Survival in infants with this interrupted aortic arch depends on ductal patency for lower torso perfusion, so prostaglandin-E (PGE) infusion is always used during medical stabilization followed by immediate surgical repair. Repair of Type A interruption (interruption beyond the left subclavian artery) is performed through a left thoracotomy. Associated anomalies [e.g., ventricular septal defect (VSD)] may be palliated with pulmonary artery banding through the same tho- racotomy or repaired primarily working through a separate median sternotomy.
Type B (interruption beyond left carotid artery) or Type C (interruption between innominate and left common carotid arteries) interruption and associated anom- alies are repaired through a median sternotomy with cardiopulmonary bypass, deep hypothermia, and temporary low-flow cerebral perfusion.
19-1. Type A Interruption
FIGURE
19-1. Working through a left thoracotomy, dissection of the aortic arch, left subclavian artery, patent ductus arteriosus, and descending thoracic aorta is carried out.
A thin fibrous cord connects the two aortic segments.
415
ant caud^- -•ceph
post
ductal stump
aortic anastomosis
FIGURE
19-2. The ductus arteriosus is divided and the pulmonary artery end is closed. A generous incision is made in the aortic arch and an end-to-end anastomosis is performed.
A continuous over-and-over suture is used for the posterior anastomosis, and interrupted everting mattress sutures are placed anteriorly.
19-2. Type B Interruption
ascending aorta
main pulmonary artery
FIGURE
19-3. Working through a median sternotomy, the typical Y shape of the ascend-
ing aorta and common carotid arteries is seen.
left subclavian artery
patent ductus arteriosus
ceph - • L
caud
FIGURE
19-4. During the dissection, large silk sutures are passed around the common carotid and left subclavian arteries for later snaring during arch reconstruction. No trans- verse arch is present and the ductus arteriosus connects the main pulmonary artery to the descending aorta.
left subclavian artery descending aorta
ductus arteriosus
FIGURE
19-5. The ductus arteriosus and upper descending thoracic aorta are dissected.
ceph R < -
caud - • L
right carotid artery
purse string stitches
FIGURE
19-6. Purse string sutures for aortic cannulation are placed in the ascending aorta and proximal main pulmonary artery (or patent ductus). The baby is placed on bypass with a cannula in the ascending aorta and a longer cannula that is passed through the main pulmonary artery and ductus into the descending aorta. Alternatively, a 3.5-mm tubular Gore-Tex® graft is stitched to the right carotid artery, which accepts the arterial perfu- sion cannula. This allows for low-flow cerebral perfusion during arch reconstruction, avoid- ing total circulatory arrest.
ceph
R+- - • L
caud
descending thoracic aorta
FIGURE
19-7. During cooling, the left pleural space is entered and the mid descending
aorta is dissected to enhance mobility for a primary aortic anastomosis.
ductus arteriosus
occluding clamp on descending thoracic aorta
FIGURE
19-8. Arch vessels are snared; cardioplegia solution is injected; and, here, circula- tory arrest is induced. Currently, low-flow cerebral perfusion would be used. Arterial and venous cannulae are removed. The ductus arteriosus is divided and the pulmonary artery end is ligated. A clamp is placed on the upper thoracic aorta for hemostasis and to prevent air from entering the descending aorta. The clamp is useful in shifting the lower aortic segment cephalad for the anastomosis.
ductus remnant
descending aorta
FIGURE
19-9. Ductal tissue attached to the thoracic aorta is excised so that sutures can be
placed in the more substantial aortic wall.
ceph
R<-
- • Lt caud
left subclavian artery
FIGURE
19-10. To enlarge the lower aortic segment, the incision is extended into the base of the left subclavian artery.
R ^
ascending aorta
descending aorta
FIGURE
19-11. A generous aortotomy is made in the ascending aorta, extending into the
proximal left common carotid artery. A continuous suture is used to construct the poste-
rior row of the anastomosis, working within the lumen of the aorta.
aortic anastomosis
cannulation site
caud
FIGURE
19-12. For the anterior anastomosis a continuous suture is used, but it is inter- rupted in a few places to allow growth of the aorta at the anastomosis. The aortic clamp used for traction on the lower aorta is removed after the anastomosis is completed.
artrial septal defect
FIGURE
19-13. Working through a right atriotomy, the atrial septal defect (ASD) is closed
primarily.
ventricular septal defect tricuspid valve
FIGURE
19-14. The tricuspid valve is retracted to expose the VSD.
ceph R < - - • L
patch
caud
FIGURE
19-15. A Dacron® patch is placed over the VSD using interrupted felted mattress
sutures.
ceph R < - - • L
caud
snares
stenotic orifice ascending aorta
FIGURE
19-16. In another child, 4 years following initial repair, anastomotic stenosis is repaired. After the patient is cooled to deep hypothermia with cardiopulmonary bypass, head vessel snares are pulled tight and circulatory arrest is induced. Currently, low-flow cerebral perfusion would be used. A longitudinal aortic opening is made proximal to the stenosis exposing the narrow area of transverse arch.
descending aorta
ridge at stenosis site
ascending aorta
FIGURE
19-17. The aortotomy is extended across the stenosis and into the descending
aorta.
ceph
R^- - • L
caud
patch
FIGURE
