Left pulmonary artery reconstruction using cryopreserved pulmonary homograft

Abstract

In patients with univentricular heart, the Fontan procedure is the final palliation. This is usually staged. A systemic-to-pulmonary artery shunt is performed in the presence of episodes of cyanotic spells in the neonatal period or in some patients in infancy; a bidirectional superior cardiopulmonary anastomosis is preferred early in life. This is followed by the final Fontan palliation on an elective basis later. For an effective bidirectional superior cavopulmonary anastomosis and Fontan palliation, good-sized confluent pulmonary arteries (PAs) are mandatory in addition to favorable hemodynamic data. Patients with discontinuous PAs that are small in size present a surgical challenge at initial palliation as the one described in this report.

Keywords: Bidirectional superior cavopulmonary anastomosis; Fontan procedure; confluent pulmonary arteries; systemic-to-pulmonary artery shunt; univentricular heart.

Figure 1

Preoperative computed tomography angiography showing (a) diffuse left pulmonary artery stenosis on the axial section and (b) three-dimensional reconstruction of the same. L: Distal left pulmonary artery, M: Main pulmonary artery, P: Patent ductus arteriosus, R: Right pulmonary artery, *: Proximal left pulmonary artery, **: Patent ductus arteriosus insertion site (removed here during image reconstruction), Double-headed arrow: Length of the stenotic left pulmonary artery

Figure 2

Diagrammatic representation of the (a) Preoperative anatomy, (b) After resection, and (c) Pulmonary homograft reconstruction of the left pulmonary artery. AO: Aorta, H: homograft, L: Left pulmonary artery, LL: Left lower lobar branch, LU: Left upper lobar branch, P: Patent ductus arteriosus, R: Right pulmonary artery. Black arrows indicate width of the homograft

Figure 3

(a) Axial and (b) coronal sections of the follow-up computed tomography angiography (CTA) after pulmonary homograft interposition and standard bidirectional Glenn. (c) Reconstructed three-dimensional CTA of the pulmonary arteries showing interposition homograft. G: Bidirectional Glenn, H: Homograft, M: Main pulmonary artery, R: Right pulmonary artery, White arrow: Bidirectional Glenn anastomosis site (Glenn removed here during image reconstruction)