Alcántara-Noguez, Carlos¹

Language: English
References: 8
Page: 122-124
PDF size: 1801.07 Kb.

ABSTRACT

Truncus arteriosus type I is a rare and complex congenital heart defect, the surgical management of which is fraught with the risk of pulmonary branch obstruction. We describe a corrective approach utilizing the Alfieri technique, with a focus on preserving the native pulmonary branch architecture, complemented by the use of a handcrafted PTFE valved conduit for right ventricular outflow tract reconstruction. This strategy mitigates anastomotic tension, thereby reducing the risk of obstruction and endocarditis, and consequently, the need for early reintervention.

ABBREVIATIONS:

• PTFE = polytetrafluoroethylene
• VSD = ventricular septal defect

Truncus arteriosus is a rare congenital heart disease characterized by a single arterial trunk giving rise to the aorta, pulmonary arteries, and coronary arteries.^1,2 The classic Collett and Edwards classification distinguishes four anatomic types (I-IV) based on the origin and arrangement of the pulmonary arteries.³ Type I (Figura 1), the most prevalent and surgically pertinent variant, features pulmonary arteries arising from a short common pulmonary trunk, thereby dictating the surgical approach required to preserve pulmonary artery integrity and architecture.^3,4 This anatomic consideration underpins the surgical technique described by Alfieris, which prioritizes preservation of the native pulmonary artery architecture during repair.⁵ Standard surgical management entails separation of the pulmonary arteries from the common trunk, closure of the ventricular septal defect, and reconstruction of the right ventricular outflow tract using a valved conduit to the pulmonary arteries.^1,6 A frequent postoperative complication is pulmonary artery branch stenosis, typically precipitated by branch division, anatomic distortion, and tension at the distal conduit anastomosis, which may precipitate early reintervention and functional decline.^6-8

SURGICAL TECHNIQUE

With the heart under aortic cross-clamping, moderate hypothermia, bicaval cannulation, and del Nido cardioplegia, a "hockey-stick" incision is made on the truncal artery and extended toward the left pulmonary artery, allowing clear identification of the common aortopulmonary window (Figura 2). This approach facilitates preservation of pulmonary artery architecture, a fundamental principle of the technique described by Alfieris.⁵

The defect within the truncal artery is closed using a 0.4-mm polytetrafluoroethylene (PTFE) patch with continuous 6-0 vascular polypropylene sutures, ensuring that the pulmonary artery confluence remains free of obstruction. Subsequently, a right ventriculotomy is performed to expose the ventricular septal defect (VSD), which is closed with a second 0.4-mm PTFE patch using continuous 5-0 vascular polypropylene sutures (Figura 3).

Prior to surgery, a 10-mm valved PTFE conduit is handcrafted using two 0.1-mm PTFE leaflets. The proximal anastomosis is initiated by positioning the valve as close as possible to the pulmonary artery confluence and suturing it with 6-0 vascular polypropylene suture. The conduit is then tailored and its distal end beveled to complete the distal anastomosis to the right ventricle using 6-0 polypropylene suture, thereby establishing continuity between the right ventricle and the pulmonary arteries. This anastomosis is performed with the heart beating (Figura 4) (Figura 5), with the aim of minimizing tension and optimizing conduit alignment.

CONCLUSION

The Alfieris repair technique, which is based on preservation of the pulmonary artery architecture via a cryopreserved aortic homograft, has yielded excellent anatomic and functional outcomes, while reducing the incidence of pulmonary artery branch stenosis.⁵ However, the scarcity of homografts in our setting constitutes a significant impediment to its routine implementation. In this context, the utilization of a handcrafted valved PTFE conduit has demonstrated good outcomes in right ventricular outflow tract reconstruction, exhibiting comparable performance to homografts in terms of patency and reintervention rates.^6,7 The combined use of the Alfieris technique, aimed at preserving pulmonary artery architecture, in conjunction with a handcrafted valved PTFE conduit, represents a viable alternative for patients with type I truncus arteriosus and, selectively, type II. This approach may reduce the risk of pulmonary artery obstruction, minimizes tension at the distal anastomosis, and attenuates the need for early reinterventions on the pulmonary arteries, without augmenting the risk of endocarditis or other major complications.^6-8

REFERENCES

1. Mery C, Bastero P, Cabrera A, Hall S. Texas children's hospital handbook of congenital heart disease. Hall AGCS (eds). Texas Children's Hospital; 2020.

2. Collett RW, Edwards JE. Persistent truncus arteriosus; a classification according to anatomic types. Surg Clin North Am. 1949;29(4):1245-1270.

3. Van Praagh R, Van Praagh S. The anatomy of common aorticopulmonary trunk (truncus arteriosus communis) and its embryologic implications. A study of 57 necropsy cases. Am J Cardiol. 1965;16(3):406-425. doi: 10.1016/0002-9149(65)90732-0.

4. Russell HM, Jacobs ML, Anderson RH, et al. A simplified categorization for common arterial trunk. J Thorac Cardiovasc Surg. 2011;141(3):645-653. doi: 10.1016/j.jtcvs.2010.08.022.

5. Alfieris G, Swartz M. Technique for the repair of truncus arteriosus to maintain pulmonary artery architecture. Oper Tech Thorac Cardiovasc Surg. 2011;16(2):98-103. doi: 10.1053/j.optechstcvs.2011.06.001.

6. Mercer CW, West SC, Sharma MS, Yoshida M, Morell VO. Polytetrafluoroethylene conduits versus homografts for right ventricular outflow tract reconstruction in infants and young children: An institutional experience. J Thorac Cardiovasc Surg. 2018;155(5):2082-2091.e1. doi: 10.1016/j.jtcvs.2017.11.107.

7. Buckley JR, Amula V, Sassalos P, et al. Multicenter analysis of early childhood outcomes after repair of truncus arteriosus. Ann Thorac Surg. 2019;107(2):553-559. doi: 10.1016/j.athoracsur.2018.08.094.

8. Herrmann JL, Larson EE, Mastropietro CW, et al. Right ventricular outflow tract reconstruction in infant truncus arteriosus: a 37-year experience. Ann Thorac Surg. 2020;110(2):630-637. doi: 10.1016/j.athoracsur.2019.11.023.

AFFILIATIONS

¹ Department of Cardiovascular Surgery, Hospital Infantil de México "Federico Gómez". National Institute of Health. Mexico City, Mexico.

Funding: none.

Disclosure: the authors have no conflict of interest to disclose.

CORRESPONDENCE

Dr. Carlos Alcántara Noguez. E-mail: dr.charlyalcantara@gmail.com

Received: 19-01-2026. Accepted: 09-02-2026.