Reintervention Burden and Vessel Growth After Surgical Reimplantation of a Pulmonary Artery During Childhood

Congenital disconnection of the pulmonary arteries

OBJECTIVES

Disconnected pulmonary artery (PA) is a rare anomaly that can be isolated or associated with complex intracardiac malformations. Early reimplantation of the disconnected PA is recommended to allow growth and satisfactory pulmonary perfusion while preventing collateral artery development. The aim of this study was to describe the characteristics of patients with disconnected PA and, for those who had surgical reimplantation, to determine the incidence, delay and predictive factors of reintervention for reconnected PA stenosis.

METHODS

We include patients with the diagnosis of congenitally disconnected PA and surgical repair at our institution.

RESULTS

Retrospective observational study of 55 patients with a disconnected PA. Fifty-one underwent surgical correction and were followed up at our institution between 2000 and 2022. Disconnected PAs were observed in isolation in 31% of the cases. The most frequent form was left PA originating from the arterial duct (58%). The reimplantation was done at the median age of 12 days. Anastomotic stenosis was observed during follow-up in 71% of the patients with 75% of them requiring reintervention (55% of the population). The median delay to reintervention was 3.2 years after reimplantation, and >25% of reinterventions on the reimplanted PA occurred within the first postoperative year. We found more reintervention if associated cardiac defect, without significant statistic difference. Weight at re-confluence, presence of ductal tissue at the origin of the PA and prior shunt placement on the disconnected PA were not found to be risk factors for reintervention.

DISCUSSION

After surgical reimplantation of PA, >50% of patients required reintervention for PA stenosis. Technical improvements should be sought to reduce the incidence of this complication.

Preoperative Morphological Prediction of Early Reoperation Risk After Primary Repair in Tetralogy of Fallot: A Contemporary Analysis of 83 Cases

This study was conducted to investigate the pulmonary artery (PA) variations in tetralogy of Fallot (TOF) and preoperative morphological predictors for early reoperation. Eighty-three TOF patients and 20 children with normal PA were included. The TOF group was divided into two subsets according to whether or not reoperation was performed within 3 years postoperatively. Clinical information was obtained, along with computed tomography (CT)-based three-dimensional geometry of the PA. Morphological measurements of the length of the main PA branches, the angles between them, and the cross-sectional area of each segment of the PAs were acquired using computer software. Logistic regression and receiver operating characteristic curves were applied to analysis. The TOF group showed a significantly smaller PA size and irregular PA shape, with lower Nakata and McGoon indices, than the control group. The median bifurcation angle (angle-γ) was greater than 100° in the TOF group, as compared to 66.70° in the control group (P < 0.000). Residual obstruction of the infundibulum or PAs was the main reason for early reoperation in this series. The development of the main PA and left PA was poorer in the reoperation subset than in the non-reoperation subset (P ≤ 0.01). The preoperative angle-γ in the reoperation subset was larger than that in the non-reoperation subset (median, 117.8° vs. 112.0°, P = 0.026). Higher weight (OR = 0.372) and McGoon index (OR = 0.122) were protective factors, while larger angle-γ (> 114.8°, OR = 5.040) and angle-γ normalized by body surface area (BSA) (γ/BSA > 297.9, OR = 18.860) were risk factors. This study provides an intuitive perspective of PA anatomical variations in TOF. Larger preoperative PA bifurcation angle and γ/BSA were morphological risk predictors of postoperative reoperation in patients with TOF.

A pulmonary artery sling with a vascular ring in a toddler: an uncommon combination

Pulmonary artery slings and vascular rings are very rare congenital anomalies. It is even rarer to have both anomalies in the same setting. We present a case of a toddler who was diagnosed with a left pulmonary artery sling and a vascular ring as part of the screening process for the VACTERL association - co-occurrence of vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb malformations. He underwent a successful surgical repair via median sternotomy and on cardiopulmonary bypass with an uneventful postoperative course.