3 Aortopulmonary Window

Transcription

1 Aortopulmonary Window Introduction Communications between the ascending aorta and pulmonary artery constitute a spectrum of malformations which is collectively designated aortopulmonary window, aortic septal defect, or aorticopulmonary window. The communication is distal to the aortic and pulmonary valvar leaflets, but may be found in any position where the great vessels are contiguous, from the sinus of Valsalva to the origin of the brachiocephalic vessels. Aortopulmonary windows have been subclassified into Type I (proximal defects between the left lateral wall of the ascending aorta and the pulmonary trunk), Type II (defects involving the right pulmonary artery and its origin also called distal defects), and Type III (a large defect combining the other two types). It is probably more useful to view them as a continuum of pathology. The proximal communications tend to be very large and round or oval-shaped, while smaller, more rare and distal lesions may join the posterior aorta to the anterior right pulmonary artery, similar to a Waterston anastomosis. As suggested by the name window, there is usually no length to the communicating channel. The origin of the right pulmonary artery from the aorta is sometimes considered to be an example of the most extreme type of aortopulmonary window. Either the right or (less commonly) the left coronary artery may arise on the pulmonary side of the window. About half of the cases of aortopulmonary window occur as isolated lesions, while the other half has associated major or minor cardiac malformations. These include interrupted aortic arch, tetralogy of Fallot, persistently patent arterial duct, and ventricular septal defect. Surgical repair of aortopulmonary window is done virtually always as an open heart procedure with cardiopulmonary bypass or, in small infants, with low flow or profound hypothermia and total circulatory arrest. A patch of Dacron or other material is used to close the defect, taking care to leave the orifices of the coronary arteries in continuity with the aorta. Associated malformations are generally repaired at the same time.

2 A Practical Atlas of Congenital Heart Disease Innominate Artery Window PA LAA Ao RAA. Aortopulmonary window. The external appearances of a large proximal defect are seen from the front. Innominate Artery Window LCA AoV RPA RCA. The aorta has been opened in the case above to show the large aortopulmonary window just above the orifice of the left coronary artery. The orifice of the right coronary artery lies close to the window, although this is not immediately apparent in the photograph. The origins of the right and left branch pulmonary arteries are seen through the window.

3 Aortopulmonary Window Patch A B RPA LCA AoV. Repair of the aortopulmonary window may be done through an incision in the aorta (), through the window itself () with a sandwich technique, or through an incision in the pulmonary artery (). Cannulation must be sufficiently distal on the lateral side of the aorta (A) or transverse aortic arch (B) to permit safe application of a clamp above the window; the branch pulmonary arteries are temporarily occluded to maintain a perfusion pressure and prevent flooding of the lungs on bypass.. Exposure through an aortic incision allows visualization of the coronary arterial orifices, both of which must be identified with certainty. A patch of either prosthetic material or composite prosthetic material/ pericardium is then inserted with a continuous monofilament suture. Sutures near the coronary orifice are placed accurately, with the patch at a distance for good visualization.. The patch is lowered down when the suture line has cleared the coronary arterial orifices. It may be carried into the pulmonary artery when a coronary artery lies on that side of the window. Alternatively, a flap of vessel wall may be used to tunnel the aorta to the coronary artery. As the suture line approaches the origin of the right pulmonary artery (star), it is deviated into the aorta to avoid any narrowing of that vessel.. The aortotomy is closed, working from proximal to distal end, so that the aortic leaflets and coronary arterial orifices may be visualized at the bottom of the suture line.

4 A Practical Atlas of Congenital Heart Disease Suggested Reading Burroughs JT, Schumutzer KJ, Linder F, Neuhans G.Anomalous origin of the right coronary artery with aortico-pulmonary window and ventricular septal defect. J Cardiovasc Surg ;:. Casillas JA, Delcon JP, Villagra F, Checa SL, Sanchez PA, Gomez R, Fortuny R, MaBrito J. Aortopulmonary window with anomalous origin of the right coronary artery from the pulmonary trunk. Texas Heart Inst J ;:. Castaneda AR, Kirklin JW. Tetralogy of Fallot with aorticopulmonary window. Report of two surgical cases. J Thorac Cardiovasc Surg ;:. Doty DB, Richardson JV, Falkovsky GE, Gordonova MI, Burakovsky VI. Aortopulmonary septal defect; hemodynamics, angiography and operation. Ann Thorac Surg ;:. Gula G, Chew C, Radley-Smith R, Yacoub M. Anomalous origin of the right pulmonary artery from the ascending aorta associated with aortopulmonary window. Thorax ;:. Ho SY, Gerlis LM, Anderson C, Devine WA, Smith A. The morphology of aortopulmonary windows in regard to their classification and morphogenesis. Cardiol Young ;:. Kirkpatrick SE, Girod DR, King H. Aortic origin of the right pulmonary artery; surgical repair without graft. Circulation ;:. Kutsche LM, Van Mierop LHS. Anatomy and pathologenesis of aorticopulmonary septal defect. Am J Cardiol ;:. Mori K, Ando M, Takao A, Ishikawa S, Imai Y. Distal type of aortopulmonary window; report of four cases. Br Heart J ;0:. Penkoske PA, Castaneda AR, Fyler DC, Van Praagh R. Origin of pulmonary artery branch from ascending aorta; primary surgical repair in infancy. J Thorac Cardiovasc Surg ;:. Ravikumar E, Whight CM, Hawker RE, Celermajer JM, Nunn G, Cartmill TB. The surgical management of aortopulmonary window using the anterior sandwich patch closure technique. J Cardiovasc Surg ;:. Richardson JV, Doty DB, Rossi WP, Ehrenhaft JL. The spectrum of anomalies of aortopulmonary septation. J Thorac Cardiovasc Surg ;:. Van Praagh R, Van Praagh S. The anatomy of common aorticopulmonary trunk (truncus arteriosus communis) and its embryologic implications. A study of necropsy cases. Am J Cardiol ;:0.

5