Lateral x-ray shows the calcified pulmonary artery conduit anteriorly just under the sternum.
Truncus arteriosus with calcified conduit, requiring re-operation
16 y.o. female with truncus arteriosus type II, underwent repair at 4 weeks of age, with VSD closure and insertion of a 12 mm porcine valved conduit from RV to PA. At age 2 1/2 she underwent conduit replacement with a 22mm aortic homograft. She has been asymptomatic. Recent echocardiography revealed conduit obstruction and proximal PA obstruction as well as moderately severe truncal (aortic) valve regurgitation.
Cath data: RVP=70, PAP 22, LVP 105/6. BP 110/50. Angiogram; aortic root dilation to 3.8 cm. PVR normal. Medications: vasotec. Weight 56 kg.
RE-OPERATION NOTES:
Operative considerations:
Operation: Re-do median sternotomy from below-up using an oscillating saw. Replacement of the valved conduit with a 27 mm pulmonary homograft: left and right branch PA patch-plasty with homograft patch. Exposure of the right pulmonary artery was accomplished by aortic transection: aortic valve replacement with a 29 mm St Jude valve. Aortic valve repair was abandoned due to abnormal location of both coronary ostia at the commisures and thickened leaflets. Patient had normal PA pressures post-op with uneventful recovery from surgery.
Potential pitfalls in this operation include: hemmorhage with sternotomy due to adhesions between sternum, heart, and conduit; left phrenic nerve injury with dissection of left pulmonary artery; left coronary artery injury in back of previous conduit; and problems with myocardial protection due to severe aortic
insufiency.
Lateral x-ray shows the calcified pulmonary artery conduit anteriorly just under the sternum.
CT scan with contrast at great vessel level shows the rim of calcification in the pulmonary artery conduit just before the bifurcation. Note the right aortic arch.
Pre-operative 3D CT reconstruction with coronal and axial views shows the conduit.
Still images from angiography. The "heads-up" frontal PA-gram shows narrowing at the origin of the left pulmonary artery and a small aneurysm arising from an earlier balloon dilation of that segment. The lateral RV-gram shows the very close proximity of the conduit to the underside of the sternal, making surgical access challenging.
Aortogram showing the regurgitation through the deformed truncal ("aortic valve"). Note the right aortic arch and the normal left ventricular contractility.
Right ventriculogram showing the flow through the conduit.
CW doppler interrogation of RV conduit outflow shows a pressure gradient drop from 27 mm Hg pre-op, to 8 mm Hg post-op.
This three-step diagram shows the technique by which the regurgitant truncal ("aortic") valve is replaced by a St Jude valve and the RV outflow tract receives a pulmonary homograft.
