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.