Z scores - Pulmonary Arteries

PHN values are in Red

(Click on the image to enlarge)

 

Bifurcation stent - RVOT, Branch PA, Coarctation

Click on this link below:
Journal Club: Bifurcation stenting - RVOT. Branch PA, Coarctation

Pulmonary Artery Hypertension - Arborization by Pulmonary Angiography

Postmortem angiogram of normal and abnormal pulmonary artery arborization:
From Anderson RH & Becker AE. The Heart. Structure in Health and Disease. Gower Medical Publishing. London & New York 1992.

Upper panel - Normal arborization pattern
Lower panel - Winter Tree pattern of Advanced pulmonary hypertension

Surgery: Pulmonary atresia - VSD, MAPCAs, Unifocalization

Staged repair of tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. Duncan, BW., Mee, RBB, et al. JTCVS 2003;126:694-702.

Bill Brawn group: JTCVS 2004;127:251-8

Treatment algorithm:

Survival after first surgery:

Freedom from reintervention (surgery or cath) after complete repair:

Frank Hanley group re: Surgical creation of "A-P window"

Rodefeld, MD. et al. JTCVS 2002;123:1147-54.

Selection criteria for surgical creation of A-P window:

1) Presence of centrally confluent pulmonary arteries (1 - 2.5 mm in diameter with well-developed peripheral arborization)

2) Multiple, hypoplastic AP collaterals that communicated with true pulmonary artery system

3) Presence of marked cyanosis

Avoid this procedure in the following situations:

1) High flow from MAPCAs

2) Isolated supply from MAPCAs (indicates native PAs do not have good peripheral arborization...to stand the high flow-high pressure from aorta)

3) Native PAs > 2.5 mm and

4) non-confluent native PAs.

Frank Hanley group: (Circulation 2000)
V. Mohan Reddy et al. Circulation 2000;101:1826-32
Early and Intermediate outcomes after repair of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries.
Treatment algorithm

Also see:

Journal Club: PA-VSD, MAPCAs, Unifocalization

MAPCAs in PA-VSD

Preop Evaluation of PAs in PA-VSD

Anatomy: Preop. evaluation of pulmonary arteries/MAPCAs in Pulmonary Atresia - VSD

Review article

1) McGoon ratio:
(Diameter of RPA/DAo + Diameter of LPA/DAo)
Normal 2.1
Adequate for VSD closure 1.2
Inadequate <0.8 for VSD closure

2) Nakata Index:
(CSA of RPA + CSA of LPA)/BSA
Normal value > 200 mm2/m2
> 150 mm2/m2 is adequate.
(Not usable preoperatively when MAPCAs are the major source of PBF & one-stage unifocalization + full repair is planned).
(> 200 for single ventricle repair, > 100 for 2-ventricle repair...check correctness of this statement first)

3) Total Neo-Pulmonary Artery Index (TNPAI) = APC index + Nakata Index
APC index is the sum of CSA of all usable APCs/BSA
>250 - suitable for one-stage repair including VSD closure (These pts. have low RV/LV pressure ratio postoperatively).

Critique of all these indices: These indices consider only the size of proximal vessel and not consider the condition of distal parts of the vessels (which may be stenosed, etc).

Also see:
MAPCAs in PA-VSD
Surgical Outcome (Journal Club blog)
Surgical Treatment algorithm