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The Yasui procedure with a modified right ventricle-to-pulmonary artery connection utilizing autologous left atrial appendage as a free graft
A 9-month-old girl born with an interrupted aortic arch type B, an arteria lusoria (aberrant right subclavian artery) and a multilevel left ventricular outflow tract obstruction underwent a Yasui completion after an initial interim palliation. After the Damus-Kaye-Stansel procedure was carried out and the Sano shunt had been established as a source of pulmonary flow, the reported procedure comprised closure of the ventricular septal defect and the intraventricular baffling of left ventricular outflow through a malaligned ventricular septal defect, incision and partial resection of a conal septum and establishment of a right ventricle-to-pulmonary artery connection using an autologous left atrial appendage as a free graft. This technique consisted of dissecting and harvesting the left atrial appendage, which was then used as autologous material for an interposition plasty connecting the central pulmonary artery bifurcation segment with the upper rim of the infundibulotomy. Native, autologous tissue thus comprised the backwall of the newly created right ventricle-to-pulmonary artery continuity. Porcine pericardial patch plasty was then used to complete the remaining circumference of the right ventricle-to-pulmonary artery continuity.
If a valveless right ventricle (RV)-to-pulmonary artery (PA) connection, for example in the setting of a Yasui repair, is to be created to avoid the use of a xenograft conduit with known limitations, connecting the central PA segment with the cranial border of the right ventriculotomy can result in undue tension on the PA bifurcation or can be technically impossible. Using the left atrial appendage as an interposition plasty of an autologous nature is thought to retain growth potential by means of native tissue continuity of about one-third of the circumference of the newly created RV-to-PA continuity.
A baby girl born with an interrupted aortic arch type B, a large ventricular septal defect (VSD), an aberrant right subclavian artery (arteria lusoria) and a multilevel left ventricular outflow tract obstruction underwent a Damus-Kaye-Stansel (DKS) procedure, aortic arch reconstruction using a subclavian flap technique and aortic arch patch augmentation as well as a 3.5-mm Blalock-Taussig shunt (BTS) at 9 days of age (Norwood-type procedure). Subsequently, the BTS had to be switched to a Sano shunt as a source of pulmonary blood flow because of suboptimal inflow into the BTS from an isolated right carotid artery. After a good recovery and appropriate somatic growth, the Yasui completion was scheduled at 9 months of age against the background of an increasingly obstructive 5-mm ring-enforced Sano shunt.
1 – Preoperative echocardiogram at 5 days of age (0:12)
The echocardiogram shows a balanced ventricular anatomy, a hypoplastic aortic valve, a normal pulmonary valve and a non-restrictive VSD of the posterior malalignment type. A diffusely hypoplastic left ventricular outflow tract with normal left ventricular inflow is present. The aortic valve and ascending aorta are markedly hypoplastic. PA flow and pulmonary valve function are normal. The systemic perfusion is partially duct-dependent. The anatomy of the pulmonary artery is normal. The patient has a type B interrupted aortic arch with an arteria lusoria.
2 – Catheter angiography at age 9 months (1:19)
Catheter angiography shows the DKS, a marked posteriorly malaligned conal septum and a reconstructed aortic arch. A strip of radiopaque material was positioned during the first operation to mark a suitable place for an infundibulotomy. The 5-mm Sano shunt is obstructive, as demonstrated in the angiographic scan. PA growth is satisfactory except for the central PA segment and a hypoplastic left PA. The Sano shunt and the left PA are balloon-dilated, which leads to mild improvement of the obstruction.
3 – Preoperative echocardiogram at age 9 months (2:47)
The reconstructed aortic arch with normal flow and the mildly hypoplastic left PA can be seen in this transthoracic echocardiogram obtained at 9 months of age before completion of the Yasui procedure.
4 – Operative steps (3:10)
After a resternotomy, dense adhesions can be seen around the Sano shunt. The right PA has been encircled with a vessel loop. The heavy scar formation around the 5-mm Sano shunt, the innominate vein and the reconstructed aortic arch can be seen. With the patient on pump and in mild hypothermia, the Sano shunt is separated from the RV and then dissected free from dense adhesions up to the central PA segment. The VSD is visualized through the tricuspid valve as well as through an infundibulotomy. The first single interrupted stitches are placed from the right atrial side along the tricuspid valve annulus. These stitches are then pulled through the opening of the infundibulotomy, and the remaining stitches are placed through the infundibulotomy. A 12-mm vascular prosthesis is cut open and used as a VSD patch that baffles the flow through the VSD into the native pulmonary valve. The incised conal septum can be seen. The left atrial appendage is first dissected free from dense adhesions and then amputated and prepared for use as autologous material for a modified RV-to-PA connection. It is first anastomosed to the central PA segment with a running Prolene suture. After the connection of the LAA interposition plasty to the upper rim of the infundibulotomy is accomplished, the whole RV-to-PA connection is then finalized with porcine pericardium. In this view, the intraventricular baffle prosthesis, the LAA interposition plasty and the central PA segment can be seen.
5 - Postoperative echocardiogram at age 9 months (6:21)
The postoperative echocardiogram shows the DKS anastomosis and the VSD patch with normal functionality. There is a free right ventricular outflow tract with pulmonary insufficiency and normal flow in the right and left pulmonary arteries. The reconstructed aortic arch is free of obstruction and shows a regular flow pattern.
The newly created RV-to-PA connection using autologous left atrial appendage should have long-term growth potential.
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PubMed Abstract | Publisher Full Text
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PubMed Abstract | Publisher Abstract
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PubMed Abstract | Publisher Abstract
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Authors
Fabian A. Kari, Fatos Ballazhi, Katja Reineker, Thilo Fleck, Rene Hoehn & Johannes Kroll
Affiliation
Heart Center Freiburg University, Freiburg, BW, 79106, Germany
Corresponding Author
Fabian A. Kari
Heart Center Freiburg University
Freiburg, BW
79106
Germany
Email: fab.a.kari@googlemail.com
Keywords
© The Author 2023. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
