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One-Stage Neonatal Arterial Switch With Mee Procedure and Repair of Aortic Arch Hypoplasia

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posted on 18.04.2022, 17:44 by Sameh M. Said

  

An eleven-day-old female neonate, 4.3kg, presented with cyanosis and had a postnatal diagnosis of transposition of the great arteries (d-TGA), ventricular septal defect (VSD), and aortic arch hypoplasia with coarctation. Prostaglandins were initiated to maintain ductal patency. 

A transthoracic echocardiogram showed moderate-to-large size paramembranous VSD, TGA with significant aortic, and pulmonary annular sizes mismatch. There was concomitant aortic coarctation with arch hypoplasia that was confirmed with computed tomography scan. The left main coronary artery was suspected to be intramural. So she underwent transcatheter balloon atrial septostomy. 

The patient was then taken to the operating room, where median sternotomy was performed. Next, cardiopulmonary bypass was initiated via indirect cannulation of the innominate artery using a 3.5mm Gore-Tex graft and both superior and inferior venae cavae. The ductus arteriosus was ligated, and once cardioplegic arrest was achieved, an oblique right atriotomy was made where both atrial and ventricular septal defects were closed. The ductus arteriosus was then further ligated and divided. Selective antegrade cerebral perfusion (ACP) was initiated, and the coarctation segment was resected. The descending aorta was then anastomosed to the distal aortic arch, followed by augmentation of the anastomosis and the aortic arch anteriorly with a decellularized pulmonary homograft patch. The circulation was then restored to the head and the body, and selective ACP was ceased. 

After this, the LeCompte maneuver was performed. Coronary buttons were harvested next. To harvest the left button, the posterior commissure of the aortic valve (neopulmonary valve) was detached first. The intramural segment was opened, and part of the wall was resected with Potts scissors. The neopulmonary sinuses of Valsalva were reconstructed with a pantaloon-shaped pulmonary homograft patch. The posterior commissure was then reattached to the homograft patch. The posterior aortic suture line for the distal aortic reconstruction was created. The left, followed by the right, coronary buttons were reimplanted in the neoaortic root, and the anterior aortic anastomosis was completed. The right atriotomy was then closed with running polypropylene suture in two layers. 

Following this, the heart was deaired and the aortic cross-clamp was removed. The pulmonary artery anastomosis to its bifurcation was translocated to the right main pulmonary artery to avoid compressing the left main coronary artery button. The patient was then weaned off cardiopulmonary bypass without difficulty and post-bypass transesophageal echocardiogram confirmed good biventricular function and good flow in both branch pulmonary arteries, distal arch, and widely patent left and right ventricular outflow tracts. Good myocardial perfusion and good coronary blood flow were confirmed with intraoperative fluorescent angiography using indocyanine green. 

Sternal closure occurred four days later, and the patient was extubated on the seventh postoperative day. She was discharged nearly a month after her procedure.


References


  

1. Yacoub MH, Radley-Smith R. Anatomy of the coronary arteries in transposition of the great arteries and methods for their transfer in anatomical correction. Thorax 1978;33: 418-24

2. Asou T, Karl T, Pawade A, Mee RB. Arterial switch: translocation of the intramural coronary artery. Ann Thorac Surg 1994; 57: 461-5

3. Jatene AD, Fontes VF, Paulista PP et al (1976) Anatomic correction of transposition of the great vessels. J Thorac Cardiovasc Surg 72:364–370

4. Said SM, Marey G, Hiremath G. Intraoperative fluorescence with indocyanine green in congenital cardiac surgery: Potential applications of a novel technology. JTCVS Tech. 2021 Feb 25; 8: 144-155


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