Primary central pulmonary artery plasty for single ventricle with ductal-associated pulmonary artery coarctation
Kisaburo Sakamoto1, Noritaka Ota1, Yoshifumi Fujimoto2
1Department of Cardiovascular Surgery, Mount Fuji Shizuoka Children's Hospital, Shizuoka, Japan.
Insights
Primary pulmonary artery plasty in infants with single ventricle effectively prevents pulmonary artery stenosis and ensures balanced pulmonary perfusion for subsequent surgeries. This approach facilitates the safe completion of next-stage operations in various complex congenital heart conditions.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Vascular Reconstruction
Background:
- Infants with single ventricle undergoing modified Blalock-Taussig shunt are at risk for pulmonary artery stenosis at the ductal insertion site.
- This stenosis can lead to unbalanced pulmonary perfusion, complicating subsequent surgical stages.
Purpose of the Study:
- To evaluate the efficacy of primary pulmonary artery plasty during initial palliation in preventing pulmonary artery stenosis.
- To assess the impact of this strategy on pulmonary perfusion and the safety of subsequent surgical interventions.
Main Methods:
- A cohort of 40 functional single-ventricle patients with pulmonary atresia were managed between 1998 and 2012.
- The primary intervention involved central pulmonary artery plasty (resection of ductal tissue) during the initial palliative operation.
- Patients underwent pre-bidirectional cavopulmonary shunt (BCPS) catheter studies and lung perfusion tests.
Main Results:
- No pulmonary stenosis was detected before BCPS in any patient.
- Pulmonary artery diameter and lung perfusion ratios were balanced (0.93 ± 0.25 and 0.9 ± 0.2, respectively).
- Persistent total anomalous pulmonary venous drainage was associated with unbalanced branch pulmonary arteries (p = 0.002).
Conclusions:
- Primary pulmonary artery plasty is effective in preventing pulmonary artery stenosis and ensuring balanced pulmonary perfusion.
- This strategy facilitates the safe execution of subsequent surgical stages, including BCPS and Fontan procedures, across diverse patient anatomies.
Background:
Infants with a single ventricle who require a modified Blalock-Taussig shunt can have stenosis at the ductal insertion site on the pulmonary artery (PA). We hypothesized that primary PA plasty in the first palliation would limit PA stenosis and unbalanced pulmonary perfusion, and thereby facilitate safe accomplishment of the next operation.
Methods:
From 1998 to 2012, functional single-ventricle patients with pulmonary atresia were managed as follows: initial operative strategy based on midline approach, using cardiopulmonary bypass, and central PA plasty (resection of all ductal tissue). All patients underwent catheter study and lung perfusion test before bidirectional cavopulmonary shunt (BCPS).
Results:
Forty consecutive patients (heterotaxy, n = 27; others, n = 13) were enrolled in this study. Seven patients (17.5%) had repair of obstructed total anomalous pulmonary venous drainage, and 4 (10%) had repair of common atrioventricular valve at the first palliative operation. Fifteen patients (37.5%) underwent first palliation in the neonatal period. The mean PA index (mm(2)/m(2)) before BCPS was 230.7 ± 101.7. No pulmonary stenosis was detected before BCPS. Pulmonary artery diameter ratio (nonshunt side/shunt side) was 0.93 ± 0.25; pulmonary lung perfusion ratio (nonshunt side/shunt side) was 0.9 ± 0.2. A multivariate analysis identified persistent total anomalous pulmonary venous drainage (extracardiac type; p = 0.002) as a factor associated with unbalanced branch pulmonary arteries at BCPS. Thirty-five patients underwent BCPS, and 31 underwent Fontan procedures. There were 4 early deaths and 4 late deaths.
Conclusions:
The strategies we have employed facilitate safe accomplishment of the next-stage operation in diverse anatomic groups, with avoidance of unbalanced pulmonary vascular bed.
