Pulmonary atresia with ventricular septal defect, extremely hypoplastic pulmonary arteries, major aorto-pulmonary collaterals

Objective: Among 63 patients with pulmonary atresia and ventricular septal defect (VSD), 10 patients with extreme hypoplasia of the pulmonary arteries (PA) (mean Nakata index 20.6 mm(2)/m(2)), but with confluent arteries and a diminutive main PA, and major aortopulmonary collaterals (MAPCAS), have b een submitted to a 'rehabilitation' of the PA with several stages: (i) conn ection between RV and PAs, (ii) interventional catheterizations, (iii) comp lete correction with or without unifocalisation. We report here the results of this approach. Methods: The RV-PA connection was direct (nine cases) or with an homograft conduit (one case), done under normothermic cardiopulmon ary by-pass in patients aged 4.9 months (range 0.1-18 months). Subsequently , six underwent interventional catheterizations (dilations and stents in th e PA, MAPCAS occlusion by coils). Complete correction was done in seven pat ients (mean age 30 months, range 8-49). One patient is awaiting correction. Results: One patient died after the first stage. All patients having had t he third stage had a satisfactory development of the PA, had a complete clo sure of the VSD and a satisfactory reconstruction of the PA bifurcation. Th ere was one death of severe pulmonary infection 6 months after repair. All other patients have been followed by catheterization and/or echocardiograms . With a follow-up of 83 +/- 65 months, all patients are improved, 50% have no cardiac medications, none has residual shunt, RV/LV pressure ratio is 0 .6 (range 0.3-1). Conclusions: The strategy of 'rehabilitation' of PA allow ing: (i) antegrade flow in the PA, (ii) interventional catheterizations, (i ii) growth of the PA with possible angiogenesis, (iv) complete correction, is a logical approach to be undertaken in the young patient and is a valid alternative to strategies relying more on MAPCAS for pulmonary vascular sup ply. The therapeutic sequences depend upon the individual anatomy. (C) 2001 Elsevier Science B.V. All rights reserved.