Damus-Stansel-Kaye Procedure: Technical Modifications Hillel Laks, MD, Richard N. Gates, MD, Amir Elami, MD, and Jeffrey M. Pearl, MD Division of Cardiothoracic Surgery, Department of Surgery, UCLA Medical Center, Los Angeles, California
The Damus-Stansel-Kaye procedure has been applied for the relief of outflow tract obstruction caused by a restrictive bulboventricular foramen or subaortic stenosis in patients with complex univentricular heart disease. The procedure may also be part of a biventricular repair of a Taussig-Bing transposition of the great arteries. This
report details technical modifications of the procedure to ensure unobstructed blood flow from the pulmonary artery to the aorta and to maintain the integrity of the pulmonary and aortic valves.
0
introduced into the proximal pulmonary artery. In the presence of a competent pulmonary valve a high pressure is rapidly generated by injecting a small amount of saline solution. If a continuous infusion is required to maintain pressure, the pulmonary valve is insufficient and a Damus-Stansel-Kaye procedure is not advisable. The pulmonary artery is now divided just proximal to the pulmonary artery band. The pulmonary valve should be visually inspected for morphologic abnormalities such as cusp deformity, thickening, or redundancy. If such abnormalities are present to a substantial degree, a Damus-Stansel-Kaye procedure is contraindicated. The length of the remaining pulmonary artery from its divided end to the top of the commissure is then noted. If the pulmonary artery segment is short, with the band having been placed near the level of the commissures, a modification of the standard Damus-Stansel-Kaye operation is employed. If the band was placed distally, and a long segment of pulmonary artery is present, a standard Damus-StanselKaye procedure may be performed. A triangular segment is excised from the side of the pulmonary artery adjacent to the aorta and at a distance from the commissures (Fig 1). A similar triangle is then excised from the adjacent aorta. The most inferior aspect of these incisions should not extend below the level of the commissures. The excised triangle in the aorta is then extended superiorly into the shape of a diamond (Fig 2). Beginning from the inferior aspect of these incisions, the aorta and pulmonary artery are sutured together to the level of the transected pulmonary artery. A pericardial patch, which is treated with 0.6% glutaraldehyde for 10 minutes and rinsed with normal saline solution, is now coated on its exterior surface with a fine Dacron mesh (Larsmesh; Meadox, Oakland, NJ). The combined patch is then fashioned for anastomosis (Fig 3). The patch is sutured from posterior to anterior using a running technique (Fig 4). The completed anastomosis appears as in Figure 5 . In those cases where the pulmonary artery band has been placed proximally, a modification of the standard
utflow tract obstruction from subaortic stenosis or a restrictive bulboventricular foramen may complicate the clinical course of patients with complex univentricular heart disease [l,21. Three basic surgical approaches have been advocated to alleviate this obstruction. These include the Damus-Stansel-Kaye procedure, subaortic or septa1 resection, and apical to aortic conduits [%5]. The DamusStansel-Kayeprocedure is an attractive option because it is extracardiacand avoids ventriculotomy, heart block, and the use of a conduit. Nonetheless, enthusiasm for the procedure has been dampened by early reports of high mortality [6,7]. There has also been concern about the fate of the aortic and pulmonary valves [8, 91. This report details technical modifications of the procedure developed to ensure unobstructed blood flow from the pulmonary artery to the aorta while simultaneously maintaining optimal valve function and preservation.
Material and Methods Procedures are generally performed using moderate hypothermia and low-flow cardiopulmonary bypass. Blood cardioplegia is used for myocardial protection. Aortic cannulation should be distal on the aorta and close to the innominate artery as this will provide for maximum length of the proximal aorta. Bicaval cannulation is employed, and the coronary sinus is cannulated for the delivery of retrograde cardioplegia. Most patients who are candidates for the DamusStansel-Kayeprocedure will have had a previously placed pulmonary artery band. With proximally placed bands, serious band-induced distortion of the pulmonary valve may be present. It is therefore necessary to assess the pulmonary valve for competence. In cases where pulmonary insufficiency is suspected, the distal pulmonary artery may be clamped and a pressure transducing line Accepted for publication March 20, 1992 Address reprint requests to Dr Laks, Division of Cardiothoracic Surgery, UCLA Medical Center, CHS 62-182, 10833 LeConte Ave, Los Angeles, CA 90024.
0 1992 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:169-72)
0003-4975/92/$5.00
170
HOW TO DO IT LAKS ET AL MODIFIED DAMUS-STANSEL-KAYE PROCEDURE
Ann Thorac Surg 1992;X 169-72
Fig 1 . The standard Damus-Stansel-Kaye procedure: a triangular segment has been excised from the side of the pulmonary artery adjacent to the aorta and at a distance from the commissures.
Fig 3. The standard Damus-Stansel-Kaye procedure: the inferior margin of the aortic and pulmonary arteries have been sutured together to the level of the transected pulmonary artery. A glutaraldehyde-treated Dacron mesh-reinforced pericardial patch has been fashioned for roofing of the pulmonary artery to aorta anastomosis.
Damus-Stansel-Kaye procedure is used. To begin, a triangle is mapped on the aorta (Fig 6). A transverse incision is made in the aorta adjacent to the top of the transected pulmonary artery. A posteriorly based triangular flap is then made in the aorta by incising the anterior one third of the mapped triangle. The inferior margin of the opened aorta is then sutured to the adjacent edge of the pulmo-
nary artery (Fig 7). The inferior margin of the aortic flap is then sutured to the posterior aspect of the transected pulmonary artery (Fig 8). At this point, a similarly fashioned pericardial patch is placed as described for the standard Damus-Stansel-Kaye procedure (see Fig 5). The competence of the aortic and pulmonary valves is then tested by the administration of cardioplegia while
Fig 2 . The standard Damus-Stansel-Kaye procedure: a diamondshaped segment of the aorta has been excised. The inferior triangle of the diamond is excised as a mirror image directly adjacent to the pulmonary artery.
Fig 4. The standard Damus-Stansel-Kaye procedure: the patch is SUtured in place using continuous technique.
Ann Thorac Surg 1992;54:169-72
Fig 5. Appearance of the completed anastomosis.
monitoring the root pressure and examining the transesophageal echocardiography monitor. Competent aortic and pulmonary valves at the conclusion of the procedure are a prerequisite for success. If the aortic valve is insufficient, it may be closed either by suturing the leaflets together with pericardial pledgets or by use of a Gore-Tex patch (W.L. Gore & Assoc, Naperville, IL). If the pulmonic valve is incompetent, an annuloplasty or valve
Fig 6. The modified Damus-Stansel-Kaye procedure: the incision for a posteriorly based triangular flap has been outlined on the aorta.
HOW TO DO IT LAKS ET AL MODIFIED DAMUS-STANSEL-KAYE PROCEDURE
171
Fig 7. The modified Damus-Stansel-Kaye procedure: the transverse margin of the transverse incision in the aorta is sutured to the adjacent transected pulmonay artey.
suspension may be required. In patients with univentricular hearts, the aortic valve is not routinely closed unless preoperative or intraoperative incompetence is demonstrated. However, when the Damus-Stansel-Kaye procedure is performed as part of a biventricular repair, the
Fig 8. The modified Damus-Stansel-Kaye procedure: the inferior margin of the aortic triangular flap is sutured to the posterior aspect of the transected pulmona y artey.
172
Ann Thorac Surg 1992;54:169-72
HOW TO DO IT LAKS ET AL MODIFIED DAMUS-STANSEL-KAYE PROCEDURE
aortic valve should be closed using either pericardial strips to reinforce the aortic leaflets or a Gore-Tex patch sutured to the annulus.
We thank Joanie Livermore for her excellent illustrations.
Comment
References
In our recent experience with the Damus-Stansel-Kaye procedure for 29 patients with either complex univentricular congenital heart disease or Taussig-Bing transposition of the great arteries there were three operative deaths (10%). Two deaths occurred in patients undergoing concurrent Fontan procedures who had relatively high pulmonary artery pressures and moderate ventricular hypertrophy. Currently, these patients would be selected for a bidirectional Glenn shunt with a concomitant DamusStansel-Kaye procedure. Valvular insufficiency has been reported to be a problem with the Damus-Stansel-Kaye procedure [8, 91. Incisions into the valve sinuses, as recommended by some [7], may play a role in causing valvular insufficiency. The technique we have described avoids incisions below the superior aspect of the valve commissures. This avoids distortion of the coronary ostia and separation of the commissures. By using the modified Damus-Stansel-Kaye procedure the normal architecture of the pulmonic valve remains intact even when the segment of pulmonary artery proximal to the pulmonary artery band is short. Recent experience with these technical modifications has resulted in the avoidance of valvular insufficiency. Recent reports of the Damus-Stansel-Kaye procedure show a substantial improvement in operative mortality [lo]. Avoidance of valve regurgitation should lead to the increased use of this operation, particularly in those cases where resection of the subaortic area cannot be performed through the aortic valve and a ventriculotomy is required.
1. Freedom RM, Sondheimer H, Dische R, Rowe RD. The development of "subaortic stenosis" after pulmonary artery banding for common ventricle. Am J Cardiol 1977;39:7&83. 2. Van Praagh R, Ongley PA, Swan HJC. Anatomic types of single or common ventricle in man. Morphologic and geometric aspects of 60 necropsied cases. Am J Cardiol 1961;13: 367-86. 3. Lin AE, Laks H, Barber G, Chin A, Williams RG. Subaortic obstruction in complex congenital heart disease: management by proximal pulmonary artery to ascending aorta end to side anastomosis. J Am Coll Cardiol 1986;73:617-24. 4. Cheung HC, Lincoln C, Anderson RH, et al. Options for surgical repair in hearts with univentricular atrioventricular connection and subaortic stenosis. J Thorac Cardiovasc Surg 1990;100:672-81. 5. Bethea MC, Reynolds JL. Treatment of bulboventricular foramen stenosis by ventricle-ascending aorta valvedconduit bypass. Ann Thorac Surg 1989;47765-6. 6. Ceithaml EL, Puga FJ, Danielson GK, McGoon DC, Ritter DG. Results of the Damus-Stansel-Kaye procedure for transposition of the great arteries and for double-outlet right ventricle with subpulmonic ventricular septa1 defect. Ann Thorac Surg 1984;38:5:433-7. 7. Waldman JD, Lamberti JJ, George L, et al. Experience with the Damus procedure. Circulation 1988;78(Suppl 3):5:32-9. 8. Chin AJ, Barber G, Heltin JG. Fate of the pulmonic valve after pulmonary artery-to-ascending aorta anastomosis for aortic outflow obstruction. Am J Cardiol 1988;62:435-8. 9. Giuffre RM, Musewe NN, Smallhorn JF, Freedom RM. Aortic regurgitation during systole: color flow mapping and Doppler interrogation following the Damus-Stansel-Kaye procedure. Pediatr Cardiol 1991;12:46-8. 10. Ilbawi MN, DeLeon SY, Wilson WR Jr, et al. Advantages of early relief of subaortic stenosis in single ventricle equivalents. Ann Thorac Surg 1991;52:842-9.
The Damus-Stansel-Kaye procedure has been applied for the relief of outflow tract obstruction caused by a restrictive bulboventricular foramen or subaortic stenosis in patients with complex univentricular heart disease. The procedure may also be part of a biventricular repair of a Taussig-Bing transposition of the great arteries. This
report details technical modifications of the procedure to ensure unobstructed blood flow from the pulmonary artery to the aorta and to maintain the integrity of the pulmonary and aortic valves.
0
introduced into the proximal pulmonary artery. In the presence of a competent pulmonary valve a high pressure is rapidly generated by injecting a small amount of saline solution. If a continuous infusion is required to maintain pressure, the pulmonary valve is insufficient and a Damus-Stansel-Kaye procedure is not advisable. The pulmonary artery is now divided just proximal to the pulmonary artery band. The pulmonary valve should be visually inspected for morphologic abnormalities such as cusp deformity, thickening, or redundancy. If such abnormalities are present to a substantial degree, a Damus-Stansel-Kaye procedure is contraindicated. The length of the remaining pulmonary artery from its divided end to the top of the commissure is then noted. If the pulmonary artery segment is short, with the band having been placed near the level of the commissures, a modification of the standard Damus-Stansel-Kaye operation is employed. If the band was placed distally, and a long segment of pulmonary artery is present, a standard Damus-StanselKaye procedure may be performed. A triangular segment is excised from the side of the pulmonary artery adjacent to the aorta and at a distance from the commissures (Fig 1). A similar triangle is then excised from the adjacent aorta. The most inferior aspect of these incisions should not extend below the level of the commissures. The excised triangle in the aorta is then extended superiorly into the shape of a diamond (Fig 2). Beginning from the inferior aspect of these incisions, the aorta and pulmonary artery are sutured together to the level of the transected pulmonary artery. A pericardial patch, which is treated with 0.6% glutaraldehyde for 10 minutes and rinsed with normal saline solution, is now coated on its exterior surface with a fine Dacron mesh (Larsmesh; Meadox, Oakland, NJ). The combined patch is then fashioned for anastomosis (Fig 3). The patch is sutured from posterior to anterior using a running technique (Fig 4). The completed anastomosis appears as in Figure 5 . In those cases where the pulmonary artery band has been placed proximally, a modification of the standard
utflow tract obstruction from subaortic stenosis or a restrictive bulboventricular foramen may complicate the clinical course of patients with complex univentricular heart disease [l,21. Three basic surgical approaches have been advocated to alleviate this obstruction. These include the Damus-Stansel-Kaye procedure, subaortic or septa1 resection, and apical to aortic conduits [%5]. The DamusStansel-Kayeprocedure is an attractive option because it is extracardiacand avoids ventriculotomy, heart block, and the use of a conduit. Nonetheless, enthusiasm for the procedure has been dampened by early reports of high mortality [6,7]. There has also been concern about the fate of the aortic and pulmonary valves [8, 91. This report details technical modifications of the procedure developed to ensure unobstructed blood flow from the pulmonary artery to the aorta while simultaneously maintaining optimal valve function and preservation.
Material and Methods Procedures are generally performed using moderate hypothermia and low-flow cardiopulmonary bypass. Blood cardioplegia is used for myocardial protection. Aortic cannulation should be distal on the aorta and close to the innominate artery as this will provide for maximum length of the proximal aorta. Bicaval cannulation is employed, and the coronary sinus is cannulated for the delivery of retrograde cardioplegia. Most patients who are candidates for the DamusStansel-Kayeprocedure will have had a previously placed pulmonary artery band. With proximally placed bands, serious band-induced distortion of the pulmonary valve may be present. It is therefore necessary to assess the pulmonary valve for competence. In cases where pulmonary insufficiency is suspected, the distal pulmonary artery may be clamped and a pressure transducing line Accepted for publication March 20, 1992 Address reprint requests to Dr Laks, Division of Cardiothoracic Surgery, UCLA Medical Center, CHS 62-182, 10833 LeConte Ave, Los Angeles, CA 90024.
0 1992 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:169-72)
0003-4975/92/$5.00
170
HOW TO DO IT LAKS ET AL MODIFIED DAMUS-STANSEL-KAYE PROCEDURE
Ann Thorac Surg 1992;X 169-72
Fig 1 . The standard Damus-Stansel-Kaye procedure: a triangular segment has been excised from the side of the pulmonary artery adjacent to the aorta and at a distance from the commissures.
Fig 3. The standard Damus-Stansel-Kaye procedure: the inferior margin of the aortic and pulmonary arteries have been sutured together to the level of the transected pulmonary artery. A glutaraldehyde-treated Dacron mesh-reinforced pericardial patch has been fashioned for roofing of the pulmonary artery to aorta anastomosis.
Damus-Stansel-Kaye procedure is used. To begin, a triangle is mapped on the aorta (Fig 6). A transverse incision is made in the aorta adjacent to the top of the transected pulmonary artery. A posteriorly based triangular flap is then made in the aorta by incising the anterior one third of the mapped triangle. The inferior margin of the opened aorta is then sutured to the adjacent edge of the pulmo-
nary artery (Fig 7). The inferior margin of the aortic flap is then sutured to the posterior aspect of the transected pulmonary artery (Fig 8). At this point, a similarly fashioned pericardial patch is placed as described for the standard Damus-Stansel-Kaye procedure (see Fig 5). The competence of the aortic and pulmonary valves is then tested by the administration of cardioplegia while
Fig 2 . The standard Damus-Stansel-Kaye procedure: a diamondshaped segment of the aorta has been excised. The inferior triangle of the diamond is excised as a mirror image directly adjacent to the pulmonary artery.
Fig 4. The standard Damus-Stansel-Kaye procedure: the patch is SUtured in place using continuous technique.
Ann Thorac Surg 1992;54:169-72
Fig 5. Appearance of the completed anastomosis.
monitoring the root pressure and examining the transesophageal echocardiography monitor. Competent aortic and pulmonary valves at the conclusion of the procedure are a prerequisite for success. If the aortic valve is insufficient, it may be closed either by suturing the leaflets together with pericardial pledgets or by use of a Gore-Tex patch (W.L. Gore & Assoc, Naperville, IL). If the pulmonic valve is incompetent, an annuloplasty or valve
Fig 6. The modified Damus-Stansel-Kaye procedure: the incision for a posteriorly based triangular flap has been outlined on the aorta.
HOW TO DO IT LAKS ET AL MODIFIED DAMUS-STANSEL-KAYE PROCEDURE
171
Fig 7. The modified Damus-Stansel-Kaye procedure: the transverse margin of the transverse incision in the aorta is sutured to the adjacent transected pulmonay artey.
suspension may be required. In patients with univentricular hearts, the aortic valve is not routinely closed unless preoperative or intraoperative incompetence is demonstrated. However, when the Damus-Stansel-Kaye procedure is performed as part of a biventricular repair, the
Fig 8. The modified Damus-Stansel-Kaye procedure: the inferior margin of the aortic triangular flap is sutured to the posterior aspect of the transected pulmona y artey.
172
Ann Thorac Surg 1992;54:169-72
HOW TO DO IT LAKS ET AL MODIFIED DAMUS-STANSEL-KAYE PROCEDURE
aortic valve should be closed using either pericardial strips to reinforce the aortic leaflets or a Gore-Tex patch sutured to the annulus.
We thank Joanie Livermore for her excellent illustrations.
Comment
References
In our recent experience with the Damus-Stansel-Kaye procedure for 29 patients with either complex univentricular congenital heart disease or Taussig-Bing transposition of the great arteries there were three operative deaths (10%). Two deaths occurred in patients undergoing concurrent Fontan procedures who had relatively high pulmonary artery pressures and moderate ventricular hypertrophy. Currently, these patients would be selected for a bidirectional Glenn shunt with a concomitant DamusStansel-Kaye procedure. Valvular insufficiency has been reported to be a problem with the Damus-Stansel-Kaye procedure [8, 91. Incisions into the valve sinuses, as recommended by some [7], may play a role in causing valvular insufficiency. The technique we have described avoids incisions below the superior aspect of the valve commissures. This avoids distortion of the coronary ostia and separation of the commissures. By using the modified Damus-Stansel-Kaye procedure the normal architecture of the pulmonic valve remains intact even when the segment of pulmonary artery proximal to the pulmonary artery band is short. Recent experience with these technical modifications has resulted in the avoidance of valvular insufficiency. Recent reports of the Damus-Stansel-Kaye procedure show a substantial improvement in operative mortality [lo]. Avoidance of valve regurgitation should lead to the increased use of this operation, particularly in those cases where resection of the subaortic area cannot be performed through the aortic valve and a ventriculotomy is required.
1. Freedom RM, Sondheimer H, Dische R, Rowe RD. The development of "subaortic stenosis" after pulmonary artery banding for common ventricle. Am J Cardiol 1977;39:7&83. 2. Van Praagh R, Ongley PA, Swan HJC. Anatomic types of single or common ventricle in man. Morphologic and geometric aspects of 60 necropsied cases. Am J Cardiol 1961;13: 367-86. 3. Lin AE, Laks H, Barber G, Chin A, Williams RG. Subaortic obstruction in complex congenital heart disease: management by proximal pulmonary artery to ascending aorta end to side anastomosis. J Am Coll Cardiol 1986;73:617-24. 4. Cheung HC, Lincoln C, Anderson RH, et al. Options for surgical repair in hearts with univentricular atrioventricular connection and subaortic stenosis. J Thorac Cardiovasc Surg 1990;100:672-81. 5. Bethea MC, Reynolds JL. Treatment of bulboventricular foramen stenosis by ventricle-ascending aorta valvedconduit bypass. Ann Thorac Surg 1989;47765-6. 6. Ceithaml EL, Puga FJ, Danielson GK, McGoon DC, Ritter DG. Results of the Damus-Stansel-Kaye procedure for transposition of the great arteries and for double-outlet right ventricle with subpulmonic ventricular septa1 defect. Ann Thorac Surg 1984;38:5:433-7. 7. Waldman JD, Lamberti JJ, George L, et al. Experience with the Damus procedure. Circulation 1988;78(Suppl 3):5:32-9. 8. Chin AJ, Barber G, Heltin JG. Fate of the pulmonic valve after pulmonary artery-to-ascending aorta anastomosis for aortic outflow obstruction. Am J Cardiol 1988;62:435-8. 9. Giuffre RM, Musewe NN, Smallhorn JF, Freedom RM. Aortic regurgitation during systole: color flow mapping and Doppler interrogation following the Damus-Stansel-Kaye procedure. Pediatr Cardiol 1991;12:46-8. 10. Ilbawi MN, DeLeon SY, Wilson WR Jr, et al. Advantages of early relief of subaortic stenosis in single ventricle equivalents. Ann Thorac Surg 1991;52:842-9.
