Patient selection includes infants requiring aortic arch reconstruction with concomitant intracardiac repair, particularly those with a dilated main pulmonary artery associated with pulmonary hypertension.
Operative Steps
A median sternotomy was performed, followed by pericardial harvest and standard aortic and bicaval cannulation. The patent ductus arteriosus (PDA) was ligated, and cardiopulmonary bypass was initiated. The aorta was cross-clamped, del Nido cardioplegia was administered, the patient was cooled to 18°C, and total circulatory arrest was initiated. A pulmonary artery wall patch was harvested from the main pulmonary artery. The hypoplastic arch was opened longitudinally and augmented with the pulmonary artery autograft. Circulation was re-established, and rewarming was initiated.
The large subpulmonic ventricular septal defect (VSD) was then closed through a transpulmonary approach using an autologous pericardial patch. The main pulmonary artery was reconstructed with autologous pericardium. The small patent foramen ovale (PFO) was left open. The patient was then weaned from cardiopulmonary bypass, followed by modified ultrafiltration, decannulation, and chest closure.
Preference Card
- Deep hypothermia with total circulatory arrest
- Del Nido cardioplegia
- Pulmonary artery autograft for arch augmentation
- Autologous pericardium for VSD closure and main pulmonary artery (MPA) reconstruction
Tips and Pitfalls
Most patients with a hypoplastic aortic arch requiring reconstruction have a dilated pulmonary artery associated with pulmonary hypertension.
The pulmonary artery’s elastic properties, contour, and compliance allow it to adapt favorably to the aortic position, potentially providing durable arch growth and reducing the need for reintervention.
Reconstruction of the pulmonary artery with autologous pericardium provides a durable repair; in the authors’ experience, no subsequent pulmonary artery reintervention has been required.
Outcomes
Postoperative echocardiography demonstrated good arch flow with a 10 mmHg gradient, pulsatile descending aortic flow, and an intact VSD patch without residual shunt. Mild left ventricular (LV) dysfunction persisted. The patient required inhaled nitric oxide for pulmonary hypertension, was extubated on postoperative day four, and discharged on postoperative day eight.
Conclusion
The autologous pulmonary artery is an excellent patch material for patients requiring arch reconstruction with concomitant intracardiac procedure.
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