Technique for Supravalvular Pulmonary Artery Stenosis

A book beating-heart way of supravalvular pulmonary artery stenosis

INTRODUCTION:

Pulmonary artery stenosis (PAS) may be congenital or bought and occurs as isolated or multiple lesions. Obtained PAS generally occurs following the surgical modification of congenital cardiac malformations such as anomalous origins of the still left coronary artery arising from the pulmonary artery (ALCAPA) and tetralogy of Fallot (TOF). Treatment options for critical PAS include stent implantation, balloon angioplasty, and surgery.

In this report, our aim is to present a new medical technique without the need for cardiopulmonary bypass used for an individual going through surgery for ALCAPA who required re-operation on the first postoperative day credited to supravalvular pulmonary stenosis.

CASE Statement:

In a 8-season old boy, immediate re-implantation of the left coronary artery into the aortic root was completed through median sternotomy under cardiopulmonary bypass. The overall position of patient dropped with accompanying signs and symptoms of right-sided heart failing within the first six postoperative time. Also, liver organ enzyme levels were enhanced and renal functions deteriorated. A biochemical account unveiled serum glutamic-oxaloacetic transaminase (SGOT) 832 mU/dl, serum glutamic-pyruvic transaminase (SGPT) 789 mU/dl, serum urea 65 mg/dl, and creatinine 2. 1 mg/dl. Echocardiography revealed severe right ventricular dysfunction and light pulmonary insufficiency. As well as the supravalvular gradient was 80 mmHg, there is no transvalvular pressure gradient. Since supravalvular PAS was the suspected cause of the professional medical instability of the individual, an urgent surgery was planned.

SURGICAL TECHNIQUE

A median sternotomy was used for the medical procedure. Pump was not used to enough time possible adverse results of cardiopulmonary bypass in this patient with an unhealthy general status and impaired renal and liver functions.

Firstly, an incision lines on the stenotic supravalvular pulmonary artery portion was drawn. Then the proportions of the graft to be placed were determined aesthetically and the graft was prepared. The oval-shaped graft was sutured on the mark stenotic pulmonary artery segment using 6/0 polypropylene sutures. In this technique, special emphasis was positioned on two issues:

1. Apart from the proximal border of the graft (the right ventricular side) all other sides were sutured using constant sutures. However, no knots were attached and both ends of the suture were left free.

2. During the inserting of the grafts, a space was created to form a convex composition in-between the anterior surface of the pulmonary artery.

Then, a small linear incision on the pulmonary artery was made distally on the pulmonary artery using a scalpel put from the proximal beginning of the graft. Simultaneous pressure on the incision site was exerted digitally to prevent bleeding. The incision was propagated longitudinally using a Metzenbaum scissor. Upon subjection of the pulmonary artery, the convex structure disappeared spontaneously by eliminating the distance between your graft and the anterior surface of the pulmonary artery.

Soon following the incision was made in the distal course on the pulmonary artery corresponding to a pre-determined duration, the sutures on the proximal surface of the graft were extended concerning fix the graft on the pulmonary artery. At the end of the task, while a modest level of stress was preserved on the sutures personally, the proximal end of the graft was finished using ongoing sutures. Thus, at the end of the task the desired pulmonary artery diameter was achieved.

No hemodynamic instability was seen during the treatment. Intraoperative echocardiography exhibited no residual gradients on the pulmonary artery. The patient was extubated at postoperative 12th hour. A quick medical improvement of right-sided center failure was detected during the follow-up along with recovery of normal liver enzyme levels within 48 hours and normal renal functions within one week after surgery. The individual was discharged at postoperative 8th day.

Follow-up evaluation at 12 months after surgery revealed a good standard status with weight gain. No gradient was diagnosed at the pulmonary artery by echocardiography.

DISCUSSION:

PAS may be congenital or acquired. Attained pulmonary artery stenosis is generally a problem of the surgical treatments performed for the repair of complex congenital cardiac malformations (1). For example, in patients such as ours with ALCAPA, supravalvular PAS may develop pursuing surgery (2). Using circumstances, both congenital and attained types of pulmonary artery stenosis may pose significant surgical challenges. Particularly, the existence of specialized medical instability may greatly limit the restorative options in newborns.

Treatment options for critical PAS include stent implantation, balloon angioplasty, and surgery. In recent years, despite significant advances in the technology of stent and balloon creation, surgical repair remains an important therapeutic option. The success rates with balloon dilatation in these patients are limited (3). Alternatively, intravascular stents are from the creation of re-stenosis in the long term credited to somatic development (4). Thus, medical repair sticks out as an important option to both other approaches in pulmonary stenosis. We didn't like catheterization because of early on period after surgery and impaired kidney function.

The current operative options for the reconstruction of the PAS may be associated with untoward outcomes due to the need for cardiopulmonary bypass. Therefore, to avoid possible adverse effects of cardiopulmonary bypass, we developed a book surgical technique to be utilized for the repair of supravalvular pulmonary artery stenosis without pump.

The surgical strategy employed in this patient is easy and safe distinguishing itself from other techniques by negating the necessity for pump. Especially, it seems well suited for selected, clinically unpredictable instances who may be adversely influenced by cardiopulmonary bypass. In recently run patients with supravalvular pulmonary artery stenosis, this system may be properly applied with no increased risk of bleeding or thromboembolic incidents. However, bigger patient populations are warranted to more securely establish its safe practices. Nevertheless, we assume that this system for the pulmonary artery reconstruction may provide significant boosts in the diameter of the pulmonary artery in a defeating heart with minimal morbidity and mortality.

According to your knowledge, there havent been reported any off-pump technique for PAS in the British literature currently.

In summary, this newly developed method of supravalvular PAS surgery is safe and long lasting. This surgical approach may be employed on patients not only who got an isolated supravalvular PAS but also who have been previously run, developed restenosis in early on period and were under risk if pump was utilised without disrupting the hemodynamic stableness.

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