Ann Thorac Surg 1993;56173-4

CASE REPORT HASAN ET AL 173 HEART-LUNG TX AND AORTIC INTERRUPTION

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Heart-Lung Transplantation Combined With Correction of Interrupted Aortic Arch Asif Hasan, FRCS, John Au, FRCS, Alan J. B. Kirk, FRCS, Brian Glenville, FRCS, Colin J. Hilton, FRCS, and John H. Dark, FRCS

Department of Cardio-Pulmonary Transplantation, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom

We describe a new technique for heart-lung transplanta- tion in a patient with interrupted aortic arch. The oper- ation was performed in a 21-year-old patient with situs solitus, double-inlet left ventricle, transposition of great arteries, type A interrupted aortic arch, and pulmonary hypertension. One-stage correction of interrupted aortic arch was undertaken using recipient ductal and pulmo- nary arterial tissues. The early postoperative course was uneventful, with clinical and radiological evidence of satisfactory result. We conclude that it is entirely feasible to undertake heart-lung transplantation in the presence of interrupted aortic arch using this technique, which requires no period of circulatory arrest and results in a tension-free anastomosis.

(Ann Thoruc Surg 1993;56:2734)

nterrupted aortic arch is a rare congenital abnormality, I constituting less than 1% of all congenital cardiac anomalies [l]. It is commonly associated with other con- genital malformations [2]. Only 10% of patients survive the first year [3]. In patients in whom correction is not undertaken early in life, pulmonary hypertension devel- ops requiring heart-lung transplantation for long-term survival.

We do not consider aortic arch interruption to be a contraindication to heart-lung transplantation, and de- scribe a technique of aortic interruption repair with heart- lung transplantation.

Accepted for publication Sep 22, 1992.

Address reprint requests to Dr Hasan, Department of Cardio-Pulmonary Transplantation, Freeman Hospital, Rm 133, Freeman Rd, Newcastle- upon-Tyne, NE7 7DN, United Kingdom.

A 21-year-old man was referred for heart-lung transplan- tation. A diagnosis of complex congenital heart disease was made at birth; however, no palliative operation was undertaken. Over time he had become cyanotic and his exercise tolerance had deteriorated. Cardiac catheteriza- tion, echocardiography, and magnetic resonance imaging had shown situs solitus, double-inlet left ventricle, trans- position of great arteries, and interrupted aortic arch beyond the origin of the left subclavian artery (type A). Mean pulmonary artery pressure was estimated as 80 mm Hg, and pulmonary vascular resistance was mea- sured as 16 Wood units.

The operation was undertaken through a median ster- notomy. The anatomy was consistent with the preopera- tive diagnosis. The pulmonary artery was large, lay pos- terior to the smaller aorta, and merged imperceptly into the arterial duct and thence the descending aorta (Fig 1). Two arterial cannulas were inserted, one in the right femoral artery and another in the ascending aorta to perfuse the head and neck. Two venous cannulas were inserted into the cavae through the right atrium, and cardiopulmonary bypass was established. The patient was cooled to 24°C. The aorta and the main pulmonary artery were cross-clamped and divided, and the heart was excised.

The pleural cavities were entered and the lungs mobi- lized. The pulmonary arteries were stapled near their origin from the main pulmonary trunk and divided (Fig 2). The main bronchi were dissected along with the distal trachea. The trachea was divided above the bifurcation, and the lungs were removed.

The ascending aorta was then anastornosed to the front of the pulmonary artery to create a single conduit serving both proximal and distal systemic circulation (Fig 3).

The donor heart-lung block was then brought into the field. The lungs were passed into the pleural cavities through pericardial windows behind the phrenic nerves, the trachea was trimmed, and tracheal anastomosis was performed. End-to-end anastomosis was then undertaken between the donor aorta and the recipient pulmonary artery (Fig 4). The right atrial anastomosis was com- menced, but before it was completed the heart was deaired and the aortic clamp removed.

The patient was rewarmed and the heart resumed sinus

Fig 1. Preoperative anatomy. IAo = aorta; DA = arterial duct; PA = pulmonary artery.)

174 CASE REPORT HASAN ET AL HEART-L.UNG Tx AND AORTIC INTERRUPTION

Ann Thorac Surg 1993;561734

Fig 2. Structures shown after excision of heart and lungs. The aortic arch is cannulated.

rhythm. Cardiopulmonary bypass was discontinued eas- ily. Both cardiac and respiratory function were satisfac- tory with an oxygen tension of 159 mm Hg (21 kPa) on an inspired oxygen concentration of 60% and identical pres- sures in the arch and descending aorta. He was weaned off the ventilator 24 hours later.

Two weeks after his operation his gas exchange mark- edly deteriorated. His lung biopsy showed severe rejec- tion. He was treated by augmented immunosuppression; however, his condition continued to deteriorate and he died on the 26th postoperative day.

Histologic examination of the explanted lung showed grade IV pulmonary hypertensive changes [4].

Comment Heart-lung transplantation has been described before with one-stage correction of interrupted aorta. Aranki and associates [5] described direct anastomosis in a type B aortic interruption. The operative technique is analogous to primary repair for interrupted aortic arch. Although the technique of direct anastomosis for interrupted aortic arch is well documented, it has the problems of right pulmo- nary artery and left bronchial compression [6]. Direct anastomosis also requires circulatory arrest with its poten- tial hazards [7].

The use of ductal tissue and use of pulmonary artery have been described in reconstruction of interrupted aortic arch. These procedures consist of fashioning tubes out of ductal tissues [8], pulmonary arterial flaps [9], and

Fig 3 . The aortic arch is anastomosed to the main pulmonary artery, and the branches are oversewn.

Fig 4 . Final anastomosis between main pulmonary artery (PA) and donor aorta (Ao) completes the reconstruction. (* = donor.)

pulmonary arterial conduits [l]. Although there are no comparative studies, long-term results after use of ductal tissue show better results than direct anastomosis [lo]. We used both the main pulmonary artery and the duct in correcting the interrupted aortic arch before completing the heart-lung transplantation. The result was a tension- free anastomosis requiring no extra donor tissue and was achieved without resorting to circulatory arrest. Although the outcome of this case was unfortunate, there was no suggestion of failure of the operative technique. We can confidently recommend this technique for heart-lung transplantation in presence of aortic interruption.

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