Technique for Supravalvular Pulmonary Artery Stenosis

proficiency for Supravalvular Pulmonary Artery StenosisA romance beating-heart technique for supravalvular pulmonic arterial blood vessel stenosisINTRODUCTIONPulmonary arterial blood vessel stenosis (PAS) whitethorn be infixed or acquired and presents itself as isolated or sevenfold lesions. Acquired PAS gener wholey occurs following the functional correction of congenital cardiac mal compositions much(prenominal) as anomalous origin of the left coronary artery arising from the pneumonic artery (ALCAPA) and tetralogy of Fallot (TOF). Treatment options for critical PAS include stent implantation, balloon angioplasty, and surgery.In this report, our intent is to present a new surgical technique without the need for cardio pneumonic bypass used for a patient of belowgoing surgery for ALCAPA who required re-operation on the first postoperative day due to supravalvular pneumonic stenosis.CASE announceIn a 8-year old boy, direct re-implantation of the left coronary artery int o the aortic root was accomplished through medial sternotomy under cardio pulmonic bypass. The general billet of patient dec pipelined with accomp alling signs and symptoms of right-sided heart failure deep down the first six postoperative hours. Also, liver enzyme take aims were elevated and renal functions deteriorated. A biochemical profile revealed blood serum glutamic-oxaloacetic transaminase (SGOT) 832 mU/dl, serum glutamic-pyruvic transaminase (SGPT) 789 mU/dl, serum urea 65 mg/dl, and creatinine 2.1 mg/dl. Echocardiography showed severe right ventricular dysfunction and mild pulmonary insufficiency. As well as the supravalvular slope was 80 mmHg, there was no transvalvular pressure gradient. Since supravalvular PAS was the suspected cause of the clinical instability of the patient, an urgent surgery was planned.SURGICAL TECHNIQUEA median sternotomy was used for the surgical procedure. Pump was not used to turn away the thinkable adverse consequences of cardiopulmonary bypass in this patient with a poor people general status and impaired renal and liver functions.Firstly, an discussion section line on the stenotic supravalvular pulmonary artery segment was drawn. Then the dimensions of the engraft to be placed were determined visually and the graft was prepared. The oval-shaped graft was sutured on the target stenotic pulmonary artery segment using 6/0 polypropylene sutures. During this procedure, special emphasis was placed on two issues1. Other than the proximal edge of the graft (the right ventricular side) all new(prenominal) edges were sutured using continuous sutures. However, no knots were tied and both ends of the suture were left free.2. During the placing of the grafts, a space was created to form a convex social system in-between the anterior get up of the pulmonary artery.Then, a small bilinear incision on the pulmonary artery was made distally on the pulmonary artery using a scalpel inserted from the proximal opening of the gr aft. simultaneous pressure on the incision site was exerted digitally to prevent bleeding. The incision was propagated longitudinally using a Metzenbaum scissor. Upon exposure of the pulmonary artery, the convex mental synthesis disappeared spontaneously by eliminating the distance between the graft and the anterior surface of the pulmonary artery.Soon aft(prenominal) the incision was made in the distal direction on the pulmonary artery according to a pre-determined length, the sutures on the proximal surface of the graft were stretched as to fix the graft on the pulmonary artery. At the end of the procedure, while a moderate level of tension was maintained on the sutures manually, the proximal end of the graft was unappealing using continuous sutures. Thus, at the end of the procedure the desired pulmonary artery diam was achieved.No hemodynamic instability was observed during the procedure. Intraoperative echocardiography showed no counterpoise gradients on the pulmonary art ery. The patient was extubated at postoperative 12th hour. A quick clinical improvement of right-sided heart failure was observed during the revaluation along with restoration of popular liver enzyme levels within 48 hours and normal renal functions within one week after surgery. The patient was dispatch at postoperative 8th day.Follow-up examination at 1 year after surgery showed a good general status with weight gain. No gradient was detected at the pulmonary artery by echocardiography.DISCUSSIONPAS whitethorn be congenital or acquired. Acquired pulmonary artery stenosis is generally a complication of the surgical procedures performed for the fixate of complex congenital cardiac malformations (1). For instance, in patients such as ours with ALCAPA, supravalvular PAS may develop following surgery (2). In certain circumstances, both congenital and acquired types of pulmonary artery stenosis may pose significant surgical challenges. Particularly, the presence of clinical instabi lity may severely limit the remedy options in newborns.Treatment options for critical PAS include stent implantation, balloon angioplasty, and surgery. In new-made years, despite significant advances in the technology of stent and balloon production, surgical furbish up remains an important therapeutic option. The success rates with balloon dilation in these patients are limited (3). On the other hand, intravascular stents are associated with the formation of re-stenosis in the long term due to somatic growth (4). Thus, surgical repair stands out as an important alternative to both other approaches in pulmonary stenosis. We didnt prefer catheterization because of early period after surgery and impaired kidney function.The current surgical methods for the reconstruction of the PAS may be associated with untoward consequences due to the need for cardiopulmonary bypass. Therefore, in order to avoid possible adverse effects of cardiopulmonary bypass, we real a novel surgical techni que to be used for the repair of supravalvular pulmonary artery stenosis without pump.The surgical technique utilized in this patient is plain and safe distinguishing itself from other techniques by negating the need for pump. Particularly, it seems suitable for selected, clinically coseismic cases who may be adversely affected by cardiopulmonary bypass. In previously operated patients with supravalvular pulmonary artery stenosis, this technique may be safely applied without the increased risk of bleeding or thromboembolic events. However, larger patient populations are warranted to more firmly establish its safety. Nevertheless, we believe that this technique for the pulmonary artery reconstruction may provide significant increases in the diameter of the pulmonary artery in a beating heart with negligible morbidity and mortality.According to our knowledge, there have not been reported any off-pump technique for PAS in the English literature to date.In conclusion, this newly deve loped method of supravalvular PAS surgery is safe and long lasting. This surgical technique may be applied on patients not only who had an isolated supravalvular PAS plainly also who were previously operated, developed restenosis in early period and were under risk if pump was used without disrupting the hemodynamic stability.