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.