Pulmonary artery coarctation repair in univentricular heart: indications and optimal timing

BACKGROUND

To analyse surgical outcomes of pulmonary artery coarctation in univentricular hearts, focusing on surgical indications and optimal timing.

METHODS

We retrospectively reviewed 49 patients with pulmonary artery coarctation in univentricular hearts treated at our institution between 1993 and 2022. Twenty-eight patients were diagnosed before first-stage palliation. Of these, 14 underwent systemic-pulmonary shunt only as first-stage palliation (Group 1), and 14 underwent systemic-pulmonary shunt plus surgical pulmonary artery plasty as first-stage palliation (Group 2). Twenty-one patients diagnosed after first-stage palliation underwent surgical pulmonary artery plasty at the time of bidirectional Glenn procedure (Group 3).

RESULTS

Follow-up period after initial palliation was 6±8 years. The Fontan procedure was successful in 35 patients (71%) aged 28±26 months (range 18-139). Freedom from interstage death (Group 1, 53%; Group 2, 85%; Group 3, 93%) and interstage reintervention (Group 1, 50%; Group 2, 75%; Group 3, 73%) rates were significantly lower in Group 1 (p = 0.01). Five and four patients in Group 1 and Group 3, respectively, needed additional shunts before the bidirectional Glenn procedure. In Group 1, one patient with a non-confluent pulmonary artery achieved hemi-lung Fontan circulation. In Group 2, one patient suffering with a non-confluent pulmonary artery could not achieve Fontan circulation, whereas another patient with pulmonary venous obstruction achieved hemi-lung Fontan circulation.

CONCLUSIONS

Surgical pulmonary artery plasty performed at first-stage palliation improved outcomes of pulmonary artery coarctation in univentricular hearts, particularly when pulmonary artery coarctation had already progressed during the neonatal period or early infancy.

Bilateral Lung Transplant with Pulmonary Artery Reconstruction using Donor Aorta for Pulmonary Hypertension with a Giant Pulmonary Arterial Aneurysm

BACKGROUND

Standard bilateral lung transplantation (BLT) is not feasible for patients with pulmonary arterial hypertension (PAH) complicated with a giant pulmonary arterial aneurysm (PAA). This study aimed to describe the outcomes of BLT with pulmonary artery reconstruction (PAR) using donor aorta for such patients.

METHODS

This is a retrospective single-center study reviewing PAH patients with a PAA who received BLT with PAR using donor aorta from January 2010 through December 2020. We compared the characteristics and short- and long-term outcomes of recipients receiving PAR (PAR group) with those who had no PAA and received standard BLT (non-PAR group).

RESULTS

Nineteen adult PAH patients underwent cadaveric lung transplantation during the study period. Among them, 5 patients with a giant PAA (median pulmonary artery trunk diameter, 69.9 mm) underwent BLT with PAR using donor aorta and the others received standard BLT. Although the operation time tended to be longer in the PAR group compared with the non-PAR group (1239 vs 958 mins, p = 0.087), 90-day mortality (PAR group: 0% vs non-PAR group: 14.3%, p > 0.99) and 5-year survival rate (PAR group: 100% vs non-PAR group: 85.7%, p = 0.74) was comparable between the groups. No dilatation, constriction or infection of the aortic grafts were recorded during the study period with a median follow-up time of 94 months in PAR group.

CONCLUSIONS

Lung transplantation with PAR using donor aorta is a valid surgical option for PAH patients complicated with a giant PAA.

Alagille Syndrome and Repeat Oxygenator Failure during Cardiopulmonary Bypass: A Word of Caution

Alagille syndrome is an autosomal dominant disorder that is caused by heterozygous mutation of JAG1 or NOTCH2 gene that impacts several multisystem organs including but may not be limited to the liver, heart, musculoskeletal, skin, and the eyes. The most common congenital heart defect associated with Alagille syndrome is multilevel right ventricular outflow tract obstruction with multiple central and peripheral branch pulmonary arterial stenoses occurring in up to two-thirds of these patients. We report two cases of Alagille syndrome who underwent extensive pulmonary arterial branch rehabilitation and experienced unusual oxygenator failure during cardiopulmonary bypass (CPB). We present lessons learned from these two cases and the changes that we implemented in our practice that facilitated smooth conduct of CPB in other cases that we performed subsequently.

Parenchymal Sparing Surgery for Lung Cancer: Focus on Pulmonary Artery Reconstruction

Reconstruction of the pulmonary artery (PA) associated with lobectomy for the radical resection of lung cancer has been progressively gaining diffusion in lung cancer surgery as a safe and effective therapeutic option that may allow radical resection when lobectomy is not technically feasible, avoiding pneumonectomy. There are some controversial aspects concerning the intraoperative and perioperative management of a sleeve resection with PA reconstruction that may influence the outcome. In the present article, the authors have analyzed some of the main technical and oncological aspects to take stock of what they have learned from their lung-sparing operations experience over time. PA reconstruction may require prosthetic materials including different options with variable cost. A main concern in vascular reconstructive procedures is avoiding tension on the anastomosis. When PA reconstruction is required, appropriate anticoagulation management is crucial. Results from the main literature data confirm the reliability of lobectomy associated with PA reconstruction in terms of perioperative morbidity and long-term survival. Sleeve lobectomy and PA reconstruction can be performed safely and effectively even after induction therapy.

[Immediate results of angio- and bronchoplastic lobectomies for non-small cell lung carcinoma in patients over 70 years old]

OBJECTIVE

To study the immediate results of angio- and bronchoplastic lobectomies for non-small cell lung carcinoma (NSCLC) in patients over 70 years old.

MATERIAL AND METHODS

Thirty-one extended angio- and/or bronchoplastic lobectomies were performed in patients with NSCLC over 70 years old between January 2015 and December 2020. Mean age of patients was 74.5 ± 3.2 years. NSCLC stage IA was found in 5 (16.1%) cases, IB - 11 (35.5%), IIA - 12 (38.7%), IIB - 3 (9.7%) patients. Squamous cell carcinoma was diagnosed in 19 (61.3%) patients, adenocarcinoma - in other ones (n=12). All patients had concomitant diseases with predominance of cardiorespiratory pathology. Severity of postoperative complications was assessed according to the Clavien - Dindo grading system.

RESULTS

Mean Charlson index was 5.34 ± 1.46 scores. ASA grade III was observed in 21 patients, grade IV - in 10 patients. Postoperative complications occurred in 12 (38.7%) patients, mortality rate was 6.4%. Prolonged air discharge through pleural drainage tubes (12.9%) and paroxysms of atrial fibrillation (16.1%) were the most common complications. Cardiac arrhythmia is a serious and fatal complication.

CONCLUSION

Anatomical lung resections for NSCLC in patients over 70 years old have certain features of surgical technique and postoperative management. Prevention and prediction of postoperative complications along with rational perioperative management are of priority importance for increasing the safety of these interventions. Angio- and/or bronchoplastic lobectomy should be considered as the only surgical option characterized by high quality and satisfactory immediate results. This procedure is an adequate alternative to pneumonectomy.

Outcomes in Patients with Alagille Syndrome and Complex Pulmonary Artery Disease

OBJECTIVE

To assess outcomes in a large cohort of patients with Alagille syndrome (ALGS) who underwent pulmonary artery reconstruction surgery for complex pulmonary artery disease.

STUDY DESIGN

Patients with ALGS who underwent pulmonary artery reconstruction surgery at Lucile Packard Children's Hospital Stanford were reviewed. Patients were examined as an overall cohort and based on the primary cardiovascular diagnosis: severe isolated branch pulmonary artery stenosis, tetralogy of Fallot (TOF) without major aortopulmonary collateral arteries (MAPCAs), or TOF with MAPCAs.

RESULTS

Fifty-one patients with ALGS underwent pulmonary artery surgery at our center, including 22 with severe branch pulmonary artery stenosis, 9 with TOF without MAPCAs, and 20 with TOF and MAPCAs. Forty-one patients (80%) achieved a complete repair. Five of the patients with TOF with MAPCAs (25%) underwent complete repair at the first surgery, compared with 8 (89%) with TOF without MAPCAs and 19 (86%) with isolated branch pulmonary artery stenosis. At a median follow-up of 1.7 years after the first surgery, 39 patients (76%) were alive, 36 with a complete repair and a median pulmonary artery:aortic systolic pressure of 0.38. Nine patients (18%), including 8 with isolated branch pulmonary artery stenosis, underwent liver transplantation.

CONCLUSIONS

Most patients with ALGS and complex pulmonary artery disease can undergo complete repair with low postoperative right ventricular pressure. Patients with TOF/MAPCAs had the worst outcomes, with higher mortality and more frequent pulmonary artery interventions compared with patients with TOF without MAPCAs or isolated branch pulmonary artery stenosis. Complex pulmonary artery disease is not a contraindication to liver transplantation in patients with ALGS.

Emergent surgical treatment for acute thrombosis caused by pulmonary artery kinking after left upper sleeve lobectomy

This is a report on the pulmonary arterioplasty for mechanical stenosis post-left upper sleeve lobectomy. A 64-year-old man had a tumour protruding into the left upper bronchus with a diagnosis of squamous cell carcinoma (cT1cN1M0). Left upper bronchial sleeve lobectomy was performed through posterolateral thoracotomy. On postoperative day 1, he received veno-arterial extracorporeal membrane oxygen support due to sudden pulseless electrical activity. We detected left pulmonary artery (PA) kinking with an impaired blood flow by using pulmonary angiography and immediately performed PA thrombectomy and arterioplasty using rethoracotomy. Following the en bloc removal of a thrombus that had completely occluded the left PA, the redundant PA was resected, and PA reconstruction was performed by direct end-to-end anastomosis. A postoperative contrast-enhanced computed tomography scan showed no signs of PA kinking and no residual thrombus formation. When PA bending and mechanical stenosis are detected after bronchial sleeve lobectomy, resection of the redundant PA is also required to prevent PA thrombosis.

Bronchial and arterial sleeve resection for centrally-located lung cancers

The use of bronchial and arterial sleeve resections for the treatment of centrally-located lung cancers, when available, has become the option of choice in comparison with pneumonectomy (PN). Technical expertise, in particular in vascular reconstruction, and perioperative management improved over time allowing excellent short-term and long-term results. This is even truer if considering literature data from the main experiences published in the last years. These evidences have given to such lung sparing reconstructive procedures more and more acceptance among the surgical community. This article focuses on the main technical aspects and literature data regarding bronchovascular sleeve resections.

Reconstruction of the bronchus and pulmonary artery

Bronchovascular reconstructive procedures employed in order to avoid pneumonectomy (PN) in patients functionally unsuitable have provided, over time, excellent results, similar or even better than those obtained by PN. In recent years, new successful techniques have been developed that pertain in particular the prevention of major complications and the reconstruction of the pulmonary artery (PA). Encouraging data from increasing number of published experiences support the choice of parenchymal sparing procedures for lung cancer also in patients with good functional reserve. This is even more true if considering trials published in the last 10 years, thus indicating that improved outcome can be achieved with increased experience in reconstructive techniques and perioperative management. This article discusses the main technical aspects and results of literature.

Bronchovascular right upper lobe reconstruction by uniportal video-assisted thoracoscopic surgery

Lung cancer requiring double bronchial and vascular reconstruction of the pulmonary artery is a challenging procedure usually performed by thoracotomy. However, recent development of video-assisted thoracoscopic techniques allows experienced and skilled surgeons to perform these cases through a minimally invasive approach. Most of these complex thoracoscopic resections are performed by using 3 to 4 incisions. We present the first report of a right side combined vascular reconstruction and bronchoplasty performed through a single-incision video-assisted thoracoscopic surgery (VATS) technique.

Partial removal of the pulmonary artery in video-assisted thoracic surgery for non-small cell lung cancer

Lobectomy with partial removal of the pulmonary artery in video-assisted thoracic surgery (VATS) currently remains a challenge for thoracic surgeons. We were interested in introducing pulmonary vessel blocking techniques in open thoracic surgery into video-assisted thoracic surgery (VATS) procedures. In this study, we reported a surgical technique simultaneously blocking the pulmonary artery and the pulmonary vein for partial removal of the pulmonary artery under VATS. Seven patients with non-small-cell lung cancer (NSCLC) received lobectomy with partial removal of the pulmonary artery using the technique between December 2007 and March 2012. Briefly, rather than using a small clamp on the distal pulmonary artery to the area of invading cancer, we replaced a vascular clamp with a ribbon and Hem-o-lock clip to block the preserved pulmonary veins so as to prevent back bleeding and yield a better view for surgeons. The mean occlusion time of the pulmonary artery and pulmonary veins were 44.0±10.0 and 41.3±9.7 minutes, respectively. The mean repair time of the pulmonary artery was 25.3±13.7 minutes. No complications occurred. No patients showed abnormal blood flow through the reconstructed vessel. There were no local recurrences on the pulmonary artery. In conclusion, the technique for blocking the pulmonary artery and veins is feasible and safe in VATS and reduces the risk of abrupt intraoperative bleeding and the chance of converting to open thoracotomy, and extends the indications of VATS lobectomy.