Biventricular Repair Of Complex Interrupted Aortic Arch And Small Left Ventricular Outflow Tract Following Hybrid First Stage Palliation
Bahaaldin Alsoufi, Brian Holland, Erle Austin, Edward Kim, Deborah Kozik.
University of Louisville, Louisville, KY, USA.
Background: Single-stage repair of complex cardiac anomalies with arch obstruction can be very risky in neonates with extreme prematurity, small weight, severe extra-cardiac problems or sepsis. Our institutional practice is hybrid first-stage palliation (branch PA banding and ductal stenting) that defers repair to later stage. Methods: A neonate born at 28 weeks gestation, weighed 1.3kg, Had DiGeorge syndrome. Cardiac diagnosis was interrupted aortic arch, VSD, very narrow LV outflow tract. Due to over-circulation, respiratory distress and poor feeding, he underwent bilateral PA branch banding (at 14-days) and ductal stenting (at weight 2kg). He thrived at home and presented at 6 months (weight 5.8kg) for repair. Results: Following redo sternotomy and CPB using dual arterial and bicaval cannulation, dissection or arch, descending aorta and PA branches to hilum was performed. After cross clamp, the main PA was transected and ductus (with cannula in place) separated from PA branches. PA bands were removed and opening extended across banded area to lobar branches. Each PA was augmented with autologous pericardium. After cooling and with selective cerebral perfusion, The PDA with stent was excised, ascending aorta opened, descending aorta mobilized and connected to ascending aorta, Damus-Kaye-Stansel anastomosis performed and arch reconstruction completed with pulmonary homograft patch. After VSD enlargement, the LV was baffled to neo-aorta using Dacron patch, RV-PA conduit was placed completing Yasui-type reconstruction. Recovery was uneventful. Conclusion: Despite redo and need for extensive arch and PA reconstruction, complex biventricular repair is well tolerated in infants following hybrid first-stage palliation.
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