Letters to the Editor
Surgical Closure of Aortopulmonary Window Without Cardiopulmonary Bypass We read with much interest the recent report of Schmid et al. [6] concerning surgical closure of aortopulmonary window (APW) with a U-shaped Teflon felt strip without extracorporeal circulation or circulatory arrest. Although we realize that the proposed closed surgical technique avoids the well-known risks of cardiopulmonary bypass or circulatory arrest in the neonate or young infant, we have some concern about this technique. In our experience and from reports in the literature [2, 5] the window is located in the left lateral wall of the ascending aorta, almost always close to the orifice of the left coronary artery, and in the contiguous right wall of the pulmonary trunk inferior to, or extending to, the origin of the right pulmonary artery. Inherent in the morphology are some dangers which may threaten the proposed closure of the APW. First, because of the close contact of the defect to the orifice of the left coronary artery in the majority of cases, there is a potential risk of iatrogenic stenosis or occlusion of the orifice [7], with the possible ominous sequel of myocardial infarction. Second, this technique may lead to supravalvar aortic or pulmonary artery obstruction. Later surgical repair of this complication is usually difficult. Third, there is a risk of recurrence, in analogy to suture ligation of persistent ductus arteriosus, and of bleeding, which may be difficult to control when this occurs at the dorsal aspect of the APW. Reports from the literature [1, 4] and our own results [8] show that the hospital mortality in neonates or young infants is low after repair of APW using cardiopulmonary bypass, even if major associated cardiac malformations exist. To minimize the above-mentioned complications, we recommend that the operation be performed under cardiopulmonary bypass. This allows careful inspection of the APW and its relationship to the origins of the coronary arteries and the right pulmonary artery. The defect is preferably closed with a Dacron patch through a transaortic approach or, alternatively, through a vertical incision in the anterior wall of the APW itself [3].
References 1. Clarke CP, Richardson JP (1976) The management of aortopulmonary window: Advantages of transaortic closure with a Dacron patch. J Thorac Cardiovasc Surg 72:48-51 2. Deverall PB, Lincoln JCR, Aberdeen E, Bonham-Carter RE,
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Waterston DJ (1969) aortopulmonary window. J Thorac Cardiovasc Surg 57:479-486 Johansson L, Michaelsson M, Westerholm CJ, Aberg T (1978) Aortopulmonary window: A new operative approach. Ann Thorac Surg 25:564-567 Kirklin JW, Barratt-Boyes BG (1986) Aortopulmonary window. In: Kirklin JW, Barratt-Boyes BG (eds) Cardiac Surgery. John Wiley & Sons, New York, pp 933-937 Richardson JV, Doty DB, Rossi NP, Ehrenhaft JL (1979) The spectrum of anomalies of aortopulmonary septation. J Thorac Cardiovasc Surg 78:21-27 Schmid F, Hake U, Iversen S, Schranz D, Oelert H (1989) Surgical closure of aortopulmonary window without cardiopulmonary bypass. Pediatr Cardiol 10:166-169 Sethi GK, Scott SM, Takaro T (1979) Iatrogenic coronary artery stenosis following aortic valve replacement. J Thorac Cardiovasc Surg 77:760-767 Van Son JAM, Kaan GL, van Oort A, van de Wal HJCM, Vincent JG, Lacquet LK (1990) Aortopulmonaal venster: Noodzaak tot vroege operatieve correctie. Tijdschr Kindergeneeskd (in press)
Jacques A.M. von Son ~ Gilles L. Kaan 1 Anton van Oort 2 Henry J.C.M. van de Wal ~ Josef G. Vincent l Leon K. Lacquer ~ tDepartment (~f"Thoracic and Cardiac Surgeo' 2Department of Pediatric Cardiology University Hospital in Nijmegen Nijmegen, The Netherlands
The above letter was shown to the authors, who reply as follows:
We would like to thank Dr. van Son and his colleagues for their comments on our modification of a closed technique recommended for surgical closure of isolated aortopulmonary window (APW), actually a very uncommon congenital cardiovascular malformation. Therefore, there is very little experience with surgical treatment of APW, especially in infants requiring an operation during the first months of their life. In a review of nine children reported by Deverall [2], only one was under the age of ! year (10 months), whereas in Richardson's series [6] nine out of 13 patients were less than 2 years (the youngest being 8 months). Only three of six patients with type-I APW (proximal type) who underwent correction on cardiopulmonary bypass survived. According to the findings of Richardson et al. [6] and Mori et al. [4] those types of APW involving the origin of the right pulmonary artery (distal type) occur in about 25% of cases. Origin from or intimate contact of the left coronary artery to the defect is even rarer [1, 5].
Surgical Closure of Aortopulmonary Window Without Cardiopulmonary Bypass We read with much interest the recent report of Schmid et al. [6] concerning surgical closure of aortopulmonary window (APW) with a U-shaped Teflon felt strip without extracorporeal circulation or circulatory arrest. Although we realize that the proposed closed surgical technique avoids the well-known risks of cardiopulmonary bypass or circulatory arrest in the neonate or young infant, we have some concern about this technique. In our experience and from reports in the literature [2, 5] the window is located in the left lateral wall of the ascending aorta, almost always close to the orifice of the left coronary artery, and in the contiguous right wall of the pulmonary trunk inferior to, or extending to, the origin of the right pulmonary artery. Inherent in the morphology are some dangers which may threaten the proposed closure of the APW. First, because of the close contact of the defect to the orifice of the left coronary artery in the majority of cases, there is a potential risk of iatrogenic stenosis or occlusion of the orifice [7], with the possible ominous sequel of myocardial infarction. Second, this technique may lead to supravalvar aortic or pulmonary artery obstruction. Later surgical repair of this complication is usually difficult. Third, there is a risk of recurrence, in analogy to suture ligation of persistent ductus arteriosus, and of bleeding, which may be difficult to control when this occurs at the dorsal aspect of the APW. Reports from the literature [1, 4] and our own results [8] show that the hospital mortality in neonates or young infants is low after repair of APW using cardiopulmonary bypass, even if major associated cardiac malformations exist. To minimize the above-mentioned complications, we recommend that the operation be performed under cardiopulmonary bypass. This allows careful inspection of the APW and its relationship to the origins of the coronary arteries and the right pulmonary artery. The defect is preferably closed with a Dacron patch through a transaortic approach or, alternatively, through a vertical incision in the anterior wall of the APW itself [3].
References 1. Clarke CP, Richardson JP (1976) The management of aortopulmonary window: Advantages of transaortic closure with a Dacron patch. J Thorac Cardiovasc Surg 72:48-51 2. Deverall PB, Lincoln JCR, Aberdeen E, Bonham-Carter RE,
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3.
4.
5.
6.
7.
8.
Waterston DJ (1969) aortopulmonary window. J Thorac Cardiovasc Surg 57:479-486 Johansson L, Michaelsson M, Westerholm CJ, Aberg T (1978) Aortopulmonary window: A new operative approach. Ann Thorac Surg 25:564-567 Kirklin JW, Barratt-Boyes BG (1986) Aortopulmonary window. In: Kirklin JW, Barratt-Boyes BG (eds) Cardiac Surgery. John Wiley & Sons, New York, pp 933-937 Richardson JV, Doty DB, Rossi NP, Ehrenhaft JL (1979) The spectrum of anomalies of aortopulmonary septation. J Thorac Cardiovasc Surg 78:21-27 Schmid F, Hake U, Iversen S, Schranz D, Oelert H (1989) Surgical closure of aortopulmonary window without cardiopulmonary bypass. Pediatr Cardiol 10:166-169 Sethi GK, Scott SM, Takaro T (1979) Iatrogenic coronary artery stenosis following aortic valve replacement. J Thorac Cardiovasc Surg 77:760-767 Van Son JAM, Kaan GL, van Oort A, van de Wal HJCM, Vincent JG, Lacquet LK (1990) Aortopulmonaal venster: Noodzaak tot vroege operatieve correctie. Tijdschr Kindergeneeskd (in press)
Jacques A.M. von Son ~ Gilles L. Kaan 1 Anton van Oort 2 Henry J.C.M. van de Wal ~ Josef G. Vincent l Leon K. Lacquer ~ tDepartment (~f"Thoracic and Cardiac Surgeo' 2Department of Pediatric Cardiology University Hospital in Nijmegen Nijmegen, The Netherlands
The above letter was shown to the authors, who reply as follows:
We would like to thank Dr. van Son and his colleagues for their comments on our modification of a closed technique recommended for surgical closure of isolated aortopulmonary window (APW), actually a very uncommon congenital cardiovascular malformation. Therefore, there is very little experience with surgical treatment of APW, especially in infants requiring an operation during the first months of their life. In a review of nine children reported by Deverall [2], only one was under the age of ! year (10 months), whereas in Richardson's series [6] nine out of 13 patients were less than 2 years (the youngest being 8 months). Only three of six patients with type-I APW (proximal type) who underwent correction on cardiopulmonary bypass survived. According to the findings of Richardson et al. [6] and Mori et al. [4] those types of APW involving the origin of the right pulmonary artery (distal type) occur in about 25% of cases. Origin from or intimate contact of the left coronary artery to the defect is even rarer [1, 5].
