A modified approach in the repair of type I and II truncus arteriosus to promote branch pulmonary arterial growth and limit early reoperation

Michael F Swartz; Shuichi Yoshitake; Jill M Cholette; Nader Atallah-Yunes; Hongyue Wang; George M Alfieris

doi:10.1016/j.xjtc.2022.09.012

A modified approach in the repair of type I and II truncus arteriosus to promote branch pulmonary arterial growth and limit early reoperation

JTCVS Tech. 2022 Sep 29:16:196-211. doi: 10.1016/j.xjtc.2022.09.012. eCollection 2022 Dec.

Authors

Michael F Swartz^{1

2}, Shuichi Yoshitake^{1

2}, Jill M Cholette^{2

3}, Nader Atallah-Yunes^{2

3}, Hongyue Wang⁴, George M Alfieris^{1

2

3}

Affiliations

¹ Department of Surgery, University of Rochester Medical Center, Rochester, NY.
² Pediatric Cardiac Consortium of Upstate New York, Syracuse, NY.
³ Department of Pediatrics, University of Rochester Medical Center, Rochester, NY.
⁴ Department of Biostatistics, University of Rochester Medical Center, Rochester, NY.

Abstract

Objective: Maintaining adequate branch pulmonary arterial growth is critical in preventing early (<3 years) right ventricular outflow tract reoperation after the repair of truncus arteriosus. We hypothesized that a modified truncus arteriosus repair keeping the branch pulmonary arteries in situ would promote branch pulmonary arterial growth and limit early right ventricular outflow tract reoperation.

Methods: For infants requiring repair for type I and II truncus arteriosus, the truncal root was septated through a hockey stick incision keeping the branch pulmonary arteries in situ, the ventricular septal defect was closed, and a short aortic homograft was used to reconstruct the right ventricular outflow tract. Echocardiograms measured preoperative and follow-up branch pulmonary artery diameter.

Results: Between 1998 and 2020, 41 infants were repaired using the modified approach (type I, 28; type II, 13). With a median follow-up of 11.6 (interquartile range, 3.1-15.5) years, there was no significant change between preoperative left pulmonary artery and right pulmonary artery Z-scores and their corresponding follow-up measurement (left pulmonary artery: 0.97, interquartile range, 0.6-1.6 vs left pulmonary artery: 1.4, interquartile range, -0.3 to 1.9) (right pulmonary artery: 0.6, interquartile range, -0.4 to 1.7 vs right pulmonary artery: 0.3 interquartile range, 0.5-0.9). Only 7.3% (n = 2) of follow-up right pulmonary artery Z-scores were less than 2.5 Z-scores below preoperative measurements. Four children (9.8%) required early right ventricular outflow tract reoperation. On multivariable analysis, larger conduit Z-scores were associated with greater time to right ventricular outflow tract reoperation (hazard ratio, 0.55, confidence interval, 0.307-0.984; P = .043).

Conclusions: Maintaining the branch pulmonary arteries in situ at initial truncus arteriosus repair allows for branch pulmonary arterial growth, limiting early right ventricular outflow tract reoperation.

Keywords: CI, confidence interval; CMR, cardiac magnetic resonance; IQR, interquartile range; LPA, left pulmonary artery; PA, pulmonary artery; RPA, right pulmonary artery; RVOT, right ventricular outflow tract; TA, truncus arteriosus; branch pulmonary artery stenosis; reoperation; truncus arteriosus.