Establishment of right ventricle-hypoplastic pulmonary artery continuity without the use of extracorporeal circulation

A technique that allows establishment of continuity between the right ventricle and the hypoplastic pulmonary confluence without the use of extracorporeal circulation in patients with pulmonary atreasia and ventricular septal defect has been applied successfully in six consecutive patients. Exposure is achieved by an anterolateral thoracotomy through the left third intercostal space. A Dacron tubular graft of appropriate size is anastomosed to the hypoplastic but confluent pulmonary artery bifurcation. A fine, stranded, steel wire is passed throught the anterior wall of the outflow portion of the right ventricle so that a 2 to 3 cm loop lies in the right ventricular cavity. The proximal end of the nonvalved tubular graft is anastomosed to the epicardial surface of the right ventricle around the exit points of the wire. The ventricular incision is achieved by sawing through the right ventricular wall with the wire as one would with a Gigli saw. No systemic heparinization is used. Six consecutive patients have undergone this procedure. All had confluent but hypoplastic pulmonary arteries of 6, 5, 5, 3, 3, and 4 mm in diameter. There were no surgical deaths. Average blood loss was 366 ml, and all patients had an increase in peripheral arterial oxygen saturation. All patients underwent postoperative cardiac catheterization and angiography. All patients had patent conduits and pulmonary arteries that had increased in diameter. Advantages of the procedure are avoidance of the median sternotomy, which may simplify future closure of the ventricular septal defect; simplification of an effective technique which, under extracorporeal circulation, is complicated by profuse collateral flow that tends to obscure the operative field and distend the heart; minimal bleeding resulting from avoidance of systemid heparinization, which in these very cyanotic patients can lead to severe bleeding diathesis; and a possible decrease in the surgical risk.