Staged Repair of Tetralogy of Fallot with Pulmonary Atresia and Major Aortopulmonary Collateral Arteries

A: MAPCA L1 has dual supply, but L2 has an arborization anomaly. B: The aberrant left subclavian artery rounds the left bronchus anteriorly. MAPCA L1 and L2 round the left bronchus posteriorly. PLSVC = persistent left superior vena cava. C: MAPCA L1 is ligated. A modified Blalock–Taussig shunt is established between the aberrant left subclavian artery and the left pulmonary artery with a 5-mm Gore-Tex graft. D: MAPCA L2 is anastomosed to the left pulmonary artery. E: Left unifocalization is completed. LPA = left pulmonary artery.

A: MAPCA L1 has dual supply, but L2 has an arborization anomaly. B: The aberrant left subclavian artery rounds the left bronchus anteriorly. MAPCA L1 and L2 round the left bronchus posteriorly. PLSVC = persistent left superior vena cava. C: MAPCA L1 is ligated. A modified Blalock–Taussig shunt is established between the aberrant left subclavian artery and the left pulmonary artery with a 5-mm Gore-Tex graft. D: MAPCA L2 is anastomosed to the left pulmonary artery. E: Left unifocalization is completed. LPA = left pulmonary artery.

A: MAPCA L1 has dual supply, but L2 has an arborization anomaly. B: The aberrant left subclavian artery rounds the left bronchus anteriorly. MAPCA L1 and L2 round the left bronchus posteriorly. PLSVC = persistent left superior vena cava. C: MAPCA L1 is ligated. A modified Blalock–Taussig shunt is established between the aberrant left subclavian artery and the left pulmonary artery with a 5-mm Gore-Tex graft. D: MAPCA L2 is anastomosed to the left pulmonary artery. E: Left unifocalization is completed. LPA = left pulmonary artery.

A: After right modified Blalock–Taussig shunt. A main pulmonary trunk is absent. Two MAPCAs originate from the left descending aorta. B: Two MAPCAs originate from the descending aorta. MAPCA L1 courses beneath the vagus nerve. C: Anastomosis of the inferior branch of MAPCA L1. D: Anastomosis of MAPCA L2 to L1. E: Left unifocalization is accomplished. LPA = left pulmonary artery.

A: After right modified Blalock–Taussig shunt. A main pulmonary trunk is absent. Two MAPCAs originate from the left descending aorta. B: Two MAPCAs originate from the descending aorta. MAPCA L1 courses beneath the vagus nerve. C: Anastomosis of the inferior branch of MAPCA L1. D: Anastomosis of MAPCA L2 to L1. E: Left unifocalization is accomplished. LPA = left pulmonary artery.

A: A narrow segment connects MAPCA L1 and the left pulmonary artery. B: The narrow segment and MAPCA L2 are widely opened. C: MAPCA L2 is anastomosed to the narrow segment. D: The left modified Blalock–Taussig shunt is established. E: A piece of MAPCA L1 is adopted for enlargement of the left pulmonary artery. LPA = left pulmonary artery; LSCA = left subclavian artery.

A: A narrow segment connects MAPCA L1 and the left pulmonary artery. B: The narrow segment and MAPCA L2 are widely opened. C: MAPCA L2 is anastomosed to the narrow segment. D: The left modified Blalock–Taussig shunt is established. E: A piece of MAPCA L1 is adopted for enlargement of the left pulmonary artery. LPA = left pulmonary artery; LSCA = left subclavian artery.

A: A narrow segment connects MAPCA L1 and the left pulmonary artery. B: The narrow segment and MAPCA L2 are widely opened. C: MAPCA L2 is anastomosed to the narrow segment. D: The left modified Blalock–Taussig shunt is established. E: A piece of MAPCA L1 is adopted for enlargement of the left pulmonary artery. LPA = left pulmonary artery; LSCA = left subclavian artery.

A: The long segment connecting MAPCA R1 to the right pulmonary artery courses between the right pulmonary artery and the right bronchus. B: MAPCA R2 is anastomosed to the long connecting segment in end-to-end fashion. A modified Blalock–Taussig shunt is anastomosed to the azygos vein patch. Asc. Ao. = ascending aorta; RPA = right pulmonary artery.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: Many MAPCAs on both sides. MAPCA R1 supplies the central pulmonary arteries. B: The right chest is opened. The azygos vein is removed. C: MAPCA R1 is enlarged by an azygos vein patch and anastomosed to R2. R3 is anastomosed to R2 as well. D: Right-sided unifocalization is accomplished. E: Two MAPCAs, L1 and L2, are near to the left bronchus, but L3 is beneath the left pulmonary vein. F: Through the seventh intercostal space, MAPCA L3 is divided and anastomosed to MAPCA L1. G: L2 is widely spatulated. Inset, the upward arrow on the superior branch of the LPA is the incision for unifocalization; the downward arrow on the LPA is the incision for the subsequent Rastelli operation. H: L2 is sutured along the inferior margin of the incision on the superior branch of the left pulmonary artery. I: The spatulated flap of L2 is sutured along the superior margin of the incision. J: MAPCA L1 is sutured to the anastomosis of L2 and the superior branch of the LPA. K: Left-sided unifocalization is accomplished. Gore-Tex tape around the modified Blalock–Taussig shunt is anchored over the phrenic nerve. L: Through a median sternotomy incision, a longitudinal incision is placed across the right ventricular outflow tract, blind pulmonary trunk, and left pulmonary artery. M: The incision is extended into the main basal branch of the left pulmonary artery. N: The proximal end of the pulmonary trunk is sutured to the right ventricular outflow tract. O: The ventricular septal defect is closed by interrupted sutures and a patch. Inferiorly, two sutures are placed in the membranous flap. P: The left pulmonary artery is enlarged by an autologous pericardial patch. Q: Total correction is accomplished after bilateral unifocalizations.

A: The right chest is opened. MAPCA R1 has a small connection with the right pulmonary artery. B: Unifocalization utilizing the azygos vein. C: Right-sided unifocalization is accomplished by a xenopericardial conduit as a central pulmonary artery. D: The ventricular septal defect is closed by interrupted sutures and a patch. E: A Rastelli operation is accomplished after bilateral unifocalizations for nonconfluent pulmonary arteries.

A: The right chest is opened. MAPCA R1 has a small connection with the right pulmonary artery. B: Unifocalization utilizing the azygos vein. C: Right-sided unifocalization is accomplished by a xenopericardial conduit as a central pulmonary artery. D: The ventricular septal defect is closed by interrupted sutures and a patch. E: A Rastelli operation is accomplished after bilateral unifocalizations for nonconfluent pulmonary arteries.

A: The right chest is opened. MAPCA R1 has a small connection with the right pulmonary artery. B: Unifocalization utilizing the azygos vein. C: Right-sided unifocalization is accomplished by a xenopericardial conduit as a central pulmonary artery. D: The ventricular septal defect is closed by interrupted sutures and a patch. E: A Rastelli operation is accomplished after bilateral unifocalizations for nonconfluent pulmonary arteries.

A: The right chest is opened. MAPCA R1 has a small connection with the right pulmonary artery. B: Unifocalization utilizing the azygos vein. C: Right-sided unifocalization is accomplished by a xenopericardial conduit as a central pulmonary artery. D: The ventricular septal defect is closed by interrupted sutures and a patch. E: A Rastelli operation is accomplished after bilateral unifocalizations for nonconfluent pulmonary arteries.

A: View is through a right thoracotomy. Three MAPCAs originate from the right descending aorta. B: Half circumferences of R1 and R2 are sutured together. C: A xenopericardial conduit is anastomosed to the R1-R2 junction. D: View is through a left thoracotomy. A single MAPCA, L1, comes from the right between the bronchus and esophagus. E: L1 is divided and spatulated. F: Left-sided unifocalization is accomplished. G: Large holes are created in the bilateral xenopericardial conduits. H: The third xenopericardial conduit is interposed between the bilateral xenopericardial conduits. I: A Gore-Tex tricusp xenopericardial conduit is anastomosed to the newly created central pulmonary arteries. J: The ventricular septal defect is closed by interrupted sutures. K: A Rastelli procedure is accomplished after bilateral unifocalizations and creation of confluent central pulmonary arteries.

A: View is through a right thoracotomy. Three MAPCAs originate from the right descending aorta. B: Half circumferences of R1 and R2 are sutured together. C: A xenopericardial conduit is anastomosed to the R1-R2 junction. D: View is through a left thoracotomy. A single MAPCA, L1, comes from the right between the bronchus and esophagus. E: L1 is divided and spatulated. F: Left-sided unifocalization is accomplished. G: Large holes are created in the bilateral xenopericardial conduits. H: The third xenopericardial conduit is interposed between the bilateral xenopericardial conduits. I: A Gore-Tex tricusp xenopericardial conduit is anastomosed to the newly created central pulmonary arteries. J: The ventricular septal defect is closed by interrupted sutures. K: A Rastelli procedure is accomplished after bilateral unifocalizations and creation of confluent central pulmonary arteries.

A: View is through a right thoracotomy. Three MAPCAs originate from the right descending aorta. B: Half circumferences of R1 and R2 are sutured together. C: A xenopericardial conduit is anastomosed to the R1-R2 junction. D: View is through a left thoracotomy. A single MAPCA, L1, comes from the right between the bronchus and esophagus. E: L1 is divided and spatulated. F: Left-sided unifocalization is accomplished. G: Large holes are created in the bilateral xenopericardial conduits. H: The third xenopericardial conduit is interposed between the bilateral xenopericardial conduits. I: A Gore-Tex tricusp xenopericardial conduit is anastomosed to the newly created central pulmonary arteries. J: The ventricular septal defect is closed by interrupted sutures. K: A Rastelli procedure is accomplished after bilateral unifocalizations and creation of confluent central pulmonary arteries.

A: View is through a right thoracotomy. Three MAPCAs originate from the right descending aorta. B: Half circumferences of R1 and R2 are sutured together. C: A xenopericardial conduit is anastomosed to the R1-R2 junction. D: View is through a left thoracotomy. A single MAPCA, L1, comes from the right between the bronchus and esophagus. E: L1 is divided and spatulated. F: Left-sided unifocalization is accomplished. G: Large holes are created in the bilateral xenopericardial conduits. H: The third xenopericardial conduit is interposed between the bilateral xenopericardial conduits. I: A Gore-Tex tricusp xenopericardial conduit is anastomosed to the newly created central pulmonary arteries. J: The ventricular septal defect is closed by interrupted sutures. K: A Rastelli procedure is accomplished after bilateral unifocalizations and creation of confluent central pulmonary arteries.

A: View is through a right thoracotomy. Three MAPCAs originate from the right descending aorta. B: Half circumferences of R1 and R2 are sutured together. C: A xenopericardial conduit is anastomosed to the R1-R2 junction. D: View is through a left thoracotomy. A single MAPCA, L1, comes from the right between the bronchus and esophagus. E: L1 is divided and spatulated. F: Left-sided unifocalization is accomplished. G: Large holes are created in the bilateral xenopericardial conduits. H: The third xenopericardial conduit is interposed between the bilateral xenopericardial conduits. I: A Gore-Tex tricusp xenopericardial conduit is anastomosed to the newly created central pulmonary arteries. J: The ventricular septal defect is closed by interrupted sutures. K: A Rastelli procedure is accomplished after bilateral unifocalizations and creation of confluent central pulmonary arteries.

A: View is through a right thoracotomy. Three MAPCAs originate from the right descending aorta. B: Half circumferences of R1 and R2 are sutured together. C: A xenopericardial conduit is anastomosed to the R1-R2 junction. D: View is through a left thoracotomy. A single MAPCA, L1, comes from the right between the bronchus and esophagus. E: L1 is divided and spatulated. F: Left-sided unifocalization is accomplished. G: Large holes are created in the bilateral xenopericardial conduits. H: The third xenopericardial conduit is interposed between the bilateral xenopericardial conduits. I: A Gore-Tex tricusp xenopericardial conduit is anastomosed to the newly created central pulmonary arteries. J: The ventricular septal defect is closed by interrupted sutures. K: A Rastelli procedure is accomplished after bilateral unifocalizations and creation of confluent central pulmonary arteries.