Approaching the Complex Single Ventricle—DILV, D-TGA, IAA

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Objective 

The Damus-Kaye-Stansel anastomosis is a common technique for stage I palliation of single ventricle patients. This case involves a patient with double inlet left ventricle (DILV), dextro-transposition of the great arteries (D-TGA), and interrupted aortic arch (IAA) type A, and it explains a modified version of the Damus-Kaye-Stansel (DKS) anastomosis. 

Method 

After redo sternotomy, the left and right pulmonary artery (PA) bands were removed, and the previously placed ductal stent was explanted. The left PA was incised and patch-plastied with pulmonary homograft. The DKS anastomosis began by incorporating the back wall of the descending aorta into the back wall of the main pulmonary artery. Next, the left lateral descending aorta and PA were anastomosed. The ascending aorta was filleted open at its midpoint to the level of the cut edge of the main pulmonary artery. The homograft patch was incorporated into the lateral and anterior portion of the main pulmonary artery. The patch was then completed over the anterior aorta. The shape of the completed patch resembled what is known as a geometric “monkey saddle,” compared to the traditional end-to-side or double-barrel DKS. A 5 mm graft was then used to complete the modified Blalock-Thomas-Taussig (BTT) shunt from the innominate artery to the right PA. 

Results 

The patient recovered well and was readmitted at 20 months of age to undergo takedown of the modified BTT shunt and completion of his bidirectional Glenn. 

Conclusion 

The approach to complex single ventricle patients continues to evolve. Electing for early hybrid repair followed by DKS anastomosis is a feasible option that led to a successful bidirectional Glenn in this patient. 

References

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