Common Arterial Trunk Type I Repair Using Autologous Arterial Tissue

Introduction

Common arterial trunk (CAT) requires early surgical treatment to prevent high mortality and morbidity rates. The unopposed pulmonary overflow accelerates the deleterious effects of left-to-right shunting. Moreover, unprotected pulmonary circulation can lead to irreversible pulmonary hypertension, which increases the operative and postoperative risks. Therefore, repair in early infancy offers the best prognosis. 
 
The surgical strategy for CAT involves closing the ventricular septal defect (VSD), separating the systemic and pulmonary circulations, establishing new right ventricle (RV) to pulmonary artery (PA) continuity, and reconstruction of the truncal valve/root. 
 
Traditionally, an RV to PA conduit was used; however, this approach can result in size mismatch in small infants. Also, this sets the patient on a path toward multiple future redo operations. It is also not practical for low-budget healthcare systems. 
 
In this video, the authors present a surgical technique developed by Magdi Yacoub and his surgical team at Aswan Heart Centre, Egypt (1). This technique utilizes autologous arterial tissue to create new RV to PA continuity, offering growth potential and improved blood flow properties due to the incorporation of arterial tissue (1). 
 
Free pulmonary regurgitation (PR) is a concern; however, patients can tolerate this for years before the indications for pulmonary valve replacement are met (2). This technique also emphasizes limiting the size of the neo RVOT orifice to decrease the regurgitant orifice area and limit the PR. 
 
Patient Presentation

A two-month-old infant weighing 3.2 kilograms presented with repeated chest infections and dyspnea. Oxygen saturation was 95 percent.  

An echocardiogram showed CAT type I, trileaflet truncal valve with mild regurgitation and large outlet perimembranous VSD.  

A cardiac CT scan revealed a short main pulmonary artery (MPA) from the left posterolateral aspect of a dilated common trunk with confluent PA branches with good caliber. 
 
Operative Technique

 A full median sternotomy was performed, followed by aortic cannulation of the distal ascending aorta and bicaval venous cannulation. Cardiopulmonary bypass was initiated with mild hypothermia. Extensive mobilization of the common trunk and pulmonary arteries was performed. Prior to administering cardioplegia, the pulmonary arteries were snared, and a cross-clamp was applied to the distal ascending aorta. 
 
Transection of the common trunk was carried out distal to the origin of the MPA, which was harvested with a wide cuff. A rectangular patch of free arterial tissue from the trunk was harvested to be used later for reconstruction of the neo RVOT. 
 
A right anterior ventriculotomy was performed below the origin of the truncal root, ensuring a safe distance from the course of the left anterior descending artery. This ventriculotomy served as the new right ventricular outflow tract (RVOT) orifice. The VSD was closed using a Gore-Tex patch through this ventriculotomy. 
 
The defect in the truncal root was plicated, followed by reconnection to the ascending aorta. The posterior wall of the MPA was reconstructed and directly connected to the upper edge of the ventriculotomy. Finally, an anterior hood for the neo RVOT was created using the free arterial patch harvested from the trunk. 

References

1. Yacoub MH, Hosny H, Afifi A, et al. Novel concepts and early results of repairing common arterial trunk. Eur J Cardio-thoracic Surg. 2022;61(3):562-571. doi:10.1093/ejcts/ezab336
2. Geva T. Indications for pulmonary valve replacement in repaired tetralogy of fallot: The quest continues. Circulation. 2013;128(17):1855-1857. doi:10.1161/CIRCULATIONAHA.113.005878

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