Andersons pediatric cardiology 966
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FIG.36.21 Angiogramintherightventricle–to–pulmonaryarteryconduit
performed1yearafterrepairinthepatientwhosepreoperativeangiograms
areshowninFig.36.13.Theratioofrightventricletoaorticsystolic
pressurewas0.27,andnointerventionswereperformed.
FIG.36.22 Right(A)andleft(B)pulmonaryarteryangiogramsfroma1yearpostoperativecatheterizationinapatientwithtetralogyof
Fallot/pulmonaryatresia/majoraortopulmonarycollateralarterieswho
underwentsingle-stagecompleterepairat5monthsofage.Therewasa
mildstenosisoftherightupperlobe(arrowinB)thatwasnottreatedanda
mildproximalleftpulmonaryarterystenosisthatwassuccessfullydilated.
Therightventricularsystolicpressurebothbeforeandafterintervention
was29mmHg.
Aminorityofpatientswillundergosurgicalpulmonaryarteryreintervention
aftercompleteunifocalizationandrepair.Thetechniquesthatweusefor
reoperativesurgeryonthebranchandperipheralpulmonaryarteriesaresimilar
tothosethatwedevelopedforperipheralpulmonaryarterystenosisassociated
withWilliamsandAlagillesyndromes.69Specifically,weperformthemajority
ofthedissectionpriortoheparinizationandtheinstitutionofcardiopulmonary
bypass.Oncebypasshasbeeninstituted,weremovetheexistingrightventricle–
to–pulmonaryarteryconduit.Iftheareasthatrequirereconstructionarecentral,
thiscanbeperformedwithahomograftpatch.However,iftheareasofconcern
aremoredistal,wehavefounditbeneficialtodividetherightandleft
pulmonaryarteriestofacilitateaccesstothelowerlobes(Fig.36.23).An
incisionismadealongtheinferiorandmedialaspectsofthebranchpulmonary
arteryandextendedintothemedialbranchofthelowerlobe.Ahomograftpatch
issuturedinplacetoaugmenttheaxiallowerlobeartery(seeFig.36.23).
Workingfromdistaltoproximal,thesegmentalandlobarbranchesareprobed
andassessedforstenoses.Long-segmentstenosesaretreatedwithpatch
augmentation,whereasostialstenosesmaybeamenabletoaHeineke-Mikulicz
typeostioplasty.Theoperationiscompletedbyaugmentingthecentralbranch
pulmonaryarteriesandreplacingtherightventricle-to-pulmonaryarteryconduit
(seeFig.36.23).
FIG.36.23 Stepsforreoperativepulmonaryarteryreconstructionfor
residualperipheralstenoses.(A)Themainpulmonaryarteryisdivided,as
aretherightandleftbranchpulmonaryarteries.Anincisionismadealong
theinferioraspectoftheproximalbranchpulmonaryarteriesandcontinued
alongthemedialborderoftheaxiallowerlobeartery.(B)Anostioplasty
hasbeenperformedtothebasilarsegmentoftherightlowerlobe,and
separatehomograftpatchesareplacedtoaugmentlobarbranchstenoses.
Alonghomograftpatchisusedtoaugmenttheaxialandcentralbranch
pulmonaryarteries.(C)Continuityisreestablishedbetweentherightand
leftpulmonaryarteries,andanewrightventricle-to-pulmonaryartery
conduitisimplanted.(FromMainwaringRD,IbrahimiyeAN,HanleyFL.
