Steps of surgery:
The child underwent surgery for enlargement of LPA with creation of bidirectional Glenn (BDG) shunt as a first stage surgery in view of older age at presentation and dilated aortic root. The chest was opened with a midline sternotomy. The RPA pressure was measured directly prior to initiating cardiopulmonary bypass and was found to be 14 mmHg. Subsequently, cardiopulmonary bypass was established with aorta – innominate vein – right atrial cannulation. The PDA was transfixed and divided at the aortic end.
The MPA was transected and its cardiac end was sutured in 2 layers. The pulmonary end of MPA was mobilized fully by freeing it from the entire ascending aorta. Two marker stitches were placed over the pulmonary end of the MPA to avoid torsion (Figure 1B). The LPA was transected beyond the origin at its mid portion and an incision was made into the pulmonary end of the LPA extending upto the hilum so as to create wide mouth of opening. (Figures 1B, 1C) Thereafter the pulmonary end of MPA was turned down alongside the opened LPA and both stomas were anastomosed using 6/0 continuous prolene sutures (Figures 1D, 3).
Thereafter the BDG shunt was performed in standard fashion. The pressures in the RPA and left atrium were measured after discontinuing bypass and were found to be 14 and 8 mmHg respectively. The patient made an uneventful recovery with resting saturations on room air of 85%. She was discharged on Aspirin 75mg daily. The morphology of pulmonary arterial confluence and branch PAs was evaluated after 6 months using a CT angiogram and was found to be satisfactory (Figure 4) with no evidence of residual or recurrent stenosis.