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Ascending Aortic Slide Repair for Interrupted Aortic Arch

Monday, February 26, 2018

Dodge-Khatami A, Urencio M, Greenleaf CE, Aru GM, Salazar JD, Mathis CA. Ascending Aortic Slide Repair for Interrupted Aortic Arch. February 2018. doi:10.25373/ctsnet.5904727.

In interrupted aortic arch with a wide interruption gap between proximal and distal aortic portions, the ascending aortic slide is a safe and reproducible technique. It provides a tension-free native tissue bridge with potential for growth, as well as providing a scaffold for patch augmentation in biventricular hearts or for Norwood stage I in univentricular palliation, which the authors performed in eight neonates/infants.

In a neonate with type A interruption, right arch, right descending aorta, and aberrant left subclavian artery, a complete biventricular repair was planned. With a Gore-Tex graft to the innominate artery for arterial inflow and initial single venous right atrial cannulation, bypass was commenced, the distal ductus was cannulated then transected proximal to the cannula, and the patient was cooled to 25°C.

After cross-clamping and cardioplegia administration, the clamp was replaced with a hemoclip and the cardioplegia needle was removed to free up the field. The right descending aorta was clamped, the head vessels were snared, and antegrade cerebral perfusion (ACP) was commenced at 50 cc/kg/minute (and adapted up to 70 cc/kg/min as needed using near-infrared spectroscopy monitoring).

The baby whose repair is shown in this video had a diminutive aortic root and 5 mm aortic valve. Therefore, the aorta was transected at the sinotubular junction, and the root was opened down into the noncoronary sinus. The aortic valve was probed to confirm size adequacy for the anticipated biventricular repair. All remnant ductal tissue was excised from the descending aorta. The ascending aorta was then fileted open with two parallel incisions all the way up to the proximal arch.

The resulting bridge flap of native ascending aorta was rotated towards the right shoulder and anchored to the descending aorta. The posterior distal wall anastomosis was completed to form a native tissue bridge, which then formed the neo-greater arch curvature. The diameter of the distal opening connected to the native bridge tissue was checked.

The proximal anastomosis was made between the fileted ascending aorta and the aortic root. Finally, the root was enlarged with a patch of homograft in the opened noncoronary aortic sinus, followed by homograft arch augmentation into the existing native tissue greater curvature scaffold. After de-airing, the clamps were removed, and the ACP was converted to full flow bypass. In the video, one can see the reconstructed right-sided arch, aortic root, and right descending thoracic aorta.

Transatrial ventricular septal defect patch closure was performed after conversion to bicaval cannulation and repeat cardioplegia. The patient’s postoperative course was uneventful.

Recommended Reading: 

  1. Oosterhof T, Azakie A, Freedom RM, Williams WG, McCrindle BW. Associated factors and trends in outcomes of interrupted aortic arch. Ann Thorac Surg. 2004;78(5):1696-1702.
  2. McCrindle BW, Tchervenkov CI, Konstantinov IE, et al. Risk factors associated with mortality and interventions in 472 neonates with interrupted aortic arch: a Congenital Heart Surgeons Society study. J Thorac Cardiovasc Surg. 2005;129(2):343-350.
  3. Jacobs ML, Rychik J, Murphy JD, Nicolson SC, Steven JM, Norwood WI. Results of Norwood's operation for lesions other than hypoplastic left heart syndrome. J Thorac Cardiovasc Surg. 1995;110(5):1555-1561.


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