Surgical Technique
All surgeries were performed using a routine sternotomy incision. Except for arterial cannulation in the ascending aorta, ductal cannulation was used to ensure distal perfusion. Bicaval venous cannulation was performed to avoid hypothermic circulatory arrest while repairing the intracardiac anomaly. Myocardial protection was accomplished with a single dose of histidine-tryptophan-ketoglutarate solution, regardless of the length of aortic clamping.
These 11 procedures were completed by four surgeons at our center. Therefore, the sequence and details of the repair might vary depending on the surgeon’s preference. Except for the first patient in which the VSD was closed before aortic arch reconstruction in order for the temperature to reach 18°C, the repair of the IAA was routinely performed after aortic clamping at 25–28°C core temperature. At that point, aortic cannulation in the ascending aorta was transferred into the innominate artery, and systemic arterial perfusion was stopped while selective antegrade cerebral perfusion was used. Extended resection, including the ductal tissue, was performed, and three different approaches were used for arch repair. The first three patients underwent extended end-to-end anastomosis before 2012. Subsequently, aortic arch reconstruction, including the first posterior hemi-anastomosis between the posterior walls of the distal arch and the proximal descending aorta, and then enlargement of the arch with glutaraldehyde-treated autologous pericardial patches was performed in seven patients. A 16-mm intergard woven vascular graft (Maquet, La Ciotat, France) was used for a 6-year-old child.
After IAA repair was completed, arterial cannulation was moved back into the ascending aorta, and extracorporeal perfusion was resumed. Subsequently, VSD closure and ASO were performed. The VSD was closed with a Dacron patch through the tricuspid valve in two patients, through the tricuspid valve and original pulmonary valve in seven patients, or even through an infundibulotomy incision in two patients, among whom a non-committed VSD was present in one. An approximate 5 mm fenestration was left in the VSD patch in two older patients (4-year and 6-year-old), in case of persistent postoperative pulmonary hypertension (PHT).
After harvesting from the original aortic root, the coronary buttons were anastomosed to the original pulmonary root with the most favorable orientation to avoid significant angulation of the coronary arteries using the trap-door technique. When the discrepancy between the great vessels was remarkable, part of the wall of the neoaortic non-coronary sinus was stitched together using a continuous 5/0 or 6/0 Prolene suture to diminish the size of the neoaortic root to suit the proximal ascending aorta. The Lecompte maneuver was used in all patients except one whose great vessel relationship was side by side. Resection of the prominent parietal and septal bands was accomplished carefully through the original pulmonary root in two of the four patients with RVOTO to avoid injury to the neoaortic valve. In the other two patients, an infundibulotomy incision was required. Two patients were diagnosed with moderate mitral valve regurgitation preoperatively; posterior annulus constriction with 5/0 Prolene suture was performed to complete mitral valvuloplasty.
Modified ultrafiltration is routinely performed after cardiopulmonary bypass. A left atrial pressure monitoring line was inserted intraoperatively through the atrial septum. Only two patients were transferred to the intensive care unit (ICU) with an open sternum. Operative data are presented in Table 2.