DE LA PARTE PEREZ, Lincoln. ANESTHESIA IN JATENE’S SURGERY, AN EXPERIENCE AT THE CARDIOLOGY CENTER OF “WILLIAM SOLER” HOSPITAL. Recursos Materiales y Humanos del Servicio de Cirugia cardiovascular 7. Organización para la corrección anatómica u Operación de Jatene siempre que. Cirugía de switch arterial: una historia de grandes esperanzas. mArsHALL L. JAcoBs1. Forty years ago, when Adib Jatene, in Sao Paulo, Bra- zil performed the.
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The Jatene procedurearterial switch operation or arterial switchis an open heart surgical procedure used to correct dextro-transposition of the great arteries d-TGA ; its development was pioneered by Canadian cardiac surgeon William Mustard and it was named for Brazilian cardiac surgeon Adib Jatenewho was the first to use it successfully.
It was the first method of d-TGA repair to be attempted, but the last to be put into regular use because of technological limitations at the time of its conception. Use of the arterial switch ciruugia historically preceded by two atrial switch methods: This surgery may be used in combination with other procedures for treatment of certain cases of double outlet right ventricle DORV in which the great arteries are dextro – transposed.
The Jatene procedure is ideally performed during the second week of life, before the left ventricle adjusts to the lower pulmonary pressure and is therefore unable to support the systemic circulation. In the event of sepsis or delayed diagnosisa combination of pulmonary artery banding PAB and shunt construction may be used to increase the left ventricular mass jahene to make an arterial switch possible later in infancy. The success of this procedure is largely dependent on the facilities available, the skill and experience of the surgeon, and the general health of the patient.
If the procedure is anticipated far enough in advance with prenatal diagnosis, for exampleand the individual’s blood type is known, a family member with a compatible blood type may donate some or all of the blood needed for transfusion during the use of a heart-lung machine HLM. The patient’s mother is normally unable to donate blood for the transfusion, as she will not be able to donate blood during pregnancy due to the needs of the fetus or for a few weeks after giving birth due to blood lossand the process of collecting a sufficient amount of blood may take several weeks to a few months.
However, in cases where the individual has been diagnosed but surgery must cirgia delayed, maternal or even autologousin certain cases blood donation may be possible, as long as the mother has a compatible blood type.
In most cases, though, the patient receives a donation from a blood bank. A blood transfusion is necessary for the arterial switch because the HLM needs its “circulation” filled with blood and an infant does not have enough blood on their own to jatehe this in most cases, an adult would not require blood transfusion. The patient will require a number of imaging procedures in order to determine the individual anatomy of the great arteries and, most importantly, the coronary arteries.
The coronary arteries are carefully mapped out in order to avoid unexpected intra-operative complications in transferring them from the native aorta to the neo-aorta.
Arterial switch operation – Wikipedia
As with any procedure requiring general anaesthesia, arterial switch recipients will need to fast for several hours prior to the surgery to avoid the risk of aspiration of vomitus during the cifugia of anesthesia. As the patient is anesthetized, they may receive the following drugswhich continue as necessary throughout the procedure:.
The heart is accessed via median sternotomyand ciruugia patient is given heparin to prevent the blood from clotting. A generous section of pericardium is harvestedthen disinfected and sterilized with a weak solution of glutaraldehyde ; and the coronary and great artery anatomy are examined. The ductus arteriosus and right pulmonary branchup to and including the first branches in the hilum of the right lungare separated from the surrounding supportive tissue to allow mobility of the vessels.
Silk marking sutures may dw placed in the pulmonary trunk at this time, to indicate the commissure of the aorta to the neo-aorta ; alternatively, this may be done later in the procedure.
The cardiopulmonary bypass is then initiated by inserting a cannula into the ascending aorta as distally from the aortic root as possible while still supplying all arterial branches, another cannula is inserted into the right atriumand a vent is created for the left ventricle via catheterization of the right superior pulmonary vein.
While the patient is cooling, the ductus arteriosus is ligated at both the aortic and pulmonary ostiathen transected at its center; the left pulmonary branchincluding the first branches in the hilum of the left lung, is separated from the ciirugia tissue; and the aorta is marked at the site it will be transected, which is just below the pulmonary bifurcationproximal to where the pulmonary artery will be transected.
Arterial switch operation
When the patient is fully cooled, the ascending aorta is clamped jatenee close as possible below the HLM cannula, and cryocardioplegia is achieved by delivering cold blood to the heart via the ascending aorta below the cross clamp.
The aorta is then transected at the marked spot, and the pulmonary artery is transected a few millimetres below the bifurcation. The vessels are again examined, and the pulmonary root is inspected for left ventricular outflow tract obstruction LVOTO.
If a ventricular septal defect VSD is present, it may be repaired, at this point via either the aortic or pulmonary valve ; it may alternatively be repaired later in the procedure. The great arteries are usually arranged using the LeCompte maneuverwith the aortic cross clamp positioned to hold the pulmonary artery anterior to the ascending aorta; though with some congenital arrangements of the great arteries, such as side-by-side, this is not possible and the arteries will be transplanted in the non-anatomic ‘anterior aorta’ arrangement.
If the aortic commissure has not yet been marked, it may be done at this point, using the same method as would be used prior to bypass; however, there is a third opportunity for this still later in the procedure. Coronary arteries are examined closely, and the ostia and proximal arterial course are identified, as are any infundibular branches, if they exist.
The coronary ostia and a large “button” of surrounding aortic wall are then excised from the aorta, well into the sinus of Valsalva ; and the proximal sections of the coronary arteries are separated from the surface of the heart, which prevents tension or distortion after anastomosis to the neo-aorta. Infundibular branches are sometimes unable to be spared, but this is a very rare occurrence. If the aortic commissure has not previously been marked, the excised coronary arteries will be used to determine the implantation position of the aorta.
The aorta is then transplanted onto the pulmonary root, using either absorbable or permanent continuous suture. The aortic clamp is temporarily removed while small sections of the neo-aorta are cut away to accommodate the coronary ostia, and a continuous absorbable suture is then used to anastomose each coronary “button” into the prepared space.
In most cases, the coronary implantation sites will be at left and right anterior positions at the base of the neo-aorta; however, if the circumflex coronary artery branches from the right coronary arterythe circumflex coronary artery will be distorted if the pair are not implanted higher than normal on the neo-aorta, and in some cases they may need to be implanted above the aortic commissure, on the native aorta itself. The circumflex coronary artery may originate from the same coronary sinus as, rather than directly from, the right coronary artery, in which case they may still be excised on the same “button” and transplanted similarly to if they had a shared ostium, unless one or both have intramural communication with another coronary vessel.
Sometimes, one or more coronary ostia are located very close to the valvular opening and a small portion of the native aortic valve must be removed when the coronary artery is excised, which causes a generally mild, and usually well- toleratedneo-pulmonary valve regurgitation. The HLM is turned off and the aortic and atrial cannula are removed, then an incision is made in the right atrium, through which the congenital or palliative atrial septal defect ASD is repaired; where a Rashkind balloon atrial septostomy was used, the ASD should be able to be closed with sutures, but cases involving large congenital ASDs or Blalock-Hanlon atrial septectomya pericardial, xenograftor Dacron patch may be necessary.
If there is a VSD which has not yet been repaired, this is performed via the atrial incision and tricuspid valveusing sutures for a small defect or a patch for a large defect.
When the septal defects have been repaired and the atrial incision is closed, the previously removed cannula are replaced and the HLM is restarted.
The left ventricle is then vented and the cross clamp removed from the aorta, enabling full-flow to be re-established and rewarming to begin; at this point the patient will receive an additional dose of Regitine to keep blood pressure under control. The previously harvested pericardium is then used to patch the coronary explantation sites, and to extend – and widen, if necessary – the neo-pulmonary root, which allows the pulmonary artery to be anastamosed without residual tension; the pulmonary artery is then transplanted to the neo-pulmonary root.
The patient is fitted with chest tubestemporary jatenne leads, and ventilated before weaning from the HLM is begun. The rib cage is relaxed and the external surgical wound is bandaged, but the sternum and chest incision are left open to provide extra room in the pleural cavityallowing the heart room to swell and preventing pressure caused by pleural effusion. The sternum and chest can usually be closed within a few days; however, the chest tubes, pacemaker, ventilator, and drugs may still be required after this time.
The patient will continue to fast for up to a few days, and breastmilk or infant formula can then be gradually introduced via nasogastric tube NG tube ; cirjgia primary goal after a successful arterial switch, and before hospital discharge, is for the infant to gain back the weight they have lost and continue to gain weight at a normal or near-normal rate. Scottish pathologist Matthew Baillie first described TGA inpresumably as a posthumous diagnosis.
InAmerican surgeons Alfred Blalock and C. Rollins Hanlon introduced the Blalock-Hanlon atrial septectomywhich was then routinely used to palliate patients. Jqtene would have effectively reduced early mortality rates, particularly in cases with no concomitant shunts, but is unlikely to have reduced late mortality rates.
Mustard first conceived of, and attempted, the anatomical repair arterial switch for d-TGA in the early s. His few attempts were unsuccessful due to technical difficulties posed by the translocation of the coronary arteries, and the idea was abandoned. Due to the technical complexity of the Senning procedure, others could not duplicate his success rate; in response, Mustard developed a simpler alternative method the Mustard procedure inwhich involved constructing a baffle from autologous pericardium or synthetic material, such as Dacron.
This procedure yielded early and late mortality rates comparable to the Senning procedure; however, a late morbidity rate was eventually discovered in relation to the use of synthetic graft material, which does not grow with the recipient and eventually ciruugia obstruction. InAmerican surgeons William Rashkind and William Miller transformed the palliation of d-TGA patients with the innovative Rashkind balloon atrial septostomywhich, unlike the thoracotomy required jaene a septectomy, is performed through the minimally invasive surgical technique of cardiac catheterization.
Although the atrial switch procedures dramatically reduced both early and late mortality rates, these statistics remained high, partly due to the wait time required between birth and surgery pre-operative mortality: These statistics, combined with advances in microvascular surgery, created a renewed interest in Mustard’s original concept of an arterial switch procedure.
Jatfne cardiac surgeon Magdi Yacoub was subsequently successful in treating TGA with intact septum when preceded by pulmonary artery banding and systemic-to-pulmonary shunt palliation.
Eber was the first to recount a small series of successful arterial switch procedures, and the first large successful series was reported by Guatemalan surgeon Aldo R. By cirugiaa, the arterial switch had become the procedure of choice, and remains the standard modern clrugia for d-TGA repair. The world’s smallest infant to survive an arterial switch was Jerrick De Leon, born 13 weeks premature. At the time of the operation on February 6,he weighed just over 1.
From Wikipedia, the free encyclopedia. Jatene procedure An 8 day old right after the Jatene procedure. Valve repair Valvulotomy Mitral valve repair Valvuloplasty aortic mitral Valve replacement Aortic valve repair Aortic valve replacement Ross procedure Percutaneous aortic valve replacement Mitral valve replacement production of septal defect in heart enlargement of existing septal defect Atrial septostomy Balloon septostomy creation of septal defect in heart Blalock—Hanlon procedure shunt from heart chamber to cirugai vessel atrium to pulmonary artery Fontan procedure left ventricle hatene aorta Rastelli procedure right ventricle to pulmonary artery Sano shunt compound procedures for transposition of great vessels Arterial switch operation Mustard procedure Senning procedure for univentricular defect Norwood procedure Kawashima procedure shunt from blood vessel to blood vessel systemic circulation to pulmonary artery shunt Blalock—Taussig shunt SVC to the right PA Glenn procedure.
Pericardium Pericardiocentesis Pericardial window Pericardiectomy Myocardium Cardiomyoplasty Dor procedure Septal myectomy Ventricular reduction Alcohol septal ablation Conduction system Maze procedure Cox maze and minimaze Catheter ablation Cryoablation Radiofrequency ablation Pacemaker insertion Left atrial appendage occlusion Cardiotomy Heart transplantation.
Heart valves and septa Valve repair Valvulotomy Mitral valve repair Valvuloplasty aortic mitral Valve replacement Aortic valve repair Aortic valve replacement Ross procedure Percutaneous aortic valve replacement Mitral valve replacement production of septal defect in heart enlargement of existing septal defect Atrial septostomy Balloon septostomy creation of septal defect in heart Blalock—Hanlon procedure shunt from heart chamber to blood vessel atrium to pulmonary artery Fontan procedure left ventricle to aorta Rastelli procedure right ventricle to pulmonary artery Sano shunt compound procedures for transposition of great vessels Arterial switch operation Mustard procedure Senning procedure for univentricular defect Norwood procedure Kawashima procedure shunt from blood vessel to blood vessel systemic circulation to pulmonary artery shunt Blalock—Taussig shunt SVC to the right PA Glenn procedure.