Repair of Truncus Arteriosus with Interrupted Aortic Arch and Moderate to Severe Truncal Valve Regurgitation

This video presents the case of a six-day-old boy with truncus arteriosus, interrupted aortic arch, ventricular septal defect (VSD), patent ductus arteriosus (PDA), and patent foramen ovale (PFO). A preoperative echocardiogram showed moderate to severe truncal valve regurgitation and a large ventricular septal defect.

First, the truncal root was opened, and a complete transverse ascending aortotomy was completed. A quadricuspid valve was inspected, the raphe of the two small vestigial leaflets was taken down. The left coronary button was then harvested to allow for root reduction. Central approximation of the vestigial leaflets created a tricuspid valve and further reconstruction of the posterior sinus with the left coronary button reimplantation. Several figure-eight sutures were used to reduce the anterior truncal valve leaflet prolapse and an annuloplasty was performed with subannular sutures. 

Upon inspection, excellent coaptation with no prolapse was noticed. Closure of the VSD via ventriculotomy with an autologous pericardial patch was completed. The patient then went on regional bypass and a C-clamp was placed on the descending aorta, as well as Yasargil clamps on the left subclavian and carotid. The left subclavian and left carotid were then brought together. The ductus was resected, including a posterior shelf and two V-shaped incisions in the descending aorta. The near transverse arch was then taken down to the descending aorta. The arch reconstruction was completed with a pulmonary homograft patch and a running 7-0 Prolene suture.

The postoperative echocardiogram showed trivial truncal regurgitation with good ventricular function, good coronary flow, no significant tricuspid or mitral regurgitation, and no residual VSD or arch obstruction. 

This case shows that complex truncal valve reconstruction and tricuspidization is possible in neonates and provides an excellent surgical option for this pathology.

Tips and pitfalls include not hesitating to remove the coronary button to allow optimal root reconstruction and considering bicuspidization versus tricuspidization based on geometry of leaflets.

References

1. Myers PO, Bautista-Hernandez V, del Nido PJ, et al. Surgical repair of truncal valve regurgitation. Eur J Cardiothorac Surg. 2013;44(5):813-820. doi:10.1093/ejcts/ezt213
2. Patrick WL, Mainwaring RD, Carrillo SA, et al. Anatomic Factors Associated With Truncal Valve Insufficiency and the Need for Truncal Valve Repair. World J Pediatr Congenit Heart Surg. 2016;7(1):9-15. doi:10.1177/2150135115608093
3. Gellis L, Binney G, Alshawabkeh L, et al. Long-Term Fate of the Truncal Valve. J Am Heart Assoc. 2020;9(22):e019104. doi:10.1161/JAHA.120.019104
4. Rodefeld MD, Hanley FL. Neonatal truncus arteriosus repair: surgical techniques and clinical management. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2002;5:212-217. doi:10.1053/pcsu.2002.31497
5. Naimo PS, Konstantinov IE. Surgery for Truncus Arteriosus: Contemporary Practice. Ann Thorac Surg. 2021;111(5):1442-1450. doi:10.1016/j.athoracsur.2020.06.036

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