Aortopulmonary Window
An aortopulmonary window is a relatively rare anomaly that can occur either as an isolated defect or in association with other congenital lesions, such as ventricular septal defect, atrial septal defect, interrupted aortic arch, and tetralogy of Fallot. The defect classically occurs between the main pulmonary artery and aorta just above the level of the sinuses of Valsalva (Fig. 26.1A). Occasionally, the defect may be at the origin of the right pulmonary artery (Fig. 26.1B). Rarely, the right pulmonary artery may actually have a separate anomalous origin from the aorta (Fig. 26.1C). Many classification systems exist, but using the terms proximal, distal, total, and intermediate may be useful in planning the approach. Proximal defects have a minimal inferior rim, distal defects have little superior rim, and most of the ascending aorta is involved with a total aortopulmonary window. The intermediate form has adequate rims circumferentially, and is the type, which potentially could be closed by a transcatheter device. Although simple ligation or division between clamps has been successfully performed in the past, closure of the defect under direct vision with the aid of cardiopulmonary bypass is now the method of choice. This prevents serious hemorrhagic complications that can occur because of the fragility of the great vessel walls, distortion of the aorta and coronary ostia, and allows precise closure of the various forms of the defect. The diagnosis is made with echocardiography, and closure of the aortopulmonary window is indicated without delay to prevent the development of pulmonary vascular disease.
TECHNIQUE
Through a standard median sternotomy, the aorta is cannulated distally on the aortic arch and a single venous cannula is placed in the right atrium. Snares are placed around the right and left pulmonary arteries, and the ductus arteriosus is occluded with a metal clip. With the onset of cardiopulmonary bypass, the pulmonary artery snares are snugged down. A vent is placed in the right superior pulmonary vein, and cooling to 28°C-34°C is carried out. The ascending aorta is clamped at the takeoff of the innominate artery. Cardioplegic solution is administered into the aortic root, and the ascending aorta is then incised longitudinally between two traction sutures of fine Prolene. The incision extends from just below the aortic clamp to a point above the commissure between the right and noncoronary cusps. The defect is identified, and a patch of glutaraldehyde-treated autologous pericardium or Gore-Tex is used to close the defect with a 5-0 or 6-0 continuous Prolene suture (Fig. 26.2). The suture line is completed anteriorly, and both needles are passed outside the vessel and tied. The aortotomy is then closed with a continuous suture of 5-0 or 6-0 Prolene. Alternatively, an incision is made through the anterior part of the window itself. The opening of the right pulmonary artery and the ostia of the left and right coronary arteries are identified. A patch of pericardium or Gore-Tex is then sewn to the posterior, superior, and inferior edges of the window. At the edges of the incision, the suture is continued, passing through the pulmonary artery edge,
the patch, and then the aortic wall until the entire opening is closed. In this manner, the patch is sandwiched between the aorta and pulmonary artery to close the window (Fig. 26.3).
the patch, and then the aortic wall until the entire opening is closed. In this manner, the patch is sandwiched between the aorta and pulmonary artery to close the window (Fig. 26.3).
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