed the next day after a period of hemodynamic stability. On postoperative day 4, he was transferred to the ward and was discharged home on the postoperative day 8. Follow-up echocardiogram at 6 months showed good left ventricular function with no regional wall motion abnormalities and unobstructed left and right ventricular outflow tracts.
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Fig 1. Transection of the great vessels at the level of the aortopulmonary window with the single coronary button. (AP = aortopulmonary.)
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Comment
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The arterial switch operation remains the procedure of choice in cases of transposition of the great arteries. In the presence of an aortopulmonary window, the window can be included at the level of division of the great vessels. If the coronaries are close to the window and close together, then adequate mobilization as two separate buttons may be difficult. In such cases this modification can be used. The transection of the vessels is performed in such a way that the coronaries remain attached to the original pulmonary artery (the new proximal aorta). A pouch can be created to contain the coronary arteries, which is then sutured to the ascending aorta in a similar way that intramural coronary arteries can be managed [6]. The possibility of pouch compression can be avoided by ensuring the pulmonary artery bifurcation remains distal to the coronary pouch. We have not seen aneurysmal dilatation of a bovine pericardial pouch in similar reconstructions for intramural arteries.
Krishnan and colleagues [1] have suggested a similar procedure in which a pericardial baffle can be used to redirect the blood flow into the coronaries with an atrial switch.
Takeuchi and Katogi [8] suggested a similar modification for routine management of transposition of the great arteries by shaping a flap in the anterior aortic wall, which would act as a baffle to redirect blood flow when it transferred. They recommended this technique for cases with either a single coronary or an intramural coronary. However, these authors did not recommend complete division and reconstruction of the great vessels as is done in the arterial switch operation.
In cases of the AP window with a d-transposition of the great arteries, creation of a pouch to redirect blood flow into the coronary arteries is a useful new technique.
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References
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- Kirklin JW, Barratt-Boyes BG. Cardiac Surgery: transposition of great vessels, 2nd ed, vol II. New York: Churchill Livingstone, 1993:1388, 1416–8
- Gitten Berger-de Groot AC, Sauer U, Oppenheimer-Dekker A, Quaegebeur J. Coronary arterial anatomy in transposition of the great arteries: a morphologic study. Pediatr Cardiol. 1983;4(Suppl 1):15
- Takeuchi S, Katogi T. New technique for the arterial switch operation in difficult situations. Ann Thorac Surg. 1990;50:1000–1001[Abstract]
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Abstract
Introduction
