Damus KayeStanzel Anastomosis with or without Aortic Arch Augmentation

Those patients with subaortic obstruction and who are destined to a single ventricle repair (Fontan) and who have a normal pulmonary valve, can frequently undergo a Damus/Kaye/ Stanzel anastomosis.7'8 This involves association of the divided proximal main pulmonary artery with the aortic arch so that the unobstructed outflow tract to the pulmonary valve an be utilized for systemic outflow to the aorta (Figure 61.20). Depending upon the anatomy and relationship of the great vessels and whether there is an associated aortic arch hypoplasia will determine whether the allograft needs to extend just onto the proximal aortic arch or whether it will need to be extended around the entire aortic arch onto the descending aorta similar to a Norwood type of repair. In most

Figure 61.17. Hypoplasia of the transverse aortic arch associated with a patent ductus arteriosus and coarctation of the aorta. Dashed line depicts the incision in the aortic arch and excision of the ductus from the descending aorta.
Figure 61.18. The ductus arteriosus tissue has been excised from the descending aorta. A patch of pulmonary allograft is cut and sewn into the underside of the aortic arch.

Figure 61.19. The completed repair showing a widely patent transverse aortic arch.

Figure 61.19. The completed repair showing a widely patent transverse aortic arch.

Damus Kaye Patch Revision
Figure 61.20. In patients who have subaortic divided (dashed line). An incision is made in the obstruction and require a Damus-Kaye-Stanzel ascending aorta (dashed line). anastomosis, the proximal main pulmonary artery is

Figure 61.21. The proximal mail pulmonary artery is attached for a distance of about 1 cm to the ascending aorta. The remainder of the anastomosis is made by using a hood of pulmonary allograft to direct flow from the proximal pulmonary artery into the ascending aorta. (A) A piece of pulmonary allograft is fashioned so as to direct blood flow into the ascending aorta with out distorting the pulmonary valve. (B) Completed repair.

Figure 61.21. The proximal mail pulmonary artery is attached for a distance of about 1 cm to the ascending aorta. The remainder of the anastomosis is made by using a hood of pulmonary allograft to direct flow from the proximal pulmonary artery into the ascending aorta. (A) A piece of pulmonary allograft is fashioned so as to direct blood flow into the ascending aorta with out distorting the pulmonary valve. (B) Completed repair.

instances, if the proximal main pulmonary artery is just sewn to an incision in the aortic arch, distortion of the pulmonary valve will occur with the development of pulmonary insufficiency. It is usually necessary to use a hood of pulmonary allograft to fashion a pathway from the divided proximal main pulmonary artery into the aorta so that no distortion of the pulmonary root or aortic root will occur. When the aortic arch is normal, the pulmonary allograft hood can be attached just to the ascending aorta (Figure 61.21A, B). This can be performed under continuous cardiopul-monary bypass. When the arch is hypoplastic and the entire arch needs to be augmented, deep hypothermia and circulatory arrest is required. A Norwood operation is then undertaken (Figure 61.22).

When the relationship of the great arteries is a posterior and rightward pulmonary artery and an anterior and leftward aorta, the technique depicted in Figures 61.22 and 61.23 A and B is used. The main pulmonary artery is divided and the distal end closed primarily or with a patch of pulmonary allograft. An "L" incision is made in the ascending aorta to create a flap of aorta which will make up part of the posterior wall of the connection between the proximal main pulmonary allograft and the ascending aorta (Figure 61.23 A and B). A hood of pulmonary allograft is used to complete the anastomosis. The repair is completed by making a systemic artery to pulmonary artery shunt. Usually this is a 3.5 mm or 4 mm PTFE graft from the innominate or subclavian artery to the pulmonary artery.

Figure 61.22. When the pulmonary artery is posterior and rightward, an L-shaped incision is made in the ascending aorta creating a posteriorly based flap. This flap makes up a portion of the posterior wall of the hood to direct flow from the proximal main pulmonary artery into the aorta.

Figure 61.22. When the pulmonary artery is posterior and rightward, an L-shaped incision is made in the ascending aorta creating a posteriorly based flap. This flap makes up a portion of the posterior wall of the hood to direct flow from the proximal main pulmonary artery into the aorta.

Figure 61.23. (A) A piece of pulmonary allograft is important not to distort the pulmonary valve as this tailored to direct the blood flow from the proximal will likely result in pulmonary insufficiency. pulmonary artery into the ascending aorta. (B) It is

Figure 61.23. (A) A piece of pulmonary allograft is important not to distort the pulmonary valve as this tailored to direct the blood flow from the proximal will likely result in pulmonary insufficiency. pulmonary artery into the ascending aorta. (B) It is

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