P. Leigh et al.: J Extra Corpor Technol 2026, 58, 85--89 87
Surgical and perfusion strategy
The patient’ s formal preoperative diagnosis was IAA type A with a large PDA, APW involving the main pulmonary artery( MPA) and takeoff of the right pulmonary artery( RPA)( Figures 3A, 3B), and atrial septal defect. A cardiac index of 3.0 was used to determine full flows. She was 3.1 kg with a body surface area( BSA) of 0.21 m 2, putting full flow at 0.63 L / min. An FX05 oxygenator and a Terumo neonatal 3 / 16 3 / 16 circuit were employed. Monitoring was accomplished using a right radial arterial pressure line and NIRS saturations on the cerebral left and right and somatic lower body left and right. Baseline MAP was 27 mmHg, and NIRS was 40 systemically.
Through a standard median sternotomy, the thymus was fully excised, and the pericardium was opened. The head vessels, large PDA, and branch pulmonary arteries were identified and isolated. Heparin was administered, and the patient was cannulated for bypass. A 3.5 mm Gore-Tex shunt was sewn to the innominate artery and cannulated with an 8 Fr aortic cannula. The right atrial appendage was cannulated with a 14 Fr cannula. Due to the large APW, a distal aortic cannula was not required for lower body perfusion( Figure 4). After adequate anticoagulation, cardiopulmonary bypass( CPB) was initiated. Target mean arterial pressure( MAP) on bypass was 35--45 mmHg. NIRS ranged from 70 to low 90 on bypass with an expected drop in somatic NIRS during antegrade cerebral perfusion( ACP), which was employed for arch reconstruction. During cooling and prior to the use of ACP, both branch pulmonary arteries were snared to direct flow through the APW into the PDA and to the descending aorta for lower body perfusion. A pH-stat CO 2 strategy was utilized while cooling, and alpha-stat was reinstated when rewarming. After cooling to 20 ° C, the PDA was ligated and divided, essentially placing the lower body on circulatory arrest, flowing at a 0.9 cardiac index( CI) to the entire upper body. At this point, ductal tissue was dissected from the thoracic aorta. A cross clamp was placed, and Del Nido cardioplegia was delivered antegrade into the aortic root at 20 mL / kg, which is the typical myocardial protective strategy at this institution. Clamps were placed on each head vessel, on the descending thoracic aorta, and each branch pulmonary artery, which redirected arterial flow up the innominate artery and right subclavian. ACP was initiated with a flow of 0.5 CI.
The large APW was opened, and the aortic tissue was divided from the MPA and RPA. The back wall of the native descending aorta was anastomosed to the native ascending aorta. The anterior arch was reconstructed with a large patch of pulmonary homograft material. The clamp on the thoracic aorta was removed, and the aorta was de-aired. Another cross clamp was placed, and a second dose of cardioplegia was delivered at 10 mL / kg at 53 min post XC. The snares on the head vessels were removed, and full flow CPB was reinstated with rewarming pursued. The right atrial cannula was directed into the superior vena cava. A right atriotomy was made, and a pump sucker-controlled the blood entering the right atrium from the inferior vena cava. The ASD was closed primarily. Following atriotomy closure, the venous cannula was redirected into the right atrium.
Figure 2. A. CTA image large APW in close proximity to transverse arch. B. CTA image identifying high origins of coronary arteries, above the level of the annulus. C. CTA image revealing distance between descending aorta and transverse aorta.