Descending aortic translocation for left aortic arch with right descending aorta and coarctation of the aorta

Left aortic arch with right descending aorta associated with coarctation of the aorta is a rare congenital cardiac anomaly. Conventional aortic arch repair in this condition may cause airway compression by the abnormally coursing descending aorta. We present the case of a neonate with this anomaly who underwent successful descending aortic translocation to prevent postoperative left main bronchial stenosis.

Swing-back and trap-door technique repair for interrupted aortic arch with right-sided descending aorta

A right-sided descending aorta with a left aortic arch is a rare congenital anomaly in which the aortic arch crosses the midline from the left side of the trachea coursing to the descending aorta in the right thoracic cavity. The surgical repair of an interrupted aortic arch with a right-sided descending aorta carries great risks of bronchial and oesophageal obstruction. Herein, we describe a case of successful surgical repair of an interrupted aortic arch with a right-sided descending aorta using the swing-back and trap-door techniques.

[The diagnostic value of MSCT multi-dimensional reconstructions for congenital vascular ring with tracheal stenosis]

OBJECTIVE

To evaluate the diagnostic value of multi-slice CT (MSCT) reconstructions for congenital vascular rings together with tracheal stenosis.

METHODS

9 cases of children with congenital vascular ring and tracheal stenosis confirmed by surgery were collected in the study, all cases had undergone thin slice CT contrast enhancement, the MSCT data were transmitted to the workstation for multiplanar reconstruction (MPR), volume rendering technique (VRT) and VR transparency reconstruction. With the surgical results as the gold standard, the imaging characteristics of echocardiography (UCG) and MSCT were comparatively analyzed.

RESULTS

In 9 cases, there were 4 cases of pulmonary artery sling, 3 cases of right aortic arch combination with left aberrant subclavian artery, 1 case of double aortic arch, 1 case of innominate artery compression syndrome. In this group, 5 cases were accompanied with other cardiac malformations (tetralogy of Fallot in 2 cases, double outlet right ventricle with patent ductus arteriosus and ventricular septal defect in 1 case, ventricular septal defect in 1 case, double superior vena cava in 1 case), 1 case of tetralogy of Fallot demonstrated many tortuous collateral arteries around aorta. All malformations were well displayed by VRT, MPR. VR transparency reconstruction can stereoscopically display trachea and bronchial compression condition, the main trachea was compressed in 6 cases, the main trachea and left main bronchus was compressed in 2 cases, the main trachea and left main bronchus was compressed in 1 cases, UCG detected all intracardiac malformations, 1 case of pulmonary artery sling was misdiagnosed as patent ductus arteriosus, 8 cases of vascular rings, tracheal and bronchial stenosis were missed.

CONCLUSION

MSCT reconstruction technology is a noninvasive, rapid diagnostic method, it can clearly show the congenital vascular rings abnormalities and the degree of tracheal stenosis, it has important significance for clinic treatment.

Esophageal cancer resection associated with a right aortic arch after descending aortic graft replacement

Right aortic arch is a rare abnormality. Esophageal cancer associated with a vascular ring is even more rare. We describe a patient with right aortic arch who had previously undergone a graft replacement of descending aorta for aneurysmal rupture followed by subsequent surgery for advanced esophageal cancer. Preoperative three-dimensional computed tomography revealed mirror image branching type right aortic arch and Kommerell's diverticulum of the descending aorta. The patient underwent total esophagectomy with laryngopharyngectomy and regional lymphadenectomy via a left thoracotomy. A permanent tracheal fistula was constructed. Postoperative chemo-radiotherapy was applied. The patient was discharged from hospital and is doing well. Early division of the ligamentum arteriosum with careful management of the aortic diverticulum led to release of the esophagus from the vascular ring that rendered the following procedures safe and afforded a good operative view.

Homograft valved right ventricle to pulmonary artery conduit as a modification of the Norwood procedure

BACKGROUND

The use of a right ventricle to pulmonary artery (RV-PA) conduit in the Norwood procedure has been proposed to increase postoperative hemodynamic stability. A valve within the conduit should further decrease RV volume load. We report our clinical experience with this modification.

METHODS AND RESULTS

From February 2002 through August 2005, we performed 88 consecutive Norwood procedures using RV-PA conduits. We used composite valved conduits made from cryopreserved homograft and polytetrafluoroethylene (PTFE) in 66 cases (54 pulmonary, 12 aortic homografts), other valved conduits in 14, and unvalved PTFE in 8 cases. Hospital survival was 88.6% overall and increased to 93.1% after the initial year. Early interventions were required in 18 patients (16 for cyanosis). Prestage II cardiac catheterization was performed at a mean age of 126 days. Mean Qp/Qs was 1, with mean aortic saturation 71%, mean O2 extraction 24%, and mean right ventricular end-diastolic pressure 9 mm Hg. Patient weight, use of an aortic homograft valve in the conduit, stage I palliation within the first year of our experience, and low O2 extraction and high transpulmonary gradient prestage II were risk factors for overall death. Early interventions were more frequent in aortic valve conduits compared with all other conduits.

CONCLUSIONS

The valved RV-PA conduit was associated with low early mortality after the Norwood procedure. The majority of these patients had normal cardiac output and well-maintained RV function. There may be a higher risk for early conduit interventions and death when aortic valve homografts are used in the RV-PA conduit.

Monitoring of selective antegrade cerebral perfusion using near infrared spectroscopy in neonatal aortic arch surgery

BACKGROUND AND OBJECTIVE

To prevent neurological complications, low-flow antegrade cerebral perfusion (ACP) is used during repair of complex congenital heart defects. To overcome technical problems, continuous monitoring of cerebral blood flow and oxygenation is mandatory. The aim of the study was to evaluate the effect of different ACP flow rates on cerebral oxygen saturation obtained by near infrared spectroscopy.

METHODS

Ten consecutive neonates undergoing Norwood stage I were included. In addition to near infrared spectroscopy (Invos 5100; Somanetics Corp., USA) on both hemispheres, mean arterial pressure and transcranial Doppler flow velocity were measured continuously and arterial and jugular venous oxygen saturation intermittently. Cerebral oxygen extraction ratio was calculated. Measurement points were obtained after starting bypass, during ACP with flow rates of 30, 20 and 10 mL kg(-1) min(-1) and immediately after ACP. ANOVA and Tukey-Kramer multiple comparison test were used for statistics.

RESULTS

The near infrared spectroscopy signal could be obtained in all children at all measurement points, whereas transcranial Doppler failed in 1 neonate at a flow rate of 30 mL kg(-1)min(-1), in 3 neonates at 20 mL kg(-1) min(-1) and in 4 neonates at 10 mL kg(-1)min(-1). With the reduction of flow there was a significant decrease of cerebral oxygen saturation on both hemispheres (right: 78+/-8 to 72+/-9 and 66+/-8, P < 0.001; left: 71+/-7 to 65+/-7 and 60+/-7, P < 0.001), of jugular venous oxygen saturation (94+/-6 to 89+/-13 and 83+/-15, P < 0.001) and a significant increase in oxygen extraction ratio (9.1+/-8 to 14.8+/-14 and 21+/-16, P < 0.001) respectively, for 30, 20, 10 mL kg(-1)min(-1).

CONCLUSION

Near infrared spectroscopy reliably detects flow alterations during ACP with profound hypothermia.

Risk factors associated with mortality and interventions in 472 neonates with interrupted aortic arch: A Congenital Heart Surgeons Society study

OBJECTIVE

We sought to determine the prevalence of outcomes and associated patient and management factors for neonates with interrupted aortic arch.

METHODS

From 1987 to 1997, a total of 472 neonates were enrolled prospectively from 33 institutions. Competing risks methodology was used to determine simultaneous risk and associated incremental risk factors for death, initial and subsequent left ventricular outflow tract procedures, and arch reinterventions.

RESULTS

Overall survival was 59% at 16 years after study entry but improved with successive birth cohort. In general, risk factors for death in each of the competing risks analyses included lower birth weight, younger age at study entry, type B interrupted aortic arch, and major associated cardiac anomalies. Of 453 patients who had interrupted aortic arch repair, after 16 years 33% had died and 28% had undergone an arch reintervention. Reintervention was more likely for those who had truncus arteriosus repair, interrupted aortic arch repair by a method other than direct anastomosis with patch augmentation, and the use of polytetrafluoroethylene as either an interposition graft or a patch. From study entry, competing risks after 16 years showed that 28% had died and 34% had undergone an initial left ventricular outflow tract procedure. Initial left ventricular outflow tract procedure was more likely for those with single ventricle, type B interrupted aortic arch, bicuspid aortic valve, or anomalous right subclavian artery. Among those who had undergone an initial left ventricular outflow tract procedure, after 16 years 37% had died and 28% had undergone a second procedure.

CONCLUSION

Anatomic features affect mortality and initial left ventricular outflow tract procedures, whereas characteristics of the arch repair affect arch reintervention.

A case of symptomatic aberrant right subclavian artery

Aberrant right subclavian artery is one of the aortic arch anomalies which is almost always asymptomatic. A 27-year-old lady, from Asebe Teferi, presented with dysphagia of eight months duration. Physical examination revealed no abnormality. Barium swallow and post Intravenous-contrast computerized tomography (CT) scan showed aberrant right subclavian artery. She was operated via the approach of left thoracotomy. The aberrant right subclavian was legated, brought anterior to trachea and reimplanted to the left stubclavian artery. She had uneventful postoperative course and discharged symptom free.

Cardiopulmonary bypass in surgery for interrupted aortic arch

Interrupted aortic arch is a complicated congenital heart defect. Because of its anatomic features, the conventional cardiopulmonary bypass (CPB) procedure is not suitable for the surgery of this type of lesion. Thus, we conducted a retrospective study of CPB in surgery for the disease. Ten patients with interrupted aortic arch underwent surgery by one of three different CPB methods, including profound hypothermia with circulatory arrest in four cases, profound hypothermia with low flow rate in five cases, and normothermia in one case. In profound hypothermic CPB, both ascending aorta and main pulmonary artery were cannulated. Through these two cannulas, the flow was pumped to the upper and lower body separately to cool down the body temperature. After cooling, the main pulmonary artery cannula was removed and interrupted aortic arch was corrected either under low flow rate perfusion or under circulatory arrest. After this, the other intracardiac lesions were repaired under conventional CPB. At the end of CPB, one patient demonstrated third-degree atria-ventricular block and required reinstituting CPB and a second procedure to repair the ventricular septal defect (VSD). In the intensive care unit, one patient developed lung infection and dyspnea after extubation that required intubation and mechanical ventilation for another several days. Another patient required 3 days of peritoneal dialysis caused by low cardiac output, hyperkalemia, and oliguria. All patients survived. The mechanical ventilation times were from 8 hours to 8 days and stays in the intensive care unit were from 4 to 12 days. Profound hypothermic cardiopulmonary bypass either with low flow rate or with circulatory arrest is equally the preferable choice for the surgery of interrupted aortic arch.

Interrupted aortic arch type B in trisomy 21: repair with carotid artery interposition

A 21-year-old man with Trisomy 21 was diagnosed with interrupted aortic arch type B and perimembranous ventricular septal defect in the newborn period. He underwent carotid artery interposition and pulmonary artery banding with subsequent debanding and closure of the ventricular septal defect. Cardiac catheterization 20 years later demonstrated good "carotid arch" growth with no residual arch obstruction. Carotid artery interposition provided good curative repair for arch obstruction at late follow-up in this patient.

Persistence of hypoplastic and recoarcted fifth aortic arch associated with type A aortic arch interruption: surgical and balloon angioplasty results in an infant

A rare aortic malformation, the persistence of the fifth aortic arch (PFAA) associated with coarctation of the aorta, is reported in a 3-month-old male infant who underwent an emergency surgical intervention at 10 days of life, to relieve a severe aortic coarctation by pericardial patch technique. A successful balloon angioplasty was performed 2 months later eliminating a recoarctation. The gradient fell from 77 mmHg to 0, but a definitive surgical intervention for recoarctation was necessary 14 months after angioplasty.

Truncus arteriosus communis associated with interrupted aortic arch: a report on two uncommon cases

The paper presents two infants with the A-4 type of truncus arteriosus communis (according to Van Praagh's classification). One patient who survived a surgical procedure demonstrated a rare variant of aortic arch interruption to the left off the left subclavian artery (type A according to Celoria and Patton), whereas the second presented an uncommon anomaly in which the right subclavian artery originated from the descending aorta with associated severe truncal valve incompetency. The authors describe the clinical picture along with the surgical treatment of the first infant who being six days old was subjected to a correction employing the wide patent ductus arteriosus to reconstruct the aortic arch, following the method described by Gomes and McGoon. Subsequently an aortic homograft was implanted in order to connect the right ventricle and the pulmonary artery.

[Interrupted aortic arch. A series of 15 patients]

Between 1983 and 1989, 15 children underwent surgical repair of interrupted aortic arch at 1 to 20 days of age. The anatomical form was a Celoria and Patton type B in all patients with an associated perimembranous ventricular septal defect in all but one who had multiple ventricular septal defects, and patent ductus arteriosus. Six children had a retro-esophageal right subclavian artery, two had subaortic stenosis and two had a right-sided descending thoracic aorta. In two children with severe hypoplasia of the ascending aorta the repair was performed in one stage with two deaths due to left ventricular failure. In the other B cases, a two-stage repair was carried out. The reconstruction of the aortic arch varied according to the individual case. All children had pulmonary artery banding. Seven children survived longer than 30 days. Six of them later underwent a complete repair. The only survivors were those patients in whom the neo-aortic arch grew harmoniously. The authors conclude that: a two-stage repair gave disappointing results in this series of consecutive patients, mainly because of the poor quality of the reconstruction of the aortic arch by thoracotomy.

Tracheoesophageal compression syndromes related to vascular ring

Seventeen cases of vascular ring have been encountered at Ochsner Clinic over the past 22 years. Anatomic configurations consisted of double aortic arch in 11 cases, right aortic arch with left ligamentum arteriosum in five cases, and aberrant right subclavian artery in one case. In four cases chest x-ray films revealed air block or hyperinflation and led to further diagnostic tests. The definitive diagnostic methods included esophagogram in 15 cases, aortography in 14 cases, two-dimensional echocardiography in one case, and esophagoscopy/bronchoscopy in eight cases. Presenting symptoms were respiratory in 13 cases and feeding difficulties in three; one asymptomatic case was found incidentally. Four cases of air block syndrome were observed as an early and unusual presentation of vascular ring in infants. Hyperinflation of the lung fields on chest x-ray film should spur suspicion of a possible vascular ring. Two case reports are included to demonstrate air block in relation to vascular rings in neonates.

[Complete repair of the interrupted aortic arch by an anterior approach. Apropos of 9 cases]

Interrupted aortic arch is a duct-dependent heart disease, and this is why the use of prostaglandins E, which keep the ductus arteriosus open to feed the descending aorta, has transformed its formerly sombre prognosis. The authors report the cases of 9 neonates and infants presenting with interrupted aortic arch associated with ventricular septal defect who underwent total repair of the malformations under extracorporeal circulation. Five children were less than 10 years' old. The aortic lesions were of type A in 2 cases (interruption distal to the left subclavian artery) and of type B in 7 cases (interruption between the left carotid and subclavian arteries). In the second group the lesions were of type B1 in 5 cases (without retro-oesophageal right subclavian artery) and of type B2 in 2 cases (right retro-oesophageal artery distal to the interruption). There was one death (11 p. 100). So far, no child has been reoperated upon for residual aortic obstruction or reopened ventricular septal defect. This technique of total repair in one stage, with closure of the ventricular septal defect, seems to be preferable to the two-stage technique in which stage one includes, in addition to aortic arch repair, cerclage of the pulmonary artery, a procedure with numerous disadvantages and a higher overall mortality rate.

[Interruption of the aortic arch: a neonatal emergency. Report of 50 cases ]

Interruption of the aortic arch, associated with curable cardiovascular anomalies (8 times out of 10) was observed over a period of 8 years in 50 children aged less than 10 days in 80% of cases. They presented with congestive heart failure, with variable degree of shock in most cases, suggesting the diagnoses of left ventricular hypoplasia or coarctation syndrome. Diagnosis was established with ultrasound and angiocardiography. Evolution was lethal in 21 children who were not operated on. 20 children were operated on: before treatment with prostaglandin E1, 9 attempts ended up in 78% immediate mortality and 89% global mortality; after treatment with prostaglandin. E1, these figures were respectively reduced to 45% and 55% (20 cases). This malformation should therefore be recognized as an emergency and then treated with prostaglandin up to surgery.

Natural history of vascular ring with clinical manifestations. A follow-up study of eleven unoperated cases

A clinical follow-up study was performed in 11 unoperated patients with symptoms due to vascular ring. The age at diagnosis was 2-48 months (mean 13 months); 7 of the patients were less than 12 months old. The follow-up time varied between 1 and 22 years (median 7 years). Nine patients were entirely free of symptoms, which they had outgrown in the course of 1-2 years after the diagnosis was made; none of these 9 had symptoms after the age of 4 years. Two patients had symptoms due to either oesophageal compression or to severe associated neuromuscular lesions; the follow-up time was 3 and 1 years, respectively. Our findings lead us to support a conservative attitude regarding surgery, at least if only mild symptoms are present, If the patients can be satisfactorily treated medically, they seem to outgrow their symptoms in early childhood.

[Surgical treatment of congenital interruption and hypoplasia of the aortic arch]

Three patients with interruption and seven with hypoplasia of the aortic arch were treated surgically. The subclavian artery and the aortic isthmus were employed for reconstructing the aortic arch in five, and a Dacron prosthesis was used to restore the aortic continuity in five. A ductus arteriosus coexisted in all patients and a ventricular or atrial septal defect in nine. Congestive heart failure and pulmonary hypertension were prominent clinical features, and the role of the ductus and other intracardiac anomalies on their pathogenesis in discussed. Six patients, one with an interrupted and five with a hypoplastic arch survived but three have evidence of either pulmonary vascular disease or significant pulmonary hypertension. Only one patient with hypoplasia of the arch is now considered cured after his ventricular septal defect was closed in a second operation. The analysis of this and other series in the literature indicate a high mortality rate of the conditions; however, early surgical treatment, which is the only effective means to control heart failure and avoid the effects of prolonged pulmonary hypertension, has brought upon a decline in mortality in recent years.

Aortopulmonary fenestration and aortic atresia. Report of an infant with ventricular septal defect, persistent ductus arteriosus, and interrupted aortic arch

Images

Interruption of the aortic arch without a patent ductus arteriosus

Complete interruption of the aortic arch without a patent ductus arteriosus is compatible with survival for many years. This is demonstrated by the case reported herein and two others reported in the literature. With no connection between the ascending and the descending aorta and with both subclavian arteries coming off the descending aorta, blood supply to the entire body, except for the head, was by retrograde flow through the vertebral arteries and left cervical collaterals. Bounding carotid pulsations with diminished arm and leg pulses are apparent in this anomaly. Surgical restoration of the continuity between the ascending and the descending aorta was successful in this case and the two previously reported cases. The surgical results of all cases of interruption or atresia of the aortic arch, including those with a patent ductus arteriosus, are reviewed, and the appearance of the ascending aorta on angiography is suggested as a possible differential point between interruption and atresia of the aortic arch.