Anomalous origin of the right pulmonary artery from the ascending aorta associated with aortopulmonary window

Anomalous origin of the right pulmonary artery from the ascending aorta

OBJECTIVES

The aim was to review our experience with the surgical repair of the anomalous origin of the right pulmonary artery (AORPA) from the aorta.

MATERIALS AND METHOD

Between January 1991 and March 2001, five patients with AORPA underwent surgical correction. One patient presented isolated AOPA from the aorta. Implantation of the anomalous PA to the main PA trunk was performed by (1). direct anatomosis employing an autologous pericardial patch in two patients; (2). using an aortic flap in two patients with AORPA; and (3). using an aortic and pulmonary flaps in another patient. The mean follow-up time was 27 months.

RESULTS

One patient died due to progressive heart failure unresponsive to inotropic support. Early postoperative pulmonary hypertension crisis was identified in patient 4, that was managed by intravenous prostacyclin. The same patient necessitated mechanical ventilation for 11 days. The mean residual gradient for all survivors was 9.5 +/- 4 mmHg. The postoperative Tc-99 m scintigraphy demonstrated 72 +/- 4.5(%) lung perfusion. At follow-up the survival was 100%. None of the followed patients required reoperation.

CONCLUSION

The AORPA from the aorta is a rare but important entity, necessitating a scrupulous preoperative and intraoperative evaluation. The techniques employing autologous tissues for enlarging and lengthening the AORPA seem to be associated with better results in terms of postoperative restenosis.

Anomalous origin of a pulmonary artery from the ascending aorta: associated anomalies and pathogenesis

The pathologic anatomic features and associated cardiovascular anomalies of 9 patients with anomalous origin of 1 pulmonary artery (PA) from the ascending aorta seen at the University of Florida and 99 previously reported cases were analyzed. Anomalous origin of the right PA was much more common than anomalous origin of the left PA. The anomalous right PA usually arose from the posterior aspect of the ascending aorta close to the aortic valve. Less commonly, it originated from the lateral ascending aorta just proximal to the innominate artery. Patent ductus arteriosus and aorticopulmonary septal defect were commonly associated with anomalous origin of the right PA; other cardiovascular anomalies were rare. In contrast, tetralogy of Fallot and aortic arch anomalies, e.g., right aortic arch and anomalous origin of the subclavian artery, were common in anomalous origin of the left PA. An association with DiGeorge syndrome, frequently noted with persistent truncus arteriosus, was not seen with anomalous origin of a PA from the ascending aorta. The observations indicate that anomalous origin of the right PA and anomalous origin of the left PA are pathogenetically unrelated to each other and both are unrelated to persistent truncus arteriosus. Moreover, anomalous origin of the right PA arising close to the innominate artery is thought to be pathogenetically distinct from the type that arises close to the aortic valve. These pathogenetic relations should be considered in epidemiologic studies of congenital heart disease.

Anatomy and pathogenesis of aorticopulmonary septal defect

The pathologic anatomic features and associated cardiac anomalies of 13 patients with aorticopulmonary septal defect (APSD) and of 236 previously reported cases were analyzed. Morphologically, 3 types of APSD were distinguished: a defect with a more or less circular border located about halfway between the arterial valves and the bifurcation of the pulmonary trunk; a similarly located defect in which the border represents a helix; and a usually large defect in which there is no posterior (distal) border. The appearance of these 3 types of defects suggests a different developmental mechanism for each. Approximately half of the cases of APSD are not associated with other cardiovascular anomalies. Of the anomalies that do occur, anomalous origin of a coronary artery from the pulmonary trunk and interruption of the aortic arch (IAA) type A or severe preductal coarctation are seen far more often than expected. An association with DiGeorge syndrome, frequently noted with persistent truncus arteriosus (TA) and IAA type B, was not seen. Certain cardiac anomalies often seen with TA are rarely seen with APSD, and defects often seen with APSD are rarely seen with TA. These observations indicate that APSD and TA are pathogenetically unrelated even though located in the same region of the heart and, unlike TA and IAA type B, APSD is probably not due to a developmental error involving the neural crest.

Repair of anomalous origin of the right pulmonary artery from the ascending aorta associated with subtotal left cor triatriatum

A unique case of anomalous origin of the right pulmonary artery from the ascending aorta associated with subtotal left cor triatriatum and severe pulmonary hypertension in a 4-month-old infant was successfully repaired using cardiopulmonary bypass and circulatory arrest.

The surgical treatment of aortopulmonary window

From 1956 through July 1981, 15 patients, ranging in age from 9 days to 20 years, underwent surgical correction of aortopulmonary (AP) window. Surface hypothermia and venous inflow occlusion were used in the first patient. In four patients, the technique for closure of AP window was similar to that for patent ductus arteriosus: in one, the AP window was ligated; and in three, clamping, division and suture were performed. Cardiopulmonary bypass was used in ten patients. In five patients, division and primary closure were done. In five, a patch was used to close the defect by using the transaortic and/or pulmonary approach. Associated cardiovascular anomalies were repaired concomitantly in four of seven patients. Two patients died during the immediate postoperative period; both were infants and had serious associated cardiovascular anomalies. One patient died from increased pulmonary vascular resistance and right heart failure 1 year after replacement of the tricuspid valve. Of 12 patients who survived the operation, 11 had excellent results. For the surgical treatment of patients with AP window, we stress the safety and ease afforded by extracorporeal circulation and a preference for the transaortic approach and fabric patch closure.

Variant of tetralogy of fallot with absent pulmonary valve leaflets and origin of one pulmonary artery from the ascending aorta

Absent pulmonary valve leaflets and anomalous origin of a pulmonary artery from the ascending aorta have been reported as separate lesions associated with tetralogy of Fallot but not in combination. The clinical, radiologic and pathologic findings are presented in three patients with this previously undescribed combination. A search of the literature for similar cases revealed 233 patients with absent pulmonary valve leaflets and 56 patients with anomalous origin of a pulmonary artery from the ascending aorta; these cases are reviewed. Although 17 patients with absent pulmonary valve leaflets and tetralogy of Fallot also had absence of the proximal portion of the left pulmonary artery, none had an anomalously arising pulmonary artery from the ascending aorta. In the reviewed cases, anomalous origin of the right pulmonary artery from the ascending aorta was more frequent than that of the left pulmonary artery (44 compared with 12 cases, respectively), but the latter was more often associated with tetralogy of Fallot.