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J Thorac Cardiovasc Surg 2002;124:1050-1052
© 2002 The American Association for Thoracic Surgery
Brief Communications |
From the Departments of Surgerya and Pediatrics,b National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
Received for publication Feb 2, 2002. Accepted for publication March 29, 2002. Address for reprints: Ing-Sh Chiu, MD, PhD, MDiv, Department of Surgery, National Taiwan University Hospital, No.7 Chung-Shan S Rd, Taipei, Taiwan 100 (E-mail: ingsh{at}ha.mc.ntu.edu.tw).
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1 is seldom performed, because the functional implications of the spiral relationship of the great arteries (SROGA) are not well known. Clinical summary
A 10-day-old baby boy underwent spiral ASO (Figure 1) and repair of septal defects and coarctation. The aorta was right anterior 30° to the pulmonary trunk. A single coronary artery pierced into aortic sinus 2 closer to the facing commissure with a retropulmonic left main and anteaortic Vieussen artery. We cut back into noncoronary sinus 1 to augment the pulmonary pathway by anterior wall of the neoaortic root.
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) that differs from the previous technique 1 (similar to Figure 2) includes the following three points, which can also be applied to cases with usual coronary pattern: (1) The aorta is amputated obliquely (Figure 1, A) so that a larger left lip (Figure 1, C) can be used as the floor of the pulmonary pathway (Figure 1, E). (2) The right posterior part of the pulmonary trunk is divided (Figure 1, A and B) to make a larger flap to be everted to the left and a more leftward pulmonary pathway after neoaortic anastomosis and posterior attachment (suturing the caudal edge of the right pulmonary artery to the posterior neoaorta) accordingly. (3) The posterior attachment site is ascertained after release of the aortic crossclamp, as in the previous technique. However, to facilitate exposure, the aorta is crossclamped again distal to the deepest site of attachment and then stitched from the right (Figure 1, D).
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Discussion
An article in The Lancet 2 and its figure prompted us to review distal suprapulmonary stenosis complicated after an ASO. The main reasons for this stenosis were claimed to be technical, and its incidence dropped after generous patching of the pulmonary sinus and extensive hilar dissection. However, such distal stenosis inherent with the procedure itself still existed, as noted by de Leval 3 in a comment on that article. We point out that this morbidity was closely related to the so-called Lecompte maneuver, mobilization of the pulmonary bifurcation anterior to the ascending aorta. This viewpoint is well illustrated in the Figure 1 of that article. 2 The transposed great arteries were switched in such a fashion (Figure 3, B) that the normal SROGA was not restored. The naturally created great arteries are normally in a spiral fashion (Figure 3, C); thus the pulmonary arteries are prevented from being compressed by the ascending aorta. After the Lecompte maneuver, however, not only is the anterior pulmonary trunk (low pressure) flattened, 4 resulting in branch pulmonary arterial stenosis with increased peak velocity during systole, 5 but also the posterior left bronchus may be compressed (airway pressure with cartilage). 6,7 All occurs because the high-pressure ascending aorta is not restored to its natural location. Even more ironically, the high-pressure aorta may suppress itself (high pressure). That is to say, the acute angulation of the aortic arch after the Lecompte maneuver (Figure 3, B) may cause hypoplastic arch and neocoarctation that was not present at the time of ASO. 8 We therefore advocate modified ASO by spiral reconstruction. 1
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9 The flow inside the spiral model is more streamlined than is the Lecompte model. The recognition of the transposed great arteries as an anteroposterior reversal of the great arteries without appreciation of nonexistence of the normal SROGA is too simpleminded. If one looks back into the history of surgical treatment for transposition, once the functional implication of normal ventricles was well known, nobody selected the right ventricle as the systemic pumping chamber. Likewise, we think that people adopted the nonspiral Lecompte maneuver just because the functional implication of the SROGA was not well known. Now that we know the functional implications of SROGA, spiral ASO to restore the natural SROGA should be recommended for transposition. Therefore, ASO with the Lecompte maneuver merely to reverse the anteroposterior great arteries may be wrong, or at least may provide suboptimal correction.
One may be concerned that the gradual "untwisting" as the child grows may cause pressure gradient at the "common wall" site in our technique. 1 We report the follow-up data on our original 12 patients 3.20 ± 0.54 years after the operation. In patient 3, in whom an equine pericardium was used to repair the supra-aortic stenosis, the suprapulmonary gradient as great as 65 mm Hg developed 3.5 years after reoperation but dropped after balloon dilatation. In all other 11 patients, who received autologous tissue grafts, the suprapulmonary gradient estimated by Doppler ultrasonography either became smaller or did not develop on follow-up.
Some may argue that our technique adds difficulty to an already demanding operation, in part because we depicted the details of the complicated procedure in our previous article but described the simple procedure in the text only. 1 Namely, for those with higher takeoff of the coronary artery (inadequate tissue to suture inside the sinus wall), the cephalic edge of pulmonary semiflap was sutured to the cephalic edge of sinus 1 (Figure 2). We believe that this simple technique, which was used in most cases, made life easier.
The recent modification (Figure 1) is even simpler. One can cut back into noncoronary facing sinus 1 to augment the pulmonary pathway by anterior wall of the neoaortic root. This autologous viable tissue is of course superior to the previous technique of cutting back into nonfacing anterior sinus and using a pericardial patch for augmentation (Figure 2, C). We showed that not using pericardial patch to roof the anterior pulmonary pathway is possible (Figure 1, F), like not using a patch in a Senning operation. In addition to augmenting the facing sinus 1, the first two modifications mentioned previously that can be applied to usual coronary patterns contributed to the ability to dispense with a patch. We recommend spiral reconstruction of the great arteries at least for transposition if people are used to conventional method of coronary transfer.
Addendum
After this paper was submitted, 3 babies with complete transposition and usual coronary pattern successfully underwent modified spiral ASO as above.
Acknowledgments
We are indebted to Miss Chang-Ying Lin for secretarial assistance.
References
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