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The Surgical Modification of the Hybrid Procedure With a PTFE Ringed Graft for HLHS and Repair of Obstructive TAPVR on Beating Heart
A 2 kg girl was transferred from another hospital to the ICU of Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital with a preliminary diagnosis of a hypoplastic left ventricle (AA/MA) and supracardiac TAPVR. The echocardiography showed mitral atresia, aortic atresia, 1 mm diameter ascending aorta, and mild stenosis in a vertical vein and pulmonary venous confluence. The patient was intubated and general condition was poor. A bilateral pulmonary banding was performed and the PGE infusion was continued to keep the PDA open. In the follow-up period following the pulmonary banding procedure, sepsis developed in the ICU. After the medical treatment was completed, it was decided that the patient should be operated on to address the increased stenosis in the pulmonary venous return. The chest X-ray showed pulmonary edema. Considering poor cardiac function, pulmonary edema, and a 1 mm ascending aorta in diameter, the decision was made to do the surgery on beating heart. Interventional procedures to TAPVR were not possible due to the multiple stenoses in the vertical vein and pulmonary venous confluence.
Since the hybrid procedure is not possible unless the pulmonary venous return is corrected, it was decided to modify the hybrid procedure by inserting a graft into the PDA instead of stenting the PDA (1). The mediastinum was reached through the previous incision. The innominate artery was cannulated with an 8F cannula. A bicaval cannulation was performed. Previously banded pulmonary arteries were dissected and hanged with silastic tapes after initiating a bypass. The procedure was performed under 32 degrees Celsius normothermia. Pledgeted traction sutures were placed at the apex of the heart. The heart was pulled towards the patient's right shoulder. The posterior pericardium was opened parallel to the left phrenic nerve. Pericardial traction sutures were placed. A descending aorta dissection was completed and freed from the esophagus (2). Purse sutures were placed in the descending aorta and cannulation was completed by using a side clamp.
Since the patient had aortic atresia, it was decided to correct TAPVR without placing a cross-clamp. The right atriotomy was done. The location of the pulmonary venous chamber was evaluated externally. Atrial septum was opened with a scalpel. The left atrium was very small. The right atriotomy incision was extended toward the left atrium and biatrial incision was completed (3-4). The venous confluence was opened with a scalpel. The venous confluence was anastomosed to the atrium. The atrium was closed in a double-layer fashion. Branch vessels of the aortic arch, PDA, and descending aortic dissections were completed. Cross-clamps were placed on the descending aorta and the proximal aortic arch. A pulmonary arteriotomy was done transversely below the pulmonary artery orifices. The 6 mm Hegar dilator was inserted into the PDA. In the preoperative measurements, PDA was seen as 6 mm in diameter and 1 cm in length. Therefore, a decision was made to use a 6 mm ringed PTFE graft. The ringed graft was preferred to prevent kinging. A Hegar dilator was inserted into the PDA and the graft length to be used was calculated and marked. After inserting the graft into the PDA, it was fixed with 7/0 prolene sutures to the pulmonary artery side. The proximal and distal aortic arch was checked with a right-angle clamp inserted through the graft. The right and left pulmonary artery orifices were evaluated and found to be open. The pulmonary arteriotomy was closed. The cannula in the descending aorta was removed and its sutures were tied. The bypass was completed without inotropic support. The MUF was done. It was decided that the previously placed tapes were sufficient and should not be tightened anymore. The patient was decannulated and the sternum was temporarily closed with a patch. There was no pressure difference between the femoral artery and the right radial artery. No obstruction was detected in the pulmonary venous return on transthoracic echocardiography. There was no flow acceleration in the PDA or significant gradient in the aortic arch.
- Akintuerk H, Michel-Behnke I, Valeske K, Mueller M, Thul J, Bauer J, et al. Stenting of the arterial duct and banding of the pulmonary arteries: basis for combined Norwood stage I and II repair in hypoplastic left heart. Circulation. 2002;105(9):1099-1103.
- Hammel JM. Supplemental perfusion techniques for aortic arch reconstruction, with emphasis on direct cannulation of the descending aorta. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2019;22:14-20.
- Shumaker JB, King H. A modified procedure for total anomalous pulmonary venous drainage. Surg Gyn Obstet. 1961;112:763.
- Zhao K, Wang H, Wang Z, Zhu H, Fang M, Zhu X, et al. Early- and intermediate-term results of surgical correction in 122 patients with total anomalous pulmonary venous connection and biventricular physiology. J Cardiothorac Surg. 2015;10:172.
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