Left Pulmonary Artery Reimplantation Into the Main Pulmonary Artery

This is a case presentation of an eight-day-old female who presented with an anomalous left pulmonary artery (LPA) diagnosed by fetal ultrasound. A preoperative transthoracic echocardiogram demonstrated an anomalous LPA located 4 mm above the ascending aortic sinotubular junction, with right ventricular dilation, a mildly diminished right ventricular (RV) systolic volume of 29.6 percent, and RV hypertension (HTN) of 36.36 mmHG. Additionally, there was a patent right ductus arteriosus. This diagnosis was confirmed with a sagittal computed tomography angiography (CTA) scan.

Due to the patient’s anomalous LPA and right ventricular hypertension, the surgical team elected to proceed with surgery and mobilization of the base of the LPA from the proximal aorta to the main pulmonary trunk. 

To begin, a median sternotomy was performed in the standard fashion. Attention was directed toward the mobilization of the anomalous LPA. Starting distally, the team circumferentially dissected the LPA, which was secured using a silastic vessel loop. The patient was then heparinized, and cardiopulmonary bypass was established via cannulation of the right lateral aspect of the ascending aorta and the right atrium for venous drainage. Cardiopulmonary bypass commenced in the standard fashion. 

With the heart decompressed, the vessel loop around the LPA was tightened. The LPA was further mobilized toward its anomalous proximal origin from the ascending aorta. A plane was developed between the aorta and the LPA. The aberrant origin of the LPA was circumferentially dissected from the aorta. The vessel was then ligated with a surgical clip. Following ligation, the vessel was sharply divided from the aorta. The aortic wall at the division site was then reinforced with a 5-0 polyproline suture and sewn in a running fashion. 

An arteriotomy was created on the distal body of the main pulmonary artery (MPA). The LPA–MPA anastomosis was fashioned in an end-to-side configuration, with the LPA beveled appropriately and sewn to the MPA using a continuous 6-0 Prolene suture. Before completing the suture line, a 3 mm dilator was passed through the anastomosis and advanced distally toward the branch point, demonstrating patency without obstruction.
After standard deairing maneuvers, the patient was separated from cardiopulmonary bypass, and the incision was closed in the standard fashion. The total cardiopulmonary bypass time was 22 minutes.

On follow-up transthoracic echocardiogram, the LPA pressure was 24 mmHg, with Doppler demonstrating distal flow throughout the LPA. There was no gradient noted on the LPA anastomosis, and it was widely patent. Mild dilation of the right pulmonary artery (RPA) and right atrium (RA) was also noted.  

The patient was discharged from the cardiovascular intensive care unit (CVICU) on postoperative day five and discharged from the hospital on postoperative day nine. 

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References

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