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• W2062480511 abstract "The repair of truncus arteriosus requires separation of the pulmonary artery bifurcation from the single arterial trunk, closure of the ventricular septal defect, and establishment of an unobstructed pathway from the right ventricle to the pulmonary arteries. This operation is now performed routinely in newborns at clinical presentation, which is usually within the first days or weeks of life. Waiting for the infant to grow is no longer advised. It is now recognized that leaving the pulmonary vascular bed unprotected for even a few weeks results in an augmented vasoconstrictor response that significantly increases the risk of acute pulmonary hypertensive crises during the postoperative period.1Reddy VM Wong J Liddicoat J Altered endothelium-dependent responses in lambs with pulmonary hypertension and increased pulmonary blood flow.Am J Physiol Heart Circ Physiol. 1996; 271: H562-H570Google Scholar Significant improvements in the perioperative treatment of neonates requiring complex cardiac surgery have also contributed to a marked decrease in morbidity and mortality in truncus arteriosus repair. Improved survival rates for these infants have also resulted from recognition and improved treatment of significant risk factors: (1) truncal valve insufficiency, (2) coronary artery anomalies, and (3) the presence of an interrupted aortic arch.2Rodefeld MD Hanley FL Neonatal truncus arteriosus repair: Surgical techniques and clinical management.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2002; 5: 212-217Abstract Full Text PDF PubMed Scopus (17) Google Scholar Moderate or severe truncal valve insufficiency is now better treated with techniques of valve repair rather than replacement.3Thompson LD McElhinney DB Reddy M et al.Neonatal repair of truncus arteriosus: Continuing improvement in outcomes.Ann Thorac Surg. 2001; 72: 391-395Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 4Mavroudis C Backer CL Surgical management of severe truncal insufficiency: Experience with truncal valve remodeling techniques.Ann Thorac Surg. 2001; 72: 396-400Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 5Imamura M Drummond-Webb JJ Sarris GE et al.Improving early and intermediate results of truncus arteriosus repair: A new technique of truncal valve repair.Ann Thorac Surg. 1999; 67: 1142-1146Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Recognition of the potential presence of coronary artery anomalies in infants with truncus helps avoid inadvertent injury to these vessels during separation of the pulmonary arteries from the truncal root or during the right ventriculotomy.6Lenox CC Debich DE Zuberbuhler JR The role of coronary artery abnormalities in the prognosis of truncus arteriosus.J Thorac Cardiovasc Surg. 1992; 104: 1728-1742PubMed Google Scholar The presence of a concomitant interrupted aortic arch has also become less of a risk factor as newer regional perfusion techniques permit arch reconstruction without a period of circulatory arrest.2Rodefeld MD Hanley FL Neonatal truncus arteriosus repair: Surgical techniques and clinical management.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2002; 5: 212-217Abstract Full Text PDF PubMed Scopus (17) Google Scholar, 3Thompson LD McElhinney DB Reddy M et al.Neonatal repair of truncus arteriosus: Continuing improvement in outcomes.Ann Thorac Surg. 2001; 72: 391-395Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar A variety of techniques for establishing continuity between the right ventricle and the pulmonary artery bifurcation has been described. Ideally, the connection should be widely patent, have potential for growth, and provide valve function, especially during the early postoperative period when pulmonary hypertensive crises are most likely. Although techniques of direct anastomosis between the right ventricle and pulmonary artery potentially answer these ideals, experience in comparison with conduits has not always been favorable.7Reid KG Godman MJ Burns JE Truncus arteriosus: Successful surgical correction without the use of a valved conduit.Br Heart J. 1986; 56: 388-390Crossref PubMed Scopus (15) Google Scholar, 8Barbero-Marcial M Riso A Atik E et al.A technique for correction of truncus arteriosus types I and II without extracardiac conduits.J Thorac Cardiovasc Surg. 1990; 99: 364-369PubMed Google Scholar, 9Lacour-Gayet F Serraf A Komiya T et al.Truncus arteriosus repair: Influence of techniques of right ventricular outflow tract reconstruction.J Thorac Cardiovasc Surg. 1996; 111: 849-856Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Historically, Dacron O valved conduits have served as satisfactory connections, especially for older and larger infants. However, the stiffness of the Dacron graft material limits its suitability for anastomosis to the fragile neonatal right ventricle. Our choice of conduit for repair of truncus arteriosus has been the cryopreserved pulmonary allograft. Despite its limited availability in small sizes, the pulmonary allograft provides excellent handling properties, a low resistance to ejection, and a competent valve. Although tissue allografts are essentially inert and do not have true growth potential, the relatively thin-walled pulmonary allograft often dilates enough to permit the infant to reach an age of 2 years or older before a larger conduit is required. When a suitably sized, pulmonary allograft is unavailable, our next choice is an aortic allograft, which typically has a thicker wall, and is more likely to calcify and require earlier replacement.10Heinemann MK Hanley F Fenton KN et al.Fate of small homograft conduits after early repair of truncus arteriosus.Ann Thorac Surg. 1993; 55: 1409-1412Abstract Full Text PDF PubMed Scopus (46) Google Scholar After the repair of truncus arteriosus, treatment involves minimizing pulmonary vascular resistance and supporting right ventricular function. For the first 24 hours, the infant is paralyzed, sedated, and ventilated to maintain a level of hypocapnia and respiratory alkalosis. The milrinone infusion is continued for its combined inotropic and vasodilatory effects. If the infant is hemodynamically stable after 24 hours, paralysis is discontinued, and sedation is decreased. If hemodynamic remains stable as the infant awakens, mechanical ventilation is weaned. After successful extubation, the inotropic agents (ie, milrinone and dopamine) are weaned off. The technique described incorporates several strategies designed to achieve a high rate of success for what was once a daunting congenital heart defect. The performance of the procedure during the neonatal period may be the most important factor. The use of continuous cardiopulmonary bypass rather than deep hypothermic circulatory arrest allows the surgeon to proceed through the repair in a deliberate yet unrushed fashion. Double venous cannulation and a carefully placed vent provide excellent exposure and an essentially bloodless operative field. Complete transection of the aorta compliments the exposure and helps the surgeon avoid the potential pitfalls of pulmonary artery, coronary artery, or truncal valve injury. The use of a pulmonary allograft eliminates the need to insert an oversized conduit that may not match the anatomy and space limitations of a neonate. Applying these principles, surgeons can now achieve early survival rates in excess of 95%.3Thompson LD McElhinney DB Reddy M et al.Neonatal repair of truncus arteriosus: Continuing improvement in outcomes.Ann Thorac Surg. 2001; 72: 391-395Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar" @default.
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• W2062480511 title "Repair of Truncus Arteriosus" @default.
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