11-1. Total Repair

11-1. Total Repair

atretic outflow tract

ventricular septal defect

FIGURE 11-1. Working through a median sternotomy, cardiopulmonary bypass is estab- lished. Repair is carried out with aortic clamping, cardioplegia, and profound local cardiac cooling. A high longitudinal right ventriculotomy is made extending cephalad into the outflow tract chamber which is atretic at its upper end. The ventricular septal defect (VSD) is subcristal and nonrestrictive.

198

ceph R < - - • L

caud

valve

anterior leaf of tricuspid valve

FIGURE 11-2. The VSD is retracted anteriorly, and the aortic valve is seen. Typically, this valve is equally related to right and left ventricles. Multiple interrupted felted mattress sutures are placed around the rim of the VSD. Stitches in the posterior inferior corner of the defect are placed superficially in the rim to avoid damage to the His' bundle. With location of the aortic valve partly over the right ventricle, the distance between the pos- terior inferior corner of the VSD and the cephalad margin of the aortic valve is great and requires multiple sutures to close the VSD with the Dacron® baffle.

ceph R « - - • L

caud

patch

anterior leaf of tricuspid valve

FIGURE 11-3. Stitches are placed in a rectangular-shaped patch of knitted Dacron® and

tied. The length of the patch is in the transverse plane and creates a tunnel or baffle that

connects the left ventricle to the aortic valve.

R <

main pulmonary artery

region of outflow tract atresia

infundibulum

FIGURE 11-4. There is tissue continuity between the infundibulum and the main pul- monary artery. The right ventriculotomy is extended across the area of outflow tract atresia and onto the proximal main pulmonary artery.

pericardial patch

FIGURE 11-5. Vascular continuity between the right ventricle and main pulmonary artery

is established by placing a pericardial outflow tract patch over the high ventriculotomy,

the area of atresia, and the proximal main pulmonary artery. Pericardium is used here

because of its hemostatic qualities. A patch of Gore-Tex® or homograft pulmonary artery

wall may be used and avoids the risk of late development of a pericardial patch aneurysm.

ceph R « - - • L

t caud

FIGURE 11-6. A Dacron® patch cover is stitched over the pericardial outflow tract patch.

Dense scar tissue will eventually engulf the Dacron® and form a supporting buttress over the pericardial patch. This technique is used to avoid late patch aneurysm formation.

ascending aorta

main pulmonary artery

FIGURE 11-7. In another patient, there is proximal atresia and severe hypoplasia of the

main pulmonary artery.

R ^

ventriculotomy

FIGURE 11-8. A n oblique high right ventriculotomy is made in a location to avoid injury to surrounding coronary arteries. Hypertrophied myocardium at the ventriculotomy is excised.

R ^

ventricular septal defect

FIGURE 11-9. A large VSD is exposed.

ceph R^- - • L

caud

Dacron patch

FIGURE 11-10. Repair sutures are placed in a rectangular-shaped Dacron® patch.

ceph R < - - • L

caud

patch

FIGURE 11-11. Stitches are tied orienting the length of the rectangular patch transversely

to connect the left ventricular flow tract to the aortic valve.

ceph R^- - • L

caud

patch

FIGURE 11-12. Ventricular septal defect closure is completed by passing additional stitches through the upper rim of the patch and then through the floor of the outflow tract.

ceph R < - - • L

caud

homograft wall patch

left pulmonary artery

main pulmonary artery

FIGURE 11-13. In this patient, there is stenosis of the proximal left pulmonary artery. An

incision is made across the area of stenosis and a homograft wall patch is applied to this

area.

ceph

•

caud

FIGURE 11-14. Sutures have been placed in the triangular-shaped homograft wall patch to cover the incision in the left pulmonary artery.

ceph R < -

caud - • L

homograft wall patch

left pulmonary artery

FIGURE 11-15. There is adequate relief of the area of stenosis after placement of the patch.

homograft conduit

homograft valve

posterior suture

FIGURE 11-16. To establish vascular continuity from the right ventricle to the pulmonary artery, a valved aortic homograft with attached ascending aorta and mitral leaflet is used.

The homograft is oriented so that the mitral leaflet of the graft is placed anteriorly. Graft placement is begun by stitching the posterior muscle bar below the homograft valve annulus to the native right ventricular outflow tract.

ceph R < - - • L

caud

anterior mitral leaf of homograft

posterior suture

FIGURE 11-17. The posterior muscle bar suture line is completed and tied at each corner.

ceph R « - - > L

caud

reconstructed left pulmonary artery

distal suture

homograft conduit

FIGURE 11-18. The homograft conduit is positioned with the curve of the homograft extending toward the left chest. The inner curve of the conduit hugs the lateral border of the heart. The distal conduit is cut to an appropriate length. Before this final tailoring maneuver, it is advantageous to momentarily release the aortic cross-clamp to allow the ascending aorta and the coronaries to fill. At this point, one can more accurately deter- mine the correct length of conduit needed. The distal suture line is placed within the distal main pulmonary artery but proximal to the pulmonary artery branches.

homograft conduit

anterior mitral leaf of homograft

FIGURE 11-19. The anterior part of the distal suture line is placed on the anterior surface

of the pulmonary artery to avoid narrowing of the distal anastomosis.

ceph R < - - • L

caud

homograft conduit

anterior mitral leaf of homograft

FIGURE 11-20. The anterior mitral leaf of the homograft conduit is stitched to the ante- rior rim of the ventriculotomy, creating a hood that allows the homograft valve to assume a natural position. This helps to avoid homograft valve annulus distortion and valve regur- gitation postoperatively.

R ^

homograft conduit

FIGURE 11-21. After completing homograft conduit placement, the left pericardium may

be opened to allow the conduit to rest in the left chest. This avoids compression of the

conduit by the sternum when the latter is closed.

cases. For most, staged thoracotomies offer the best chance of successful pul- monary artery reconstruction. The exposure is optimal through a lateral approach and this allows for precise anastomoses and recruitment of all anomalous vessels.

A Blalock shunt is usually included in each recruitment operation. Later, the branch pulmonary arteries are connected centrally and then to a right ventricle to pulmonary artery valved conduit with immediate or delayed VSD closure.

When working through a thoracotomy, a fifth interspace incision is used for maximal cephalad and caudad exposure.

FIGURE 11-22. During a left thoracotomy in this child, a hypoplastic left pulmonary artery

is dissected from the pericardium to its branches. A bronchial collateral artery arises from

the distal aortic arch.

ant caud^- -•ceph

post

left pulmonary artery

descending aorta

collateral arteries

FIGURE 11-23. The descending aorta is exposed and a second collateral artery is dissected.

The distal arch collateral passes beneath the native pulmonary artery before it enters the left lung.

ant caud<- -•ceph

post

collateral arteries

FIGURE 11-24. The two collateral arteries are divided near their origins to preserve

maximal length of each vessel.

ant c a u d < - - • c e p h

post

collateral arteries

FIGURE 11-25. The two collaterals are incised lengthwise to the point of convergence prior to entering the left lung. These vessels are then anastomosed lengthwise, resulting in a larger recruited vessel.

caud^

ant

post

•ceph

left pulmonary artery

collateral arteries

FIGURE 11-26. The recruited vessel is anastomosed end to side to the hypoplastic left pul-

monary artery. A modified left Blalock shunt will then be placed.

ant ceph^- -^•caud

post

right pulmonary artery collateral arteries

descending aorta FIGURE 11-27. In another child, while working through a right fifth interspace thoraco- tomy, the major fissure is completely dissected. The small right pulmonary artery is seen, as are two collateral arteries that arise from the descending aorta.

ant ceph^- -^•caud

post

right pulmonary artery

anastomosis

collateral arteries

FIGURE 11-28. The upper lobe collateral vessel is anastomosed end to side to the native

pulmonary artery. The lower lobe collateral artery is anastomosed to the side of the first

collateral.

ant ceph<- -•caud

post

right pulmonary artery

right upper lobe

FIGURE 11-29. The native right pulmonary artery is dissected in the area cephalad to the lung. The anastomosed collaterals are inferior and out of view through this exposure.

• caud

right pulmonary artery

azygos vein

Blalock shunt

FIGURE 11-30. A modified right Blalock shunt is constructed to the hypoplastic right

pulmonary artery.