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Mainwaring RD, Felmly LM, Hanley FL. A Deep Dive Into Retroesophageal Major Aortopulmonary Collateral Arteries. World J Pediatr Congenit Heart Surg 2023; 14:729-735. [PMID: 37499043 DOI: 10.1177/21501351231183970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background: The anatomy of major aortopulmonary collateral arteries (MAPCAs) can be highly variable with regard to number, anatomic origin, course, and relationship to the native pulmonary arteries. Some MAPCAs travel behind the esophagus (retroesophageal) and bronchus before entering the lung parenchyma. The purpose of this paper was to review the anatomy, physiology, and surgical characteristics of retroesophageal MAPCAs. Methods: This manuscript summarizes the data from a series of three papers that have focused on the subject of retroesophageal MAPCAs from our institution over the past ten years. Results: Two-thirds of patients evaluated had a retroesophageal MAPCA identified at surgery. Retroesophageal major aortopulmonary collateral arteries (REMs) were more common with a left arch (77%) compared with a right arch (53%). Of all REMs evaluated, 83% were single supply, 13% were dual supply with an inadequate connection, and 4% were dual supply with an adequate connection. Based on these findings, 96% of retroesophageal MAPCAs were unifocalized. Follow-up catheterization was performed at a median of 17 months after surgery; 75% of unifocalized MAPCAs were widely patent, 20% were patent but stenotic, and 5% were occluded. Conclusions: The data demonstrate that retroesophageal MAPCAs are relatively common and almost always require unifocalization. At mid-term follow-up, 95% of unifocalized MAPCAs were found to be patent.
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Affiliation(s)
- Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - L Mac Felmly
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford, CA, USA
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Stanford, CA, USA
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Topcu FS, Simsek B, Ozyuksel A. An unusual case of pulmonary atresia with ventricular septal defect and multiple major aortopulmonary collateral arteries: undiagnosed until adulthood. Cardiol Young 2023; 33:1445-1447. [PMID: 36621769 DOI: 10.1017/s1047951122004127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries is an extremely complex, heterogeneous, and rare anomaly. This group of patients may not be able to survive until adulthood without any interventions or treatment. Although surgical management of patients diagnosed in newborn, infant, or early childhood is clear, treatment of patients diagnosed in adulthood still remains a significant problem. The pre-operative clinical status, imaging methods, and operative findings might be helpful for planning the most appropriate management. Herein, we report a unique case of pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries who remained asymptomatic until the age of 18 years.
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Affiliation(s)
- Feyza Sönmez Topcu
- Department of Radiology, Aydin University, Medical Park Florya Hospital, Istanbul, Turkey
| | - Baran Simsek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Arda Ozyuksel
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
- Department of Cardiovascular Surgery, Biruni University, Istanbul, Turkey
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3
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Anderson RH. The significance of systemic-to-pulmonary collateral arteries. Eur J Cardiothorac Surg 2022; 62:6793855. [DOI: 10.1093/ejcts/ezac523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/31/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Robert H Anderson
- Biosciences Division, Newcastle University , Newcastle upon Tyne, UK
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The Case of a 44-Year-Old Survivor of Unrepaired Tetralogy of Fallot, Right Aortic Arch and Abdominal Aortopulmonary Collateral Vessels. Medicina (B Aires) 2022; 58:medicina58081011. [PMID: 36013478 PMCID: PMC9413260 DOI: 10.3390/medicina58081011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
The most common congenital cyanotic heart disease is described in the literature as the Tetralogy of Fallot. This abnormality is characterized by the presence of ventricular septal defect (VSD), obstruction of the right ventricular (RV) outflow tract, right ventricular hypertrophy, and overriding aorta. In patients with pulmonary atresia with ventricular septal defect (PA/VSD), major aortopulmonary collateral arteries (MAPCA) are common; however, although some of them do not have PA/VSD, they do have other particular anatomical variants. The case we are presenting in this article is a rare mild symptomatic adult noncorrected TOF, with preserved RV function, right aortic arch, and MAPCAs (“classic” thoracic MAPCAs but also abdominal MAPCAs). The anatomy of a complex congenital defect is well illustrated by cardiac magnetic resonance (CMR) and computer tomography angiography (CTA), and these imaging techniques are mostly used to understand the relative clinical “silence” TOF. Imaging scans thus play a key role in the evaluation of these patients, being very important to know the indications and limitations of each method, but also to learn to combine them with each other depending on the clinical picture of the patient’s presentation. Additionally, the close collaboration between clinicians and imagers is essential for a correct, complete and detailed preoperative evaluation, being subsequently essential for cardiovascular surgeons, the whole team thus deciding the best therapeutic management.
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Qiu H, Wen S, Ji E, Chen T, Liu X, Li X, Teng Y, Zhang Y, Liufu R, Zhang J, Xu X, Chen J, Huang M, Cen J, Zhuang J. A Novel 3D Visualized Operative Procedure in the Single-Stage Complete Repair With Unifocalization of Pulmonary Atresia With Ventricular Septal Defect and Major Aortopulmonary Collateral Arteries. Front Cardiovasc Med 2022; 9:836200. [PMID: 35548444 PMCID: PMC9081567 DOI: 10.3389/fcvm.2022.836200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/16/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs) is a relatively rare, complex, and heterogeneous congenital heart disease. As one of the effective treatments, the midline unifocalization strategy still remains complicated and challenging due to the diverse forms of MAPCAs and pulmonary arteries. The purpose of this study is to summarize our experience of a novel three-dimensional (3D) visualized operative procedure in the single-stage complete repair with unifocalization and to clarify the benefits it may bring to us. Methods We described our experience of the 3D visualized operative procedure such as 3D printing, virtual reality (VR), and mixed reality (MR) technology in patients with PA/VSD/MAPCAs who underwent a single-stage complete repair with unifocalization. The data from the patients who underwent this procedure (3D group) and those who underwent the conventional procedure (conventional group) were compared. Results The conventional and 3D groups included 11 patients from September 2011 to December 2017 and 9 from January 2018 to March 2021, respectively. The baseline characteristics such as age, body weight, preoperative saturation, the anatomy of the pulmonary arteries and MAPCAs, the Nakata index, and TNPAI had no statistical significance. All 9 patients in the 3D group were operated only through a median sternotomy, while 8 cases (72.7%) in the conventional group needed another posterolateral thoracotomy (p = 0.001). In the 3D group, the CPB time was shorter (93.2 ± 63.8 vs. 145.1 ± 68.4 min, p = 0.099), and the median pre-CPB time per MAPCAs was significantly shorter [25.7 (14.0, 46.3) vs. 65 (41.3, 75.0) min, p = 0.031]. There was no early death in the 3D group, while there were 3 in the conventional group (0 vs. 27.3%, p = 0.218). Conclusion The novel 3D visualized operative procedure may help improve the performance of the single-stage complete repair with the midline unifocalization of PA/VSD/MAPCAs and help shorten the dissecting time of the MAPCAs. It may promote the routine and successful application of this strategy in more centers.
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Affiliation(s)
- Hailong Qiu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shusheng Wen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Erchao Ji
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tianyu Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaobing Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaohua Li
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yun Teng
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yong Zhang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Rong Liufu
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiawei Zhang
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaowei Xu
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Meiping Huang
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Meiping Huang
| | - Jianzheng Cen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Jianzheng Cen
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Jian Zhuang
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6
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The Modern Surgical Approach to Pulmonary Atresia with Ventricular Septal Defect and Major Aortopulmonary Collateral Arteries. CHILDREN 2022; 9:children9040515. [PMID: 35455558 PMCID: PMC9030555 DOI: 10.3390/children9040515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/19/2022] [Accepted: 04/01/2022] [Indexed: 11/16/2022]
Abstract
Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals is a complex congenital heart defect that includes a heterogeneous subgroup of patients. Variation in the sources of pulmonary blood flow contributes to the complexity of the lesion and the diversity of approaches to its management. Unifocalization and rehabilitation focus on mobilization of collateral arteries and growth of native pulmonary arteries, respectively, with the ultimate surgical goal of achieving separated systemic and pulmonary circulations with the lowest possible right ventricular pressure. Regardless of the strategy, outcomes have altered the natural history of the disease, with a complete repair rate of approximately 80% and low early and late mortality rates. Given this heterogeneity of pulmonary vasculature, a tailored approach should be adopted for each patient, using all diagnostic methods currently offered by technical developments.
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7
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Nakamura Y, Burkhart HM. Staged unifocalization revisited. J Card Surg 2022; 37:967-968. [PMID: 35137983 DOI: 10.1111/jocs.16296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND A staged thoracotomy unifocalization approach has not been the dominant option over the past 20 years primarily due to the introduction of midline one-stage complete unifocalization. METHODS In this issue of the Journal of Cardiac Surgery, van de Woestijne et al. publish their experience over the past 30 years in 39 consecutive patients with "consistent" staged unifocalization through a lateral thoracotomy in patients with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (PA/VSD/MAPCA). RESULTS They report definitive repair completion in 76.3% of the patients and an overall survival after definitive repair of 96% at 20 years despite the study period ranging from 1989 to the present. CONCLUSION Given the multiple variations one could have with PA/VSD/MPACA, a midline unifocalization approach may not always be possible. Surgeons should be familiar with the lateral thoracotomy unifocalization staged approach to PA/VSD/MAPCA.
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Affiliation(s)
- Yuki Nakamura
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Harold M Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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8
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Ventricular septal defect with pulmonary atresia: approaches, results, prognosticators and current status. Indian J Thorac Cardiovasc Surg 2022; 38:28-37. [PMID: 34898873 PMCID: PMC8630160 DOI: 10.1007/s12055-020-01133-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/25/2020] [Accepted: 12/29/2020] [Indexed: 01/03/2023] Open
Abstract
Ventricular septal defect with pulmonary atresia and major aortopulmonary collateral arteries is a complex congenital cardiac anomaly with a wide spectrum of anatomical variations. Akin to the same, the management options are also very diverse ranging from aggressive single-stage repair with unifocalisation to surgical palliation and/or staged repair and also heart transplant. There is no consensus on the best management option. This review aims at highlighting the various surgical options and proposing a management pathway suited for the subcontinent patients.
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9
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Sames-Dolzer E, Fahrnberger A, Kreuzer M, Mair R, Gierlinger G, Tulzer A, Gitter R, Prandstetter C, Tulzer G, Mair R. Outcome of patients with tetralogy of Fallot with pulmonary atresia. Front Pediatr 2022; 10:1077863. [PMID: 36793501 PMCID: PMC9922747 DOI: 10.3389/fped.2022.1077863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE Tetralogy of Fallot patients with pulmonary atresia (TOFPA) have a largely varying source of pulmonary perfusion with often hypoplastic and even absent central pulmonary arteries. A retrospective single center study was undertaken to assess outcome of these patients regarding type of surgical procedures, long-term mortality, achievement of VSD closure and analysis of postoperative interventions. METHODS 76 consecutive patients with TOFPA operated between 01.01.2003 and 31.12.2019 are included in this single center study. Patients with ductus dependent pulmonary circulation underwent primary single stage full correction including VSD closure and right ventricular to pulmonary conduit implantation (RVPAC) or transanular patch reconstruction. Children with hypoplastic pulmonary arteries and MAPCAs without double supply were predominantly treated by unifocalization and RVPAC implantation. The follow up period ranges between 0 and 16,5 years. RESULTS 31 patients (41%) underwent single stage full correction at a median age of 12 days, 15 patients could be treated by a transanular patch. 30 days mortality rate in this group was 6%. In the remaining 45 patients the VSD could not be closed during their first surgery which was performed at a median age of 89 days. A VSD closure was achieved later in 64% of these patients after median 178 days. 30 days mortality rate after the first surgery was 13% in this group. The estimated 10-year-survival rate after the first surgery is 80,5% ± 4,7% showing no significant difference between the groups with and without MAPCAs (p > 0,999). Median intervention-free interval (surgery and transcatheter intervention) after VSD closure was 1,7 ± 0,5 years [95% CI: 0,7-2,8 years]. CONCLUSIONS A VSD closure could be achieved in 79% of the total cohort. In patients without MAPCAs this was possible at a significant earlier age (p < 0,01). Although patients without MAPCAs predominantly underwent single stage full correction at newborn age, the overall mortality rate and the interval until reintervention after VSD closure did not show significant differences between the two groups with and without MAPCAs. The high rate of proven genetic abnormalities (40%) with non-cardiac malformations did also pay its tribute to impaired life expectancy.
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Affiliation(s)
- Eva Sames-Dolzer
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Anna Fahrnberger
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
| | - Michaela Kreuzer
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Roland Mair
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Gregor Gierlinger
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Andreas Tulzer
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria.,Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Roland Gitter
- Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Christoph Prandstetter
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria.,Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Gerald Tulzer
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria.,Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Rudolf Mair
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
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van de Woestijne PC, Romeo JL, van Beynum I, Witsenburg M, Mokhles MM, Bogers AJ. Homograft durability after correction of pulmonary atresia and ventricular septal defect with or without systemic pulmonary collateral arteries. JTCVS OPEN 2021; 8:546-555. [PMID: 36004083 PMCID: PMC9390670 DOI: 10.1016/j.xjon.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022]
Abstract
Background Pulmonary atresia and ventricular septal defect (PA-VSD), with or without systemic pulmonary collateral arteries (SPCAs), represents a complex anatomic and surgical spectrum of congenital heart disease. Currently, there is limited evidence on homograft durability after complete correction, which potentially could be affected by anatomic differences in pulmonary vasculature. Methods This retrospective single-center study included all 69 consecutive PA-VSD patients (46 with SPCAs, 23 without SPCAs) operated on between 1978 and 2018. The primary interest was in homograft durability after complete repair. Longitudinal echocardiographic homograft function and right ventricular systolic pressure were analyzed with linear mixed-effects models. Results The median duration of follow-up was 20 years. Of the 46 patients with SPCAs, 37 (80.4%) underwent biventricular correction at a median age of 2.7 years (interquartile range [IQR], 1.8-6.3 years). Two patients are currently awaiting unifocalization and correction. All 23 patients without SPCAs underwent successful complete correction at a median age of 1.6 years (IQR, 1.1-3.6 years). Freedom from any reintervention after 20 years was 15%. When a homograft was used during correction, freedom from homograft replacement after 20 years was comparable in the 2 groups (P = .925), at 32 ± 11% in the SPCA group and 32 ± 13% in the non-SPCA group. Indications for homograft replacement were isolated stenosis (n = 7; 46.7%), isolated regurgitation (n = 3; 20.0%), and mixed stenosis and regurgitation (n = 5; 33.3%) in the SPCA group and isolated stenosis (n = 8; 88.9%) and stenosis and regurgitation (n = 1; 11.1%) in the non-SPCA group. Peak homograft gradient was significantly (P = .0003) higher in patients without SPCA, with a comparable rate of progression in the 2 groups. However, the prevalence of severe pulmonary regurgitation (PR) was higher in patients with SPCAs, estimated at 35% at 10 years, compared with 15% in patients without SPCAs. Conclusions Homografts used for right ventricular outflow tract reconstruction in patients with PA-VSD, either with or without SPCAs, have similar limited durability. Repeated reintervention is common, and careful follow-up with attention to severe PR is warranted.
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11
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Mainwaring RD, Capecci L, Collins RT, Hanley FL. Midterm fate of unifocalized major aortopulmonary collateral arteries in patients with retroesophageal major aortopulmonary collateral arteries. J Thorac Cardiovasc Surg 2021; 163:2175-2181. [PMID: 34872764 DOI: 10.1016/j.jtcvs.2021.09.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/16/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (MAPCAs) is a relatively rare and complex form of congenital heart disease. Unifocalization of MAPCAs has been advocated by some groups for the treatment of this condition. The purpose of this study was to assess the midterm fate of unifocalized MAPCAs in a cohort of patients with retroesophageal MAPCAs. METHODS This was a retrospective review of 37 patients who underwent a unifocalization procedure. All patients in this study had 1 or more retroesophageal MAPCAs, and detailed mapping of the MAPCAs was made based on a combination of the cardiac catheterization and surgical findings. RESULTS The 37 patients had a total of 166 MAPCAs, or 4.5 MAPCAs per patient. One hundred twenty-nine (78%) MAPCAs were unifocalized, whereas 37 (22%) were ligated because they were dual supply. Median follow-up was 69 months. At follow-up cardiac catheterization, evaluation of the 129 unifocalized MAPCAs demonstrated that 123 (95%) had antegrade flow, whereas 6 were occluded. For the 123 MAPCAs with antegrade flow, 97 (80%) were widely patent, whereas 26 were stenotic. Thirteen of the 37 patients have subsequently undergone reintervention on MAPCAs that were determined to be stenotic following unifocalization. Seven of these patients had mild disease and had complete resolution with balloon (n = 5) or surgical revision (n = 2). Six patients with moderate or severe disease underwent surgical revision with confirmed resolution in 4 of 6. CONCLUSIONS The data demonstrate that the majority of unifocalized MAPCAs remain widely patent following unifocalization. However, one-quarter of unifocalized MAPCAs develop stenoses or occlusion. These results suggest the fate for most unifocalized MAPCAs is favorable but highlight the need for close vigilance.
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Affiliation(s)
- Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, Calif.
| | - Lou Capecci
- Division of Pediatric Cardiac Surgery, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, Calif
| | - R Thomas Collins
- Division of Pediatric Cardiology, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, Calif
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, Calif
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12
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Quinlan CA, Latham GJ, Joffe D, Ross FJ. Perioperative and Anesthetic Considerations in Tetralogy of Fallot With Pulmonary Atresia. Semin Cardiothorac Vasc Anesth 2021; 25:218-228. [DOI: 10.1177/10892532211027395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tetralogy of Fallot with pulmonary atresia (ToF-PA) is a rare diagnosis that includes an extraordinarily heterogeneous group of complex anatomical findings with significant implications for physiology and prognosis. In addition to the classic findings of ToF, this particular diagnosis is characterized by complete failure of forward flow from the right ventricle to the pulmonary arterial system. As such, pulmonary blood flow is entirely dependent on shunting from the systemic circulation, most frequently via a patent ductus arteriosus, major aortopulmonary collaterals, or a combination of the two. The pathophysiology of ToF-PA is largely attributable to the abnormalities of the pulmonary vasculature. Ultimately, these patients require operative intervention to create a reliable, controlled source of pulmonary blood flow and ideally complete intracardiac repair. Even after operative correction, these patients remain at risk for pulmonary arterial stenoses and pulmonary hypertension. Although there have been significant advances in surgical and interventional management of ToF-PA leading to dramatic improvements in survival and long-term functional status, there is ongoing debate about the optimal management strategy given the risk of development of irreversible abnormalities of the pulmonary vasculature and the morbidity and mortality associated with sometimes multiple, complex operative interventions often occurring early in infancy. This review will discuss the findings in patients with ToF-PA with a focus on the perioperative and anesthetic management and will highlight challenges faced by the anesthesiologist in caring for these patients.
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13
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Gindes L, Salem Y, Gasnier R, Raucher A, Tamir A, Assa S, Weissman-Brenner A, Weisz B, Kasif E, Achiron R. Prenatal diagnosis of major aortopulmonary collateral arteries (MAPCA) in fetuses with pulmonary atresia with ventricular septal defect and agenesis of ductus arteriosus. J Matern Fetal Neonatal Med 2021; 35:5400-5408. [PMID: 33525939 DOI: 10.1080/14767058.2021.1881475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to describe the prenatal diagnosis of Major Aortopulmonary Collateral Arteries (MAPCAs), and to present a systematic ultrasound method for evaluating lung vascularity in fetuses with pulmonary atresia with ventricular septal defect (PAVSD) and agenesis of ductus arteriosus (DA). METHOD This retrospective study evaluated fetuses diagnosed with PAVSD with agenesis of DA, for the presence of the MAPCAs anomaly. Fetal pulmonary vasculature was investigated by 2D and 4D Spatio Temporal Image Correlation (STIC) technology using High Definition Color Doppler. RESULTS Over a 10 year period, six fetuses were diagnosed with MAPCAs. Prenatal diagnosis was made between 17 w 6 d and 28 w 4 d in five fetuses, with the sixth diagnosed at 37 w 6 d. All six had PAVSD with agenesis DA, four exhibited pulmonic atresia without any arterial outflow, while two fetuses presented with absent left pulmonary artery, and a miniscule right pulmonary artery. In five cases, the parents elected to terminate the pregnancy and the last, although born alive, did not survive an attempt at restorative surgery and died at the age of 5 months. Postnatal CT angiography imaging of this case revealed the subclavian origin of the MAPCAs. Chromosomal micro array analysis of the amniotic fluid revealed that five of the six fetuses were normal and one was lost to follow up. CONCLUSION MAPCAs should be investigated in cases of PAVSD with agenesis DA. A meticulous ultrasound evaluation using 2D and 4D STIC can permit the prenatal diagnosis of this anomaly and provide the parents with the opportunity for prenatal consultation.
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Affiliation(s)
- Liat Gindes
- Ultrasound Unit, Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yishay Salem
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology Unit, Department of Pediatrics, Sheba Medical Center, Tel-Hashomer, Israel
| | - Rose Gasnier
- Ultrasound Unit, Department of Obstetrics and Gynecology, Wolfson Medical Center, Holon, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alona Raucher
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology Unit, Department of Pediatrics, Wolfson Medical Center, Holon, Israel
| | - Akiva Tamir
- Pediatric Cardiology Unit, Department of Pediatrics, Wolfson Medical Center, Holon, Israel
| | - Sagie Assa
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology Unit, Department of Pediatrics, Wolfson Medical Center, Holon, Israel
| | - Alina Weissman-Brenner
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Ultrasound Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Boaz Weisz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Ultrasound Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Eran Kasif
- Ultrasound Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Reuven Achiron
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Ultrasound Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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14
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Mahajan S, Riggs K, Kholwadwala D, Meyer D, Parnel V. Unusual case of isolated major aortopulmonary collateral artery perfusing entire functional left lower lobe of the lung. Ann Pediatr Cardiol 2021; 14:547-549. [PMID: 35527763 PMCID: PMC9075554 DOI: 10.4103/apc.apc_133_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/17/2020] [Accepted: 05/27/2021] [Indexed: 11/04/2022] Open
Abstract
Pulmonary sequestrations are nonfunctioning pulmonary parenchyma supplied by a systemic artery. We describe an 18-month-old baby girl with no significant past medical history who was found to have a large isolated collateral from the aorta entirely perfusing the functional left lower lobe. Cardiac catheterization confirmed the major aortopulmonary collateral artery supplying the left lower lobe with normal drainage into the left atrium. At a multidisciplinary meeting, decision was made to preserve the functional lobe. During surgery, the collateral artery was dissected and its course within the pleural space appreciated, the main left pulmonary artery was isolated. Intraoperatively surgeons anastomosed an 8 mm ringed conduit from the left pulmonary artery, anteriorly to the proximal aspect of the collateral. The patient tolerated the surgery well. Postoperative echocardiogram showed pulmonary flow to the lower lobe, and she was discharged home on postoperative day 2 without complications.
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15
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Carotti A. Surgical Management of Fallot's Tetralogy With Pulmonary Atresia and Major Aortopulmonary Collateral Arteries: Multistage Versus One-Stage Repair. World J Pediatr Congenit Heart Surg 2020; 11:34-38. [PMID: 31835990 DOI: 10.1177/2150135119884914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A strict and rational approach to Fallot's tetralogy with pulmonary atresia and major aortopulmonary collateral arteries allows to achieve optimal results. Rehabilitative and unifocalization strategies do not constitute separate philosophies; instead the surgical strategy should be tailored to each individual patient. Based on our previous experience, the ability to achieve definitive intracardiac repair is the real determinant of both improved survival and adequate systolic right ventricular performance on mid-term follow-up.
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Affiliation(s)
- Adriano Carotti
- Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
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16
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Barron DJ, Kutty RS, Stickley J, Stümper O, Botha P, Khan NE, Jones TJ, Drury NE, Brawn WJ. Unifocalization cannot rely exclusively on native pulmonary arteries: the importance of recruitment of major aortopulmonary collaterals in 249 cases†. Eur J Cardiothorac Surg 2020; 56:679-687. [PMID: 30891593 DOI: 10.1093/ejcts/ezz070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/05/2019] [Accepted: 02/08/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We sought to define the early and late outcomes of unifocalization based on a classification of the native pulmonary artery (nPA) system and major aortopulmonary collateral arteries (MAPCAs) with a policy of combined recruitment and rehabilitation and to analyse the role of unifocalization by leaving the ventricular septal defect (VSD) open with a limiting right ventricle-pulmonary artery (RV-PA) conduit in borderline cases. METHODS An analysis of 271 consecutive patients assessed for unifocalization at a single institution between 1988 and 2016 was performed. Patients were classified according to the pulmonary blood supply: group A, unifocalization based on nPA only; group B, based on nPA and MAPCAs; group C, MAPCAs only (absent nPAs). RESULTS Unifocalization was achieved in 249 (91.9%) cases with an early mortality of 2.8%. Group A included 72 (28.9%) patients, group B 119 (47.8%) patients and group C 58 (23.3%) patients with no difference in early survival between groups. Survival at 5, 10 and 15 years was 90.0% (85.9-94.3), 87.2% (83.5-91.2) and 82.3% (75.2-89.9), respectively. Late survival in groups A and B was similar but 10- and 15-year survival in group C decreased to 79.2% (68.2-92.1) and 74.3% (61.1-90.4) (P = 0.02), respectively. A mean of 1.9 (±0.6) MAPCAs were recruited per patient (range 0-6). The VSD was left open with a limiting RV-PA conduit in 97 (39.0%) cases, but subsequently closed in 48 patients, giving a total of 200 (80.3%) patients achieving VSD closure (full repair). Delaying VSD closure was not associated with increased risk for early or late survival. A central shunt to rehabilitate the nPAs was used in 56 (22.5%) cases. This was associated with a reduction in the number of MAPCAs recruited, but still required a mean of 1.8 (±0.5) MAPCAs recruited per patient to achieve unifocalization. In multivariate risk analysis, those suitable for single-stage full repair had the best long-term outcomes. Group C anatomy was associated with poor late survival compared to groups A and B (hazard ratio 2.7). CONCLUSIONS Survival is maximized by a combined approach of rehabilitation and recruitment. MAPCAs should always be recruited if they supply areas with absent nPA supply. A strategy of leaving the VSD open with a limiting RV-PA conduit is a safe and effective way of managing borderline cases.
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Affiliation(s)
- David J Barron
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Ramesh S Kutty
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - John Stickley
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Oliver Stümper
- Department of Paediatric Cardiology, Birmingham Children's Hospital, Birmingham, UK
| | - Phil Botha
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Natasha E Khan
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Timothy J Jones
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Nigel E Drury
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - William J Brawn
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
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17
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Haydin S, Genç SB, Ozturk E, Yıldız O, Gunes M, Tanidir IC, Guzeltas A. Surgical Strategies and Results for Repair of Pulmonary Atresia with Ventricular Septal Defect and Major Aortopulmonary Collaterals: Experience of a Single Tertiary Center. Braz J Cardiovasc Surg 2020; 35:445-451. [PMID: 32864922 PMCID: PMC7454616 DOI: 10.21470/1678-9741-2019-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate surgical management and results of patients with pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries (PA/VSD/MAPCAs). Methods We reviewed a consecutive series of patients with PA/VSD/MAPCAs between January 2012 and October 2018. Study patients were separated into Group A, efficient MAPCAs; Group B, hypoplastic MAPCAs; Group C, severe hypoplastic MAPCAs at all divisions; and Group D, distal stenosis at most MAPCAs divisions. Results Thirty-six patients were included in the study. Median age at operation time was 5.5 months (2-110 months), median weight was 8 kg (2.5-21 kg), and median number of MAPCAs was three (1-6). In Group A, 14 patients underwent single-stage total correction (TC); in Group B, 18 patients underwent unifocalization and central shunting; and in Group C, four patients had aortopulmonary window creation and collateral ligation. No patient was placed in Group D. Seventy percent of patients (n=25) had the TC operation. Early mortality was not seen in Group A, but the other two groups had a 13.6% mortality rate. At the follow-up, three patients had reintervention, two had new conduit replacement, and one had right ventricular outflow tract reconstruction. Conclusion Evaluating patients with PA/VSD/MAPCAs in detail and subdividing them is quite useful in determining the appropriate surgical approach. With this strategy, TC can be achieved in most patients. Single-stage TC is better than other surgical methods due to its lower mortality and reintervention rates. Care should be taken in terms of early postoperative intensive care complications and reintervention indications during follow-ups.
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Affiliation(s)
- Sertac Haydin
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Serhat Bahadır Genç
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Erkut Ozturk
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Okan Yıldız
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Gunes
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Ibrahim Cansaran Tanidir
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Alper Guzeltas
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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18
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Ganigara M, Sagiv E, Buddhe S, Bhat A, Chikkabyrappa SM. Tetralogy of Fallot With Pulmonary Atresia: Anatomy, Physiology, Imaging, and Perioperative Management. Semin Cardiothorac Vasc Anesth 2020; 25:208-217. [DOI: 10.1177/1089253220920480] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Tetralogy of Fallot (ToF) with pulmonary atresia (ToF-PA) is a complex congenital heart defect at the extreme end of the spectrum of ToF, with no antegrade flow into the pulmonary arteries. Patients differ with regard to the sources of pulmonary blood flow. In the milder spectrum of disease, there are confluent branch pulmonary arteries fed by ductus arteriosus. In more severe cases, however, the ductus arteriosus is absent, and the sole source of pulmonary blood flow is via major aortopulmonary collateral arteries (MAPCAs). The variability in the origin, size, number, and clinical course of these MAPCAs adds to the complexity of these patients. Currently, the goal of management is to establish pulmonary blood flow from the right ventricle (RV) with RV pressures that are ideally less than half of the systemic pressure to allow for closure of the ventricular septal defect. In the long term, patients with ToF-PA are at higher risk for reinterventions to address pulmonary arterial or RV-pulmonary artery conduit stenosis, progressive aortic root dilation and aortic insufficiency, and late mortality than those with less severe forms of ToF.
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Affiliation(s)
- Madhusudan Ganigara
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | - Eyal Sagiv
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Sujatha Buddhe
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - Aarti Bhat
- Seattle Children’s Hospital, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
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19
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Current era outcomes of pulmonary atresia with ventricular septal defect: A single center cohort in Thailand. Sci Rep 2020; 10:5165. [PMID: 32198468 PMCID: PMC7083910 DOI: 10.1038/s41598-020-61879-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 02/28/2020] [Indexed: 11/09/2022] Open
Abstract
Pulmonary atresia with ventricular septal defect (PA/VSD) is a complex cyanotic congenital heart disease with a wide-range of presentations and treatment strategies, depending on the source of pulmonary circulation, anatomy of pulmonary arteries (PAs), and major aortopulmonary collateral arteries (MAPCAs). Data about the outcomes in developing countries is scarce. We therefore conducted a retrospective study to assess survival rates and mortality risks of 90 children with PA/VSD at Siriraj Hospital, Thailand during 2005-2016. Patients with single ventricle were excluded. Survival and mortality risks were analyzed at the end of 2018. The median age of diagnosis was 0.5 (0-13.8) years. The patients' PAs were categorized into four groups: 1) PA/VSD with confluent PAs (n = 40), 2) PA/VSD with confluent PAs and MAPCAs (n = 21), 3) PA/VSD with non-confluent PAs and MAPCAs (n = 12), and 4) PA/VSD with small native PAs and MAPCAs (n = 17). Of the 88 patients who underwent operations, 32 patients had complete repair at 8.4 ± 4.6 years old. During the follow-up [median time of 5.7 years (7 days-13.6 years)], 17 patients (18.9%) died. The survival rates at 1, 5, and 10 years of age were 95%, 83.7%, and 79.6%, respectively. Significant mortality risks were the presence of associated anomalies and non-confluent PAs.
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20
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Tailored approach to trans-catheter palliation of critically reduced pulmonary blood supply. Data on long term follow up. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Naimo PS, Konstantinov IE. Commentary: The road map for collaterals-A scenic route from the Abbey Road to the operating theater? JTCVS Tech 2020; 1:86-87. [PMID: 34317725 PMCID: PMC8288570 DOI: 10.1016/j.xjtc.2019.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 12/10/2019] [Accepted: 12/12/2019] [Indexed: 11/22/2022] Open
Affiliation(s)
- Phillip S. Naimo
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Igor E. Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Victoria, Australia
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22
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Fan F, Peng B, Liu Z, Liu Y, Wang Q. Systemic-to-pulmonary shunt vs right ventricle to pulmonary artery connection in the treatment of pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries. J Card Surg 2019; 35:345-351. [PMID: 31778584 DOI: 10.1111/jocs.14379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The systemic-to-pulmonary shunt (SPS) and right ventricle to pulmonary artery (RV-PA) connection were evaluated to pursue the goal of rehabilitating dysplastic native PAs via establishment of antegrade blood flow. However, the application of these two palliative operations was still confusing. We compared the two operations to determine their different effects on patients who have pulmonary atresia, ventricular septal defects, and major aortopulmonary collateral arteries (MAPCAs). METHODS From January 2011 to January 2016, 44 patients received the SPS procedure, and 54 patients received the RV-PA connection procedure; these procedures were compared based on perioperative data and follow-up data. There was no significant difference between the two groups for follow-up time (15.5 ± 11.8 vs 11.4 ± 10 months; P = .073). RESULTS The SPS patients had a smaller preoperative pulmonary artery index (68.57 ± 38.25 vs 112.62 ± 61.63 mm2 /m2 ; P < .01), more MAPCAs (2.4 ± 1.1 vs 1.8 ± 1.5; P = .045) and had a shorter intubation time (26.73 ± 27.20 vs 40.88 ± 36.93 hours; P = .045), intensive care unit stay (3.6 ± 3.9 vs 5.7 ± 5.5 days; P = .033), and hospital stay (9.9 ± 3.9 vs 14.7 ± 11.9 days; P = .014) than the RV-PA connection patients. The cumulative complete repair rate and cumulative survival rate did not differ significantly between the two groups. CONCLUSIONS Both the SPS and the RV-PA connection could rehabilitate the PA and produce complete repair, while the SPS could achieve better early postoperative outcomes and be suitable for patients with severe dysplastic PAs and large MAPCAs.
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Affiliation(s)
- Fan Fan
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,Pediatric Cardiac Surgical Centre, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Pediatric Cardiac Center, Beijing Children's Hospital & Capital Medical University, Beijing, China
| | - Bo Peng
- Pediatric Cardiac Surgical Centre, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhimin Liu
- Pediatric Cardiac Surgical Centre, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yinglong Liu
- Pediatric Cardiac Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qiang Wang
- Pediatric Cardiac Surgical Centre, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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23
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A Review of the Management of Pulmonary Atresia, Ventricular Septal Defect, and Major Aortopulmonary Collateral Arteries. Ann Thorac Surg 2019; 108:601-612. [DOI: 10.1016/j.athoracsur.2019.01.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 01/13/2019] [Accepted: 01/15/2019] [Indexed: 11/24/2022]
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24
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Mainwaring RD, Patrick WL, Rosenblatt TR, Ma M, Kamra K, Arunamata A, Hanley FL. Surgical results of unifocalization revision. J Thorac Cardiovasc Surg 2019; 158:534-545.e1. [DOI: 10.1016/j.jtcvs.2018.09.135] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/07/2018] [Accepted: 09/26/2018] [Indexed: 10/27/2022]
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25
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Wise-Faberowski L, Asija R, McElhinney DB. Tetralogy of Fallot: Everything you wanted to know but were afraid to ask. Paediatr Anaesth 2019; 29:475-482. [PMID: 30592107 DOI: 10.1111/pan.13569] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/30/2018] [Accepted: 12/24/2018] [Indexed: 12/28/2022]
Abstract
Tetralogy of Fallot (TOF) has four anatomic features: right ventricular hypertrophy (RVH), ventriculoseptal defect (VSD), overriding aorta and right ventricular outflow tract obstruction (RVOT) with an occurrence of 3.9 /10,000 births. The pathophysiologic effects in TOF are largely determined by the degree of RVOT and not the VSD. Intra-operative anesthetic management is also dependent on the degree of RVOT obstruction and influenced by the extent of surgical RVOT repair.
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Affiliation(s)
| | - Ritu Asija
- Department of Pediatrics, Stanford University, Palo Alto, California
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26
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Mainwaring RD, Hanley FL. The earth is round! J Thorac Cardiovasc Surg 2019; 157:e207-e208. [PMID: 30723023 DOI: 10.1016/j.jtcvs.2018.10.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Stanford University School of Medicine Lucile Packard Children's Hospital, Stanford, Calif
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Stanford University School of Medicine Lucile Packard Children's Hospital, Stanford, Calif
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27
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Collateral benefit in pulmonary atresia with ventricular septal defect? J Thorac Cardiovasc Surg 2018; 156:1205-1206. [DOI: 10.1016/j.jtcvs.2018.04.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 11/20/2022]
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28
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Pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals: collateral vessel disease burden and unifocalisation strategies. Cardiol Young 2018; 28:1091-1098. [PMID: 29978776 DOI: 10.1017/s104795111800080x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED IntroductionThe optimal approach to unifocalisation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (pulmonary artery/ventricular septal defect/major aortopulmonary collaterals) remains controversial. Moreover, the impact of collateral vessel disease burden on surgical decision-making and late outcomes remains poorly defined. We investigated our centre's experience in the surgical management of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals.Materials and methodsBetween 1996 and 2015, 84 consecutive patients with pulmonary artery/ventricular septal defect/major aortopulmonary collaterals underwent unifocalisation. In all, 41 patients received single-stage unifocalisation (Group 1) and 43 patients underwent multi-stage repair (Group 2). Preoperative collateral vessel anatomy, branch pulmonary artery reinterventions, ventricular septal defect status, and late right ventricle/left ventricle pressure ratio were evaluated. RESULTS Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.DiscussionSingle-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.
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29
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Mainwaring RD, Patrick WL, Roth SJ, Kamra K, Wise-Faberowski L, Palmon M, Hanley FL. Surgical algorithm and results for repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals. J Thorac Cardiovasc Surg 2018; 156:1194-1204. [DOI: 10.1016/j.jtcvs.2018.03.153] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 02/15/2018] [Accepted: 03/07/2018] [Indexed: 10/17/2022]
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Ikai A. Surgical strategies for pulmonary atresia with ventricular septal defect associated with major aortopulmonary collateral arteries. Gen Thorac Cardiovasc Surg 2018; 66:390-397. [DOI: 10.1007/s11748-018-0948-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 05/21/2018] [Indexed: 10/16/2022]
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Lenoir M, Pontailler M, Gaudin R, Gerelli S, Tamisier D, Bonnet D, Murtuza B, Vouhé PR, Raisky O. Outcomes of palliative right ventricle to pulmonary artery connection for pulmonary atresia with ventricular septal defect. Eur J Cardiothorac Surg 2018. [PMID: 28633393 DOI: 10.1093/ejcts/ezx194] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine the early, intermediate and long-term outcomes of pulmonary atresia with ventricular septal defect (PA/VSD) Types I, II and III initially palliated by a right ventricle to pulmonary artery (RVPA) connection. METHODS We performed a retrospective study from 2000 to 2014 that included 109 patients with PA/VSD who had undergone an RVPA connection (tetralogy of Fallot and PA/VSD Type IV excluded). The end-points of this strategy were adequate pulmonary artery tree post-palliation, second palliation, biventricular repair, right ventricular pressure post-biventricular repair and late reoperation. Mean follow-up was 5.4 years (1 day to 14-78 years). RESULTS Early mortality after an RVPA connection was 2.7% (3 of 109). The interstage mortality rate was 6.6% (7 of 106). Eighty-four (77%) patients had a biventricular repair and 8 patients (7%) are awaiting repair. Overall survival was 90% at 1 year and 81% at 10 years. The RVPA connection allowed significant growth of the native pulmonary artery with a Nakata index of 101 mm2/m2 before the RVPA connection and 274 mm2/m2 after (P = 0.001). Twenty-nine reinterventions for restrictive pulmonary blood flow have been done (9 before 2 months and 20 after 2 months). Of the 84 patients who had a repair, 22 patients (26%) initially had a right ventricular pressure greater than 40 mmHg. Twenty-eight patients (33%) required late reoperation. CONCLUSIONS Hospital deaths after the RVPA connection were low. The procedure allowed good growth of the native pulmonary artery. Biventricular repair was possible in a large number of cases. The late morbidity rate remains significant. Early reinterventions could be avoided by appropriate calibration. This technique appears to be suitable for any type of PA/VSD with central pulmonary arteries.
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Affiliation(s)
- Marien Lenoir
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Margaux Pontailler
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Régis Gaudin
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Sébastien Gerelli
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Daniel Tamisier
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Damien Bonnet
- Department of Pediatric Cardiology, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Bari Murtuza
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Pascal R Vouhé
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, University Paris Descartes and Sick Children Hospital, Paris, France
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Pulmonary reinterventions after complete unifocalization and repair in infants and young children with tetralogy of Fallot with major aortopulmonary collaterals. J Thorac Cardiovasc Surg 2018; 155:1696-1707. [DOI: 10.1016/j.jtcvs.2017.11.086] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 11/09/2017] [Accepted: 11/19/2017] [Indexed: 11/20/2022]
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Ma M, Mainwaring RD, Hanley FL. Comprehensive Management of Major Aortopulmonary Collaterals in the Repair of Tetralogy of Fallot. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2018; 21:75-82. [PMID: 29425528 DOI: 10.1053/j.pcsu.2017.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/03/2017] [Indexed: 06/08/2023]
Abstract
The heterogenous anatomy of Tetralogy of Fallot with major aortopulmonary collateral arteries has engendered a similar degree of diversity in its management and, ultimately, outcome. We summarize our comprehensive treatment paradigm for this lesion evolved over 15 years of experience through 458 patients and the results obtained. An updated analysis of 307 patients treated primarily at our institution is included. A review of recent literature, comparison of management strategies, and discussion of ongoing controversies are provided.
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Affiliation(s)
- Michael Ma
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Lucile Packard Children's Hospital, Stanford, CA, USA..
| | - Richard D Mainwaring
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Lucile Packard Children's Hospital, Stanford, CA, USA
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Barron DJ, Botha P. Approaches to Pulmonary Atresia With Major Aortopulmonary Collateral Arteries. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2018; 21:64-74. [PMID: 29425527 DOI: 10.1053/j.pcsu.2017.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 11/02/2017] [Indexed: 06/08/2023]
Abstract
Pulmonary atresia with major aortopulmonary collateral arteries (MAPCAs) is one of the most challenging surgical conditions to manage-not only because of the technical complexity of the surgery but also in terms of defining the anatomy of the pulmonary vasculature, the timing of surgery, and decision making on staged vs complete repair. The importance of early definition of pulmonary blood supply is paramount, establishing which areas of the lung are supplied by MAPCAs alone and which have dual supply with the native system (noting that 20% of patients have absent intrapericardial native vessels). Early unifocalization (3-6 months) is ideal, with closure of the ventricular septal defect (VSD) performed if 15 or more out of 20 lung segments can be recruited. Leaving the ventricular septal defect open with a limiting right ventricle-pulmonary artery conduit can be a useful interim or even definitive circulation in patients with borderline vasculature. Rehabilitation of small native vessels with central shunts can be very effective, but best outcomes are achieved by a combination of unifocalization of MAPCAs together with the native vessels (if present). A variety of reconstructive techniques are necessary to be able to effect these complex repairs with careful choice of materials. Ideally, surgery can be completed through sternotomy alone, but separate thoracotomies may be necessary to control and access some MAPCAs.
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Affiliation(s)
- David J Barron
- Department Cardiac Surgery, Birmingham Children's Hospital, UK.
| | - Phil Botha
- Department Cardiac Surgery, Birmingham Children's Hospital, UK
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Mainwaring RD, Patrick WL, Ma M, Hanley FL. An analysis of patients requiring unifocalization revision following midline unifocalization for pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals†. Eur J Cardiothorac Surg 2018; 54:63-70. [DOI: 10.1093/ejcts/ezy017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/30/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Department of Cardiac Surgery, Stanford University School of Medicine, Lucile Packard Children’s Hospital at Stanford, Stanford, CA, USA
| | - William L Patrick
- Division of Pediatric Cardiac Surgery, Department of Cardiac Surgery, Stanford University School of Medicine, Lucile Packard Children’s Hospital at Stanford, Stanford, CA, USA
| | - Michael Ma
- Division of Pediatric Cardiac Surgery, Department of Cardiac Surgery, Stanford University School of Medicine, Lucile Packard Children’s Hospital at Stanford, Stanford, CA, USA
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Department of Cardiac Surgery, Stanford University School of Medicine, Lucile Packard Children’s Hospital at Stanford, Stanford, CA, USA
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Brizard CP. The modern mission of the innovator: Data, data, and more data. J Thorac Cardiovasc Surg 2018; 155:1708-1709. [PMID: 29397154 DOI: 10.1016/j.jtcvs.2017.12.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/14/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Christian P Brizard
- Cardiac Surgery Unit, The Royal Children's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Parkville, Australia; Department of Pediatrics, The University of Melbourne, Parkville, Australia.
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Rabinowitz EJ, Epstein S, Kohn N, Meyer DB. Promoting Pulmonary Arterial Growth via Right Ventricle-to-Pulmonary Artery Connection in Children With Pulmonary Atresia, Ventricular Septal Defect, and Hypoplastic Pulmonary Arteries. World J Pediatr Congenit Heart Surg 2017; 8:564-569. [DOI: 10.1177/2150135117717266] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Complete repair of pulmonary atresia (PA) ventricular septal defect (VSD) with hypoplastic or absent native pulmonary arteries, often with major aortopulmonary collateral arteries (MAPCAs), involves construction of an adequate sized pulmonary arterial tree. We report our results with a previously described staged strategy using initial right ventricle (RV)-to-reconstructed pulmonary arterial tree (RV-PA) connection to promote pulmonary arterial growth and facilitate later ventricular septation. Methods: We retrospectively reviewed data for all patients (N = 10) with initial echocardiographic diagnosis of PA-VSD and hypoplastic pulmonary arteries operated in our center from October 2008 to August 2016. Pulmonary arterial vessel size measured on preoperative and postoperative angiography was used to calculate Nakata index. Results: Seven patients had PA-VSD, three had virtual PA-VSD, and seven had MAPCAs. All underwent creation of RV-PA connection at a median age of 7.5 days and weight 3.6 kg. Eight patients had RV-PA conduits, two had a transannular patches, and seven had major pulmonary artery reconstruction simultaneously. There were no deaths or serious morbidity; one conduit required revision prior to complete repair. Complete repair with ventricular septation and RV pressure less than half systemic was achieved in all patients at a median age of 239 days. Nakata index in neonatal period was 54 mm2/m2 (range 15-144 mm2/m2) and at time of septation 184 mm2/m2 (range 56-510 mm2/m2; P = .004). Growth rates of right and left branch pulmonary arteries were similar. The 10 patients underwent 28 catheterizations with 13 interventions in 8 patients prior to full repair. Conclusion: Early palliative RV-PA connection promotes pulmonary arterial growth and facilitates eventual full repair with VSD closure with low RV pressure and operative risk.
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Affiliation(s)
- Edon J. Rabinowitz
- Division of Pediatric Cardiology, Cohen Children’s Heart Center, Cohen Children’s Medical Center of New York—Hofstra Northwell School of Medicine, New Hyde Park, NY, USA
| | - Shilpi Epstein
- Division of Pediatric Cardiology, Cohen Children’s Heart Center, Cohen Children’s Medical Center of New York—Hofstra Northwell School of Medicine, New Hyde Park, NY, USA
| | - Nina Kohn
- Biostatistics Unit, Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY, USA
| | - David B. Meyer
- Division of Cardiovascular and Thoracic Surgery, Cohen Children’s Heart Center, Cohen Children’s Medical Center of New York–Hofstra Northwell School of Medicine, New Hyde Park, NY, USA
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Bauser-Heaton H, Borquez A, Han B, Ladd M, Asija R, Downey L, Koth A, Algaze CA, Wise-Faberowski L, Perry SB, Shin A, Peng LF, Hanley FL, McElhinney DB. Programmatic Approach to Management of Tetralogy of Fallot With Major Aortopulmonary Collateral Arteries. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004952. [DOI: 10.1161/circinterventions.116.004952] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 03/02/2017] [Indexed: 11/16/2022]
Abstract
Background—
Tetralogy of Fallot with major aortopulmonary collateral arteries is a complex and heterogeneous condition. Our institutional approach to this lesion emphasizes early complete repair with the incorporation of all lung segments and extensive lobar and segmental pulmonary artery reconstruction.
Methods and Results—
We reviewed all patients who underwent surgical intervention for tetralogy of Fallot and major aortopulmonary collateral arteries at Lucile Packard Children’s Hospital Stanford (LPCHS) since November 2001. A total of 458 patients underwent surgery, 291 (64%) of whom underwent their initial procedure at LPCHS. Patients were followed for a median of 2.7 years (mean 4.3 years) after the first LPCHS surgery, with an estimated survival of 85% at 5 years after first surgical intervention. Factors associated with worse survival included first LPCHS surgery type other than complete repair and Alagille syndrome. Of the overall cohort, 402 patients achieved complete unifocalization and repair, either as a single-stage procedure (n=186), after initial palliation at our center (n=74), or after surgery elsewhere followed by repair/revision at LPCHS (n=142). The median right ventricle:aortic pressure ratio after repair was 0.35. Estimated survival after repair was 92.5% at 10 years and was shorter in patients with chromosomal anomalies, older age, a greater number of collaterals unifocalized, and higher postrepair right ventricle pressure.
Conclusions—
Using an approach that emphasizes early complete unifocalization and repair with incorporation of all pulmonary vascular supply, we have achieved excellent results in patients with both native and previously operated tetralogy of Fallot and major aortopulmonary collateral arteries.
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Affiliation(s)
- Holly Bauser-Heaton
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Alejandro Borquez
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Brian Han
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Michael Ladd
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Ritu Asija
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Laura Downey
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Andrew Koth
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Claudia A. Algaze
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Lisa Wise-Faberowski
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Stanton B. Perry
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Andrew Shin
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Lynn F. Peng
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Frank L. Hanley
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
| | - Doff B. McElhinney
- From the Departments of Pediatrics (H.B.-H., A.B., B.H., M.L., R.A., A.K., C.A.A., S.B.P., A.S., L.F.P., D.B.M.), Anesthesia (L.D., L.W.-F.), and Cardiothoracic Surgery (F.L.H., D.B.M.), Lucile Packard Children’s Hospital Heart Center Clinical and Translational Research Program, Stanford University School of Medicine, Palo Alto, CA
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Hoashi T, Yazaki S, Kagisaki K, Kitano M, Shimada M, Shiraishi I, Ichikawa H. Importance of multidisciplinary management for pulmonary atresia, ventricular septal defect, major aorto-pulmonary collateral arteries and completely absent central pulmonary arteries. Gen Thorac Cardiovasc Surg 2017; 65:337-342. [DOI: 10.1007/s11748-017-0765-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 02/22/2017] [Indexed: 11/29/2022]
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Soquet J, Liava'a M, Eastaugh L, Konstantinov IE, Brink J, Brizard CP, d'Udekem Y. Achievements and Limitations of a Strategy of Rehabilitation of Native Pulmonary Vessels in Pulmonary Atresia, Ventricular Septal Defect, and Major Aortopulmonary Collateral Arteries. Ann Thorac Surg 2016; 103:1519-1526. [PMID: 28010875 DOI: 10.1016/j.athoracsur.2016.08.113] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 08/24/2016] [Accepted: 08/31/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND A strategy of rehabilitation for pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (PA/VSD/MAPCAs) comprises repetitive shunting and patching procedures of the central pulmonary arteries. We wanted to determine the feasibility and limitations of a strategy of rehabilitation. METHODS The outcomes of 37 consecutive patients operated from June 2003 to December 2014 for PA/VSD/MAPCAs were reviewed. The patients were directed to a rehabilitation strategy, except when they presented in heart failure with very large collaterals. RESULTS Four patients with very large MAPCAs underwent a one-stage repair with unifocalization of collateral vessels at a median age of 8.6 months. There was no mortality in this group after a median follow-up of 4.6 years. Following a strategy of staged rehabilitation, 33 patients had 2.01 ± 0.9 procedures before repair. Median age at primary shunting was 3.3 weeks (0.4 to 31.9 weeks). Repair rate was 73% (22 patients), at a median age of 1.7 years. Three patients (10%) were left palliated and 3 patients (10%) died. Median follow-up in this group was 4.5 years. Complementary procedures to the rehabilitation strategy consisted in pulmonary artery reconstruction in 25 patients (76%) and MAPCAs ligation in 7 patients (21%). Pulmonary balloon angioplasty was required in 12 patients (36%) and MAPCAs coil occlusion in 8 patients (24%). CONCLUSIONS A strategy of rehabilitation can be implemented in almost 90% of the cases, with a low mortality rate. Following this strategy, 73% of the patients can be successfully repaired.
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Affiliation(s)
- Jerome Soquet
- Department of Cardiac Surgery, the Royal Children's Hospital, Parkville, Victoria, Australia
| | - Matthew Liava'a
- Department of Cardiac Surgery, the Royal Children's Hospital, Parkville, Victoria, Australia
| | - Lucas Eastaugh
- Department of Cardiology, the Royal Children's Hospital, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, the Royal Children's Hospital, Parkville, Victoria, Australia; Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Johann Brink
- Department of Cardiac Surgery, the Royal Children's Hospital, Parkville, Victoria, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, the Royal Children's Hospital, Parkville, Victoria, Australia; Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, the Royal Children's Hospital, Parkville, Victoria, Australia; Department of Pediatrics, University of Melbourne, Parkville, Victoria, Australia; Murdoch Childrens Research Institute, Parkville, Victoria, Australia.
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Pulmonary flow study predicts survival in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. J Thorac Cardiovasc Surg 2016; 152:1494-1503.e1. [DOI: 10.1016/j.jtcvs.2016.07.082] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 07/24/2016] [Accepted: 07/26/2016] [Indexed: 11/24/2022]
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Outcomes of Patients with Pulmonary Atresia and Major Aortopulmonary Collaterals Without Intervention in Infancy. Pediatr Cardiol 2016; 37:1380-91. [PMID: 27377524 PMCID: PMC5189909 DOI: 10.1007/s00246-016-1445-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
Abstract
Treatment of pulmonary atresia with major aortopulmonary collaterals (PA MAPCAs) remains a challenge. Despite variations in surgical technique, contemporary strategies all include initial intervention in the first year of life. However, a subset of patients presents later in life, and contemporary outcomes of this group have not been reported previously. We performed a retrospective case series of consecutive cases of PA MAPCAs who were seen at our center between January 2001 and February 2016, who had not undergone surgery before the age of 1 year. We describe their presenting characteristics, operative and transcatheter interventions, and outcomes. A total of eight cases were identified from 76 children with PA MAPCAs treated over the study period. Median age at presentation was 5.9 years. Seventy-five percent had confluent pulmonary arteries with a median Nakata index of 113 mm(2)/m(2). Operative intervention was performed in 5/6 cases. Two are awaiting intervention. The combination of operative and transcatheter interventions allowed for ventricular septal defect closure in 60 % of cases, all of whom had subsystemic right ventricular pressures. Operative intervention is possible in some older cases with PA and MAPCAs. Though multiple operations and transcatheter therapies are necessary, some can achieve operative correction of serial circulation with tolerable physiology. Subjects with ventricular hypoplasia and those without confluent pulmonary arteries are more challenging.
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Ide Y, Murata M, Ito H, Sakamoto K. A successful staged Fontan operation for a right atrial isomerism neonate having major aortopulmonary collateral arteries and extracardiac total anomalous pulmonary venous connection. Interact Cardiovasc Thorac Surg 2016; 24:135-137. [DOI: 10.1093/icvts/ivw285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 06/13/2016] [Accepted: 06/27/2016] [Indexed: 11/12/2022] Open
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Iyengar AJ, Celermajer DS, Winlaw DS, D’Udekem Y. Young and Free: Over 25 Years of Seminal Contributions to Complex Congenital Heart Disease From Australia & New Zealand. Heart Lung Circ 2016; 25:529-34. [DOI: 10.1016/j.hlc.2016.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/29/2016] [Indexed: 02/05/2023]
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Chen Q, Ma K, Hua Z, Yang K, Zhang H, Wang X, Hu X, Yan F, Liu J, Zhang S, Qi L, Li S. Multistage pulmonary artery rehabilitation in patients with pulmonary atresia, ventricular septal defect and hypoplastic pulmonary artery. Eur J Cardiothorac Surg 2016; 50:160-6. [DOI: 10.1093/ejcts/ezw069] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/09/2015] [Indexed: 11/13/2022] Open
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Kaskinen AK, Happonen JM, Mattila IP, Pitkänen OM. Long-term outcome after treatment of pulmonary atresia with ventricular septal defect: nationwide study of 109 patients born in 1970–2007. Eur J Cardiothorac Surg 2015; 49:1411-8. [DOI: 10.1093/ejcts/ezv404] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 10/15/2015] [Indexed: 11/14/2022] Open
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Presnell LB, Blankenship A, Cheatham SL, Owens GE, Staveski SL. An Overview of Pulmonary Atresia and Major Aortopulmonary Collateral Arteries. World J Pediatr Congenit Heart Surg 2015; 6:630-9. [DOI: 10.1177/2150135115598559] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (PA/VSD/MAPCAs) is a rare and complex congenital cardiac lesion that has historically carried a poor prognosis. With advancements in surgical management, we have seen an improvement in the outcomes for children affected by this disease. However, this population continues to present challenges due to the complex anatomy and physiology associated with PA/VSD/MAPCA. This summary of material presented during one of the nursing sessions of the 2014 Meeting of the Pediatric Cardiac Intensive Care Society provides an overview for those in cardiac intensive care units who do not have a large experience with this lesion. We will review the anatomy, physiology, surgical approach, postoperative management strategies, and cardiac catheter intervention options for PA/VSD/MAPCAs. We will also discuss recent innovations that may lead to continued improvement in outcomes for this challenging patient population.
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Affiliation(s)
- Laura B. Presnell
- Pediatric Cardiac Intensive Care Unit, Lucile Packard Children’s Hospital, Palo Alto, CA, USA
| | | | | | - Gabe E. Owens
- C.S. Mott Children’s Hospital, University of Michigan Congenital Heart Center, Hospital Drive, Ann Arbor, MI, USA
| | - Sandra L. Staveski
- Research in Patient Services and Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Carrillo SA, Mainwaring RD, Patrick WL, Bauser-Heaton HD, Peng L, Reddy VM, Hanley FL. Surgical Repair of Pulmonary Atresia With Ventricular Septal Defect and Major Aortopulmonary Collaterals With Absent Intrapericardial Pulmonary Arteries. Ann Thorac Surg 2015; 100:606-14. [PMID: 26138766 DOI: 10.1016/j.athoracsur.2015.03.110] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 03/23/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND One anatomic variant of pulmonary atresia with ventricular septal defect and major aortopulmonary collaterals (PA/VSD/MAPCAs) is characterized by the absence of intrapericardial pulmonary arteries. This anatomy obviates the possibility of incorporating the pulmonary arteries for reconstruction or palliative procedures. The purpose of this study was to evaluate the surgical results in patients undergoing repair of PA/VSD/MAPCAs with absent pulmonary arteries. METHODS This was a retrospective review of 35 patients who underwent surgical repair of PA/VSD/MAPCAs with absent pulmonary arteries between 2007 and 2014. The median age at the time of surgery was 3.4 months, and the median weight was 4.9 kg. All patients underwent unifocalization of MAPCAs, with an average of 3.5 ± 1.4 MAPCAs per patient. RESULTS Twenty-eight of the 35 patients (80%) underwent complete single-stage surgical repair, including unifocalization of MAPCAs, VSD closure, and right ventricle to pulmonary artery conduit. After complete repair, the average right ventricular to aortic pressure ratio was 0.33 ± 0.07. There were no deaths in this subgroup. Seven patients (20%) were not deemed suitable candidates for VSD closure after their unifocalization procedure, and therefore underwent palliation with a central shunt. There was 1 operative death and 1 interim death. Three patients have subsequently undergone complete repair, and 2 are awaiting further evaluation and treatment. CONCLUSIONS The majority of patients with PA/VSD/MAPCAs and absent pulmonary arteries can undergo complete single-stage repair with satisfactory postoperative hemodynamics. These results suggest that unifocalization of MAPCAs can provide a reasonable pulmonary vascular bed in the absence of intrapericardial pulmonary arteries.
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Affiliation(s)
- Sergio A Carrillo
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital, Stanford University, Stanford, California.
| | - William L Patrick
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Holly D Bauser-Heaton
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Lynn Peng
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - V Mohan Reddy
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital, Stanford University, Stanford, California
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49
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A central shunt to rehabilitate diminutive pulmonary arteries in patients with pulmonary atresia with ventricular septal defect. J Thorac Cardiovasc Surg 2015; 149:515-20. [DOI: 10.1016/j.jtcvs.2014.10.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/25/2014] [Accepted: 10/04/2014] [Indexed: 12/13/2022]
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50
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Jaquiss RDB. Shunt first: one way to do it. J Thorac Cardiovasc Surg 2014; 149:520-1. [PMID: 25486974 DOI: 10.1016/j.jtcvs.2014.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 11/10/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Robert D B Jaquiss
- Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC.
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