Aorto pulmonary window may 2021

DR J P SONI
Professor and Head of the Department Paediatrics
Division of Pediatric Cardiology
DR S N Medical College
Jodhpur
[email protected]

1. DR J P SONI
Professor and Head of the Department Paediatrics
Division of Pediatric Cardiology
DR S N Medical College
Jodhpur
[email protected]

2. Acyanotic CHD’s
ACYANOTIC
CHDS
PURE
ACYANOTIC
POTENTIALLY
CYANOTIC

3. Acyanotic
CHD
Without shunt(normal
or decreased flow)
Right side of heart
PULMONARY
STENOSIS
Left side of heart
AORTIC STENOSIS
COARCTATIONOF
AORTA
L-> R SHUNT ↑PBF
ASD
VSD
P.D.A.
Aorto-pulmonary
Window

4. APW is a rare congenital cardiac malformation, comprising only 0.1% of all congenital heart
defects.
In most patients with this anomaly, the defect is moderate to large.
Associated anomalies occur in half of the cases which include –
1.Interrupted aortic arch (most commonly type A interrupted aortic arch)
2.Origin of right pulmonary artery from the aorta
3.Coarctation of aorta (CoA)
4.Right or left coronary artery origin from main pulmonary artery
5.Tetralogy of Fallot [TOF], etc.
The clinical manifestations of APW depend on the diameter of APW, the relative systemic and
pulmonary vascular resistances, and associated lesions.
Large APW is associated with very early development of advanced pulmonary vascular disease.

5. Types of aorto-pulmonary window
Type 1 proximal defect (most common): Defect located just above the sinus of Valsalva, with
very little inferior aortopulmonary septum above the semilunar valves.
Type 2 distal defect: Defect located in the uppermost portion of the ascending aorta, with
little superior rim of aortopulmonary septum.
Type 3 total defect: Large defect that spans from semilunar valves to the pulmonary artery
bifurcation with little superior and inferior rims.
Intermediate type: Central defect with adequate superior and inferior rims.

6. Itsclinical presentationis dependent on the size of the defect and on the associated lesions.
X-ray chest: Cardiomegaly with increased pulmonary vascularity is seen in those with significant
left-to-right shunt. There is absence of cardiomegaly with decreased vascularity in outer third
of lung fields, prominent pulmonary artery segment and dilated central pulmonary arteries in
patients with elevated PVR.
ECG: Signs of biventricular hypertrophy in response to volume overload of the left ventricle
and pressure overload of the RV. Predominant right ventricular hypertrophy is seen if the PVR
is elevated.
Echocardiography: This is the key tool for the diagnosis of APW, assessment of its size and
location, relation to semilunar valves and coronary ostia, identification of associated anomalies,
assessment of size of cardiac chambers, and estimation of pulmonary artery pressure.

7. Proximal Aortopulmonary window
DIXIT

10. Proximal Aortopulmonary window
DIXIT

11. LV
AO
RV
LV
RA
LA
AO
Ao-Pulwindow Interrupted AO Arch type III

12. Proximal Aorto pulmonary window
DIXIT

13. Interrupted aortic arch AMBA

14. Interrupted aortic arch

15. Aorto-pulmonary window type III

16. PA
A
O
R
T
A
D TGA WITH AP WINDOW
type IV intermediate

17. Right pulmonary artery from DAO

18. Right pulmonary artery from DAO

19. Cardiac catheterization
Performed for diagnostic purposes in those with pulmonary hypertension and suspected
pulmonary vascular disease.
Rarely, catheterization is performed for interventional purpose, in those with a small defect
suitable for device closure.
Computed tomography angiography (CTA):
Rarely performed as a part of preoperative workup in older children, where details of
anatomy are not clear on echocardiography.

20. Ideal age of closure of A-P window
i.Uncontrolled heart failure: Surgical repair as soon as possible (Class I)
ii.Controlled heart failure: Elective surgical repair by 3 months of age (Class I)
iii.In patients with associated anomalies, single-stage repair of all defects is preferred (Class
I).
iv.Those presenting beyond 6 months of life with severe pulmonary hypertension and
suspected elevated PVR should be referred to a higher center for further evaluation to
assess operability.
All patients with APW must be advised to maintain good oro-dental hygiene.

21. Method of closure
i.Surgical patch repair is the treatment of choice (Class I)
ii.Transcatheter device closure in selected cases of intermediate-type APW (Class IIa).

22. Recommendations for follow-up
i.Follow-up after surgery: Clinical evaluation, ECG, and echo annually till 5 years. No further
follow-up is required if no residual defect or pulmonary hypertension. Patient/guardians
should be explained about reporting to hospital in case of any cardiac symptoms.
ii.Lifelong follow-up is required in cases of APW associated with interrupted aortic arch and
other important anomalies and in those who had elevated PVR before surgery.
iii.Antiplatelet recommendation for device closure: Aspirin (3–5 mg/kg/day) is given a day
before or immediately after procedure and continued for total duration of 6 months.
iv.IE prophylaxis is recommended for 6 months after surgical or device closure. However, all
patients are advised to maintain good oro-dental hygiene after this period also.