Background: Aortopulmonary window (APW) is an extremely rare congenital anomaly of the heart where there is a direct communication between the ascending aorta and main pulmonary artery. Surgical repair of APW on cardiopulmonary bypass (CPB) is considered the standard of surgical care. In this study, we selected patients with a type I APW to undergo direct surgical ligation to determine if this technique is safe and can produce equivalent results to standard open-heart repair.

Methods: Twelve infants with simple or isolated type I APW underwent direct surgical ligation by a single surgeon at Children's Hospital, Lahore, Pakistan, from December 2020 to January 2024. Diagnosis was based on two-dimensional transthoracic echocardiography, and classification was based on the Society of Thoracic Surgeons (STS) nomenclature. A sternotomy approach was employed, and CPB was on stand-by for all cases. The aortic and pulmonary ends of the APW were ligated with close attention to anatomic details.

Results: All patients underwent successful APW ligation with no intraoperative complications. Follow-up, ranging from 6 months to 3 years, revealed no mortality, residual defects, aortic or pulmonary valve insufficiency, branch pulmonary artery stenosis, or coronary compromise. A notable cost benefit of $2,000 per patient was observed.

Conclusions: In this case series, direct surgical ligation of an APW was found to be a safe and cost-effective alternative to standard surgical repair on CPB. Further research with a larger sample size with longer follow-up is required to better determine this alternative's efficacy.