Anastomosis Of Pulmonary Artery To Aorta
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ANASTOMOSIS OF PULMONARY ARTERY TO AORTA (DAMUS-KAYE-STANSEL PROCEDURE) REASONS FOR VISIT • • • •
Double inlet left ventricle, Tricuspid atresia with transposition of the great vessels Transposition of the great vessels with a hypoplastic right ventricle Subaortic stenosis.
RISK ASSESSMENT • • • • •
Left ventricular hypoplasia An overriding atrioventricular valve, or Rastelli type C straddling of the atrioventricular valve. Premature baby Low birth weight
PREPARATION OF THE PATIENT • • • • • • • • • • • •
Blood tests Electrolyte levels Baseline nutrition laboratory values Echocardiography Cardiac angiography Cardiac catheterization MRI Chest radiograph ECG Nothing is taken by mouth 6hrs before surgery Antibiotics were given PGE1 was discontinued.
ANESTHESIA General POSITION OF THE PATIENT Supine position PROCEDURE
PRE-CARDIOPULMONARY BYPASS • • • • • • • •
Aprotinin, solumedrol, Regitine, Phenobarbital and antibiotics were given preoperatively. PGE1 was discontinued. The room temperature was lowered as much as possible to start surface cooling. A midsternotomy was performed The heart suspended in a pericardial cradle. The patient was heparinized The right branch pulmonary artery was controlled. A purse-string was placed around the right atrial appendage and retracted downwards in order to facilitate exposure.
CANNULATION: • • •
An aortic purse string was placed in the mid-ascending aorta. The venous purse string was a single large one around the right atrial appendage, in order to facilitate later atrial septectomy. The aorta and atrium was cannulated.
CARDIOPULMONARY BYPASS AND DEEP HYPOTHERMIC CIRCULATORY ARREST: • • • •
Cardiopulmonary bypass was started and Cooling to 18 - 20° C was started. Following institution of cardiopulmonary bypass, the head was packed in ice, and the ventilator was turned off. Pulmonary blood flow was controlled by controlling an arterial duct if present, by snaring both branch pulmonary arteries, / by cross-clamping the main pulmonary artery.
THE DISSECTION • • •
• •
The aorta was dissected completely from its root to the head vessels The head vessels were completely mobilized. The innominate artery was dissected above the innominate vein, and both the right subclavian and right carotid arteries were mobilized and encircled with silk snares. The left carotid and subclavian arteries were completely mobilized and encircled with silk snares. The pulmonary artery was completely mobilized.
• • • •
•
The left carotid and subclavian arteries are completely mobilized. The homograft patch was prepared from an appropriately sized pulmonary homograft. The inlet portion and the valve itself are discarded. The widest portion of the homograft patch was chosen as that at the inlet side, and was tailored to tapers with a nice curve towards the longest of the two branch pulmonary arteries. The Prolene stitch was used to sew the homograft
PROTECTION OF THE HEART AND BRAIN • • • • • • •
A period of 20 minutes of core cooling to 18 - 20° C with the head packed in ice is considered minimum cerebral protection. The pump was turned off and the patient drained into the venous reservoir. The head vessels are snared down and the aortic cannula was removed. 30 cc/kg of cold-blood potassium cardioplegia was administered via a catheter placed through the aortic purse string. The field was cleared for the palliation: The branch pulmonary artery snares are released The arterial duct, was present, was tied off, and the venous cannula removed.
RESECTION OF THE SEPTUM PRIMUM • • • • •
The septum primum was resected It was first attempted through the venous purse-string. If the atrial septum was deviated leftwards A small atriotomy was made along the right atrioventricular groove, and the septum is resected. The coronary sinus cut back into the left atrium
AORTO-PULMONARY ANASTOMOSIS • •
• •
The pulmonary trunk was divided at it’s bifurcation The underside of the distal ascending aorta to the proximal ascending aorta was made to the point where the aorta exactly meets with the facing commissure of the proximal end of the divided pulmonary artery. The reverse-bite Potts scissors was used for opening the undersurface of the aorta. The incision started distally and proceeded proximally.
• •
• • • • • • •
•
• •
•
Gently retracted the divided lip of the aorta The exact point of where the pulmonary artery meets the ascending aorta was picked up and using the reverse-bite Potts, a straight incision was made connecting the two points. The proximal aorta was anastomosed to the pulmonary artery with a continuous / interrupted 7-0 absorbable suture. A stay stitches was placed on the upper lip of the aortic incision at the base of the innominate artery The homograft was sewn into place, starting distally and working proximally. The posterior row was placed first, and the closure was done up to the innominate stay-stitch. The anterior row was placed and was completed up to the innominate stay-stitch. The length of the homograft was assessed. Extra length was removed, by gauging how long the homograft should be in order to meet the divided proximal end of the main pulmonary artery. With the assistant holding the homograft and the pulmonary artery together, the extra homograft tissue was removed from the posterior row. No extra tissue was removed from the anterior row. The posterior row was now completed, going ‘around the horn’ of the homograft - pulmonary artery anastomosis, and up to the aortic anastomosis. The anterior row was completed up to the posterior row, and the stitch tied and cut.
RESTORATION OF CARDIOPULMONARY BYPASS • • • •
The atrium and aortic root were filled with cold normal saline, and the aortic and venous cannulae were replaced. cardiopulmonary bypass was resumed Any air in the systemic circulation was allowed to flow down the aorta. The head vessel snares are released and removed.
RESTORATION OF PULMONARY BLOOD FLOW • • •
The distal divided end of the pulmonary artery was patched with GoreTex / homograft. The size of the shunt was _______ The systemic arterial side of the shunt was performed first.
•
• • • • • •
The anastomosis was performed on the posterior aspect of the innominate-subclavian artery junction in an end-to-side fashion using polypropylene suture. The pulmonary side of the shunt was performed next. The site of the anastomosis was chosen to lie as close to the ductus insertion site and the shunt sewn into this position. After completion of the shunt, a clamp was applied to the shunt until weaning from cardiopulmonary bypass was started. Heart was closed Chest tubes were inserted Chest was closed with sutures
DURATION _____________hrs
AFTER PROCEDURE • •
Patient was shifted to the I.C.U Patient was on ventilation • Heart sounds, oxygenation, and the ECG are monitored. • Chest tubes are checked to ensure that they're draining properly and there is no hemorrhage. POSTOPERATIVE CARE • •
Take antibiotic medicine as prescribed Take pain medication • Start chest exercises and chest physical therapy COMPLICATIONS • • • • • • • • • •
Infection Endocarditis Congestive heart failure Lack of oxygen Too much carbon dioxide in the blood Irregular heartbeat Stroke Kidney damage Lung blood clot Low blood pressure
• •
Hemorrhage Cardiac arrest
Double inlet left ventricle, Tricuspid atresia with transposition of the great vessels Transposition of the great vessels with a hypoplastic right ventricle Subaortic stenosis.
RISK ASSESSMENT • • • • •
Left ventricular hypoplasia An overriding atrioventricular valve, or Rastelli type C straddling of the atrioventricular valve. Premature baby Low birth weight
PREPARATION OF THE PATIENT • • • • • • • • • • • •
Blood tests Electrolyte levels Baseline nutrition laboratory values Echocardiography Cardiac angiography Cardiac catheterization MRI Chest radiograph ECG Nothing is taken by mouth 6hrs before surgery Antibiotics were given PGE1 was discontinued.
ANESTHESIA General POSITION OF THE PATIENT Supine position PROCEDURE
PRE-CARDIOPULMONARY BYPASS • • • • • • • •
Aprotinin, solumedrol, Regitine, Phenobarbital and antibiotics were given preoperatively. PGE1 was discontinued. The room temperature was lowered as much as possible to start surface cooling. A midsternotomy was performed The heart suspended in a pericardial cradle. The patient was heparinized The right branch pulmonary artery was controlled. A purse-string was placed around the right atrial appendage and retracted downwards in order to facilitate exposure.
CANNULATION: • • •
An aortic purse string was placed in the mid-ascending aorta. The venous purse string was a single large one around the right atrial appendage, in order to facilitate later atrial septectomy. The aorta and atrium was cannulated.
CARDIOPULMONARY BYPASS AND DEEP HYPOTHERMIC CIRCULATORY ARREST: • • • •
Cardiopulmonary bypass was started and Cooling to 18 - 20° C was started. Following institution of cardiopulmonary bypass, the head was packed in ice, and the ventilator was turned off. Pulmonary blood flow was controlled by controlling an arterial duct if present, by snaring both branch pulmonary arteries, / by cross-clamping the main pulmonary artery.
THE DISSECTION • • •
• •
The aorta was dissected completely from its root to the head vessels The head vessels were completely mobilized. The innominate artery was dissected above the innominate vein, and both the right subclavian and right carotid arteries were mobilized and encircled with silk snares. The left carotid and subclavian arteries were completely mobilized and encircled with silk snares. The pulmonary artery was completely mobilized.
• • • •
•
The left carotid and subclavian arteries are completely mobilized. The homograft patch was prepared from an appropriately sized pulmonary homograft. The inlet portion and the valve itself are discarded. The widest portion of the homograft patch was chosen as that at the inlet side, and was tailored to tapers with a nice curve towards the longest of the two branch pulmonary arteries. The Prolene stitch was used to sew the homograft
PROTECTION OF THE HEART AND BRAIN • • • • • • •
A period of 20 minutes of core cooling to 18 - 20° C with the head packed in ice is considered minimum cerebral protection. The pump was turned off and the patient drained into the venous reservoir. The head vessels are snared down and the aortic cannula was removed. 30 cc/kg of cold-blood potassium cardioplegia was administered via a catheter placed through the aortic purse string. The field was cleared for the palliation: The branch pulmonary artery snares are released The arterial duct, was present, was tied off, and the venous cannula removed.
RESECTION OF THE SEPTUM PRIMUM • • • • •
The septum primum was resected It was first attempted through the venous purse-string. If the atrial septum was deviated leftwards A small atriotomy was made along the right atrioventricular groove, and the septum is resected. The coronary sinus cut back into the left atrium
AORTO-PULMONARY ANASTOMOSIS • •
• •
The pulmonary trunk was divided at it’s bifurcation The underside of the distal ascending aorta to the proximal ascending aorta was made to the point where the aorta exactly meets with the facing commissure of the proximal end of the divided pulmonary artery. The reverse-bite Potts scissors was used for opening the undersurface of the aorta. The incision started distally and proceeded proximally.
• •
• • • • • • •
•
• •
•
Gently retracted the divided lip of the aorta The exact point of where the pulmonary artery meets the ascending aorta was picked up and using the reverse-bite Potts, a straight incision was made connecting the two points. The proximal aorta was anastomosed to the pulmonary artery with a continuous / interrupted 7-0 absorbable suture. A stay stitches was placed on the upper lip of the aortic incision at the base of the innominate artery The homograft was sewn into place, starting distally and working proximally. The posterior row was placed first, and the closure was done up to the innominate stay-stitch. The anterior row was placed and was completed up to the innominate stay-stitch. The length of the homograft was assessed. Extra length was removed, by gauging how long the homograft should be in order to meet the divided proximal end of the main pulmonary artery. With the assistant holding the homograft and the pulmonary artery together, the extra homograft tissue was removed from the posterior row. No extra tissue was removed from the anterior row. The posterior row was now completed, going ‘around the horn’ of the homograft - pulmonary artery anastomosis, and up to the aortic anastomosis. The anterior row was completed up to the posterior row, and the stitch tied and cut.
RESTORATION OF CARDIOPULMONARY BYPASS • • • •
The atrium and aortic root were filled with cold normal saline, and the aortic and venous cannulae were replaced. cardiopulmonary bypass was resumed Any air in the systemic circulation was allowed to flow down the aorta. The head vessel snares are released and removed.
RESTORATION OF PULMONARY BLOOD FLOW • • •
The distal divided end of the pulmonary artery was patched with GoreTex / homograft. The size of the shunt was _______ The systemic arterial side of the shunt was performed first.
•
• • • • • •
The anastomosis was performed on the posterior aspect of the innominate-subclavian artery junction in an end-to-side fashion using polypropylene suture. The pulmonary side of the shunt was performed next. The site of the anastomosis was chosen to lie as close to the ductus insertion site and the shunt sewn into this position. After completion of the shunt, a clamp was applied to the shunt until weaning from cardiopulmonary bypass was started. Heart was closed Chest tubes were inserted Chest was closed with sutures
DURATION _____________hrs
AFTER PROCEDURE • •
Patient was shifted to the I.C.U Patient was on ventilation • Heart sounds, oxygenation, and the ECG are monitored. • Chest tubes are checked to ensure that they're draining properly and there is no hemorrhage. POSTOPERATIVE CARE • •
Take antibiotic medicine as prescribed Take pain medication • Start chest exercises and chest physical therapy COMPLICATIONS • • • • • • • • • •
Infection Endocarditis Congestive heart failure Lack of oxygen Too much carbon dioxide in the blood Irregular heartbeat Stroke Kidney damage Lung blood clot Low blood pressure
• •
Hemorrhage Cardiac arrest
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