Challenging Pulmonary Arterial Reconstruction: Repeat Sternotomy With Completion Unifocalization and Extensive Pulmonary Arterial Reconstruction in ToF/PA/MAPCAs

This video is part of the Pulmonary Arterial Reconstruction Series. Click here to explore more videos in this series.  

This case demonstrated a repeat sternotomy for unifocalization of a residual major aortopulmonary collateral artery (MAPCA) and relief of right ventricular outflow tract obstruction by reconstruction of the right pulmonary artery and conduit rereplacement. 

A third sternotomy was performed, followed by initiation of cardiopulmonary bypass (CPB) via cannulation of the proximal aortic arch and both vena cavae. The previously placed right ventricle to pulmonary artery conduit was transected, and the calcified portion was removed. The stented portion of the right pulmonary artery was completely resected. A saphenous vein graft was then used to complete the unifocalization of the MAPCA to the native branch pulmonary artery. The resected right pulmonary artery was then replaced with a polytetrafluoroethylene (PTFE) graft that was bifurcated, and the two limbs of the graft were connected to the upper and lower branches of the right pulmonary artery. The unifocalized branch pulmonary artery was then connected to the right upper lobe. A Dacron graft with a bioprosthesis was sewn to the left pulmonary artery and connected to the PTFE conduit. It was then connected to the right ventriculotomy. The rest of the procedure, including decannulation, was performed in a typical fashion. 
 
CPB and aortic cross-clamp times were 204 and 22 minutes, respectively. The patient was extubated in the operating room and was discharged four days later. Postoperative and follow-up CT scan showed widely patent branch pulmonary arteries with good flow in the right-side pulmonary artery and a widely patent conduit. 

References

1. Ma M, Zhang Y, Wise-Faberowski L, Lin A, Asija R, Hanley FL, McElhinney DB. Unifocalization and pulmonary artery reconstruction in patients with tetralogy of Fallot and major aortopulmonary collateral arteries who underwent surgery before referral. J Thorac Cardiovasc Surg. 2020 Nov;160(5):1268-1280.e1. doi: 10.1016/j.jtcvs.2020.03.062. Epub 2020 Apr 11. PMID: 32444187.
2. Said SM. Commentary: Unifocalization revision: Patches, patches, and more patches…. J Thorac Cardiovasc Surg. 2019 Aug;158(2):546-547. doi: 10.1016/j.jtcvs.2018.10.072. Epub 2018 Oct 26. PMID: 30470537.

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