Pulmonary valve reconstruction by allograft replacement of underdeveloped anterior leaflet in case of late combined pulmonary restenosis after early primary repair

Background. Despite current trends toward early primary repair, the surgical systemic-to-pulmonary shunt is still considered the first-choice palliation in patients with critical tetralogy of Fallot (TOF) and duct-dependent pulmonary circulation unsuitable for primary repair. However, stenting of the right ventricular outflow tract (RVOT) is nowadays emerging as an effective alternative to surgical palliation in selected patients. Methods and results. RVOT stenting is usually performed from a venous route, either femoral or, in selected cases, the right internal jugular vein. Less frequently, mostly in pulmonary infundibular/valvar atresia, this procedure can be performed using a hybrid surgical/interventional approach by surgical exposure of the RVOT, puncture of the atretic valve, and stent deployment under direct vision. The size and type of the most appropriate stent may be chosen, based on ultrasound measurements of the RVOT, to cover the right ventricular infundibulum completely and, at the same time, sparing the pulmonary valve, unless significant pulmonary valve annulus hypoplasia and/or supra-valvular stenosis is a significant component of the obstruction. In the large series so far published, early mortality of RVOT stenting is less than 2%, comparing favourably with either Blalock-Thomas-Taussig shunt or early primary repair. In addition, morbidity and clinical sequelae of this approach do not significantly differ from surgical palliation, even if RVOT stenting shows lesser durability and a higher rate of trans-catheter re-interventions over a mid-term follow-up. Finally, similar but more balanced pulmonary artery growth than surgical palliation following RVOT stenting is reported over a mid-term follow-up. Conclusions. RVOT stenting is a technically feasible, well-tolerated, and effective palliation in critical TOF. This approach is cost-effective with respect to surgical palliation either in high-risk neonates or whenever a short-term pulmonary blood flow source is anticipated due to the early surgical repair. It effectively increases pulmonary blood flow, improves arterial saturation, and promotes balanced pulmonary artery growth over a mid-term follow-up.

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Preliminary Experience With the Use of an Extracellular Matrix to Augment the Native Pulmonary Valve During Repair of Tetralogy of Fallot

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135116682450 ◽

2017 ◽

Vol 8 (2) ◽

pp. 174-181 ◽

Cited By ~ 3

Author(s):

Anil Dharmapuram ◽

Nagarajan Ramadoss ◽

Sudeep Verma ◽

Vejendla Gouthami ◽

Ivatury Rao

Keyword(s):

Extracellular Matrix ◽

Tetralogy Of Fallot ◽

Pulmonary Valve ◽

Primary Repair ◽

Right Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Anterior Leaflet ◽

Long Term Follow Up ◽

The Right

Background: During repair of tetralogy of Fallot (TOF), when a transannular patch is needed in case of a small annulus and dysplastic pulmonary valve, we chose to reconstruct the right ventricular outflow tract by augmenting the divided anterior leaflet with an extracellular matrix (ECM) patch to produce a competent valve. In this study, we present our preliminary experience and early outcomes. Methods: From March 2013 to December 2015, of the 206 patients who underwent primary repair of TOF, 52 required a transannular incision. The median age was 18 months and the median weight was 8.2 kg. The native hinge mechanism of the valve was preserved by dividing only the anterior leaflet at the time of the transannular incision and augmenting it with an ECM patch that was sutured to the endocardium and to the divided leaflet. Results: Two patients died due to reasons not related to the use of the patch. Intraoperative evaluation showed a competent pulmonary valve without significant outflow gradient. During early follow-up (median 20 months), all patients were doing well without any decongestive therapy. Valve regurgitation was assessed as severe in 2, moderate in 26, and mild in 22 patients. In the majority of patients, the valve appeared thin and pliable in spite of mild to moderate regurgitation. Conclusions: Early experience with the use of ECM in repair of TOF shows satisfactory outcomes. It does not show obvious growth of the material. Long-term follow-up will be required in order to assess whether the valve function is durable without acquisition of significant regurgitation.

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Right ventricular outflow tract reconstruction in patients younger than five months with early primary repair of tetralogy of Fallot

Practical medicine ◽

10.32000/2072-1757-2018-16-6-205-210 ◽

2018 ◽

Vol 16 (6) ◽

pp. 205-210

Author(s):

I. A. Kozyrev ◽

◽

A. A. Latypov ◽

A. A. Morozov ◽

N. A. Kotin ◽

...

Keyword(s):

Right Ventricular ◽

Tetralogy Of Fallot ◽

Primary Repair ◽

Right Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Outflow Tract ◽

Early Primary

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Evolving Techniques for the Achievement of Optimal Long-Term Results After Tetralogy of Fallot Repair

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135120968103 ◽

2021 ◽

Vol 12 (1) ◽

pp. 116-123

Author(s):

Giovanni Stellin ◽

Alvise Guariento ◽

Vladimiro L. Vida

Keyword(s):

Tetralogy Of Fallot ◽

Balloon Dilatation ◽

Pulmonary Valve ◽

Long Term Results ◽

Complex Congenital Heart Disease ◽

Valve Reconstruction ◽

Valve Annulus ◽

Teaching Cases ◽

Tetralogy Of Fallot Repair

Several techniques designed to improve long-term results after repair of tetralogy of Fallot are described. We have recently embarked on a program focused on preserving the native pulmonary valve. Here, combined techniques are described in detail, including intraoperative pulmonary valve balloon dilatation, pulmonary valve reconstruction by delamination and resuspension of the leaflets, and pulmonary valve annulus augmentation. As with any other complex congenital heart disease, senior surgeons should select teaching cases, starting from the less severe side of the spectrum.

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Pulmonary Valve Reconstruction in Absent Pulmonary Valve Syndrome: A New Technique

Journal of Cardiac Surgery ◽

10.1111/j.1540-8191.1997.tb00120.x ◽

1997 ◽

Vol 12 (3) ◽

pp. 180-184 ◽

Cited By ~ 4

Author(s):

Pitambar Shatapathy ◽

Bhuvnesh Kumar Aggarwal ◽

S. Ganesh Kamath ◽

Srinivas Sai

Keyword(s):

Pulmonary Valve ◽

New Technique ◽

Absent Pulmonary Valve ◽

Valve Reconstruction ◽

A New Technique ◽

Absent Pulmonary Valve Syndrome

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Symptomatic Tetralogy of Fallot in Young Infants: Primary Repair or Shunt—Pediatric Health Information System Database Analysis

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135118780615 ◽

2018 ◽

Vol 9 (5) ◽

pp. 539-545 ◽

Cited By ~ 7

Author(s):

Karthik V. Ramakrishnan ◽

David Zurakowski ◽

William Pastor ◽

Richard A. Jonas ◽

Pranava Sinha

Keyword(s):

Information System ◽

Pulmonary Artery ◽

Health Information ◽

Tetralogy Of Fallot ◽

Primary Repair ◽

Health Information System ◽

Hospital Charges ◽

Pediatric Health ◽

Group 2 ◽

Early Primary

Background: Compare the early outcomes and hospital charges of early primary repair and systemic-to-pulmonary artery shunt for neonates and young infants (≤90 days of age) with tetralogy of Fallot using data from the Pediatric Health Information System database. Methods: The Pediatric Health Information System database was queried for patients <90 days of age with primary diagnosis of tetralogy of Fallot who underwent nonelective surgical repair or palliation between January 2008 and December 2014. The initial cohort of 821 patients (group 1 early primary repair, N = 554; group 2 systemic-to-pulmonary artery shunt, N = 267) was propensity score matched (248 patients in each group) to account for baseline imbalances in age and prostaglandin use. Results: Comparison of unmatched groups revealed younger age and higher incidence of extracardiac anomalies ( P = .02) and prematurity ( P = .04) in group 2. Mortality was comparable between the groups (group 1: 20 [4%] of 554 vs group 2: 11 [4%] of 267, P = .74). Irrespective of the type of procedure, prematurity (odds ratio [OR] = 3.3, 95% confidence interval [CI]: 1.5-7.4) and extracardiac anomalies (OR = 2.5, 95% CI: 1.2-5.3) were independent risk factors for mortality. Propensity score–matched analysis revealed no significant differences in patient mortality ( P = 1), duration of ventilation ( P = .64), hospital length of stay ( P = .69), or hospital charges ( P = .08) between the two groups. Conclusion: Outcomes and hospital charges associated with nonelective early primary repair are comparable to systemic-to-pulmonary artery shunt in symptomatic patients <90 days old with tetralogy of Fallot.

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Infective Endocarditis 2 Decades After Pulmonary Autograft Ross Procedure

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/2324709620940490 ◽

2020 ◽

Vol 8 ◽

pp. 232470962094049

Author(s):

Robin Boyer ◽

Charnpreet Upple ◽

Fowrooz Joolhar ◽

Greti Petersen ◽

Arash Heidari

Keyword(s):

Infective Endocarditis ◽

Pulmonary Valve ◽

Right Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Ross Procedure ◽

Pulmonary Autograft ◽

Echocardiographic Examination ◽

Valve Reconstruction ◽

The Right ◽

Pulmonary Homograft

Pulmonary autograft, or Ross procedure, is performed by supplanting a diseased aortic valve with the patient’s own pulmonary valve. Reconstruction of the right ventricular outflow tract is then completed using a pulmonary homograft. To our knowledge, infective endocarditis occurring decades after the Ross procedure has not been reported. Diligent echocardiographic examination can be crucial to ensure prompt treatment and avoid the 25% mortality rate associated with infective endocarditis. Clinical suspicion should remain high in those with a pulmonary autograft history. In this article, we report the case of a 39-year-old patient with infective endocarditis presenting 22 years after Ross procedure.

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Evaluation of right ventricle pulmonary artery coupling on right ventricular function in post operative tetralogy of Fallot patients underwent for pulmonary valve replacement

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-020-01281-1 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Bhushan Sandeep ◽

Xin Huang ◽

Yuan Li ◽

Xiaowei Wang ◽

Long Mao ◽

...

Keyword(s):

Magnetic Resonance ◽

Pulmonary Artery ◽

Right Ventricle ◽

Right Ventricular ◽

Ventricular Function ◽

Right Ventricular Function ◽

Pulmonary Valve ◽

Primary Repair ◽

Pulmonary Valve Replacement ◽

Rv Function

Abstract Background To evaluate RV-PA coupling in post operative TOF patients with ventricular dilatation underwent for PVR and investigate the correlation between ventricular functions measuring Ea/Emax ratio using cardio magnetic resonance and the effect of surgical type at primary repair of TOF on coupling. Method RV-PA coupling was measured noninvasively by Ea/Emax ratio from CMRI and ECHO. From CMRI results the patients were divided in two groups, RV-PA coupling and RV-PA uncoupling. Ea/Emax ≤1 was considered for coupling patients and Ea/Emax > 1 for uncoupling patients. Results Ninety patients were uncoupled (Ea/Emax: 1.55 ± 0.46) and 45 were coupled (Ea/Emax: 0.81 ± 0.15). Out of 75 TAP repaired patients 60 were uncoupled RV-PV. In addition, higher pro-BNP is an important factor for uncoupled RV-PV (P = 0.001). CMR evaluation for right ventricular function between uncoupling and coupling were RVEDVi (196.65 ± 63.57 vs. 154.28 ± 50.07, P = 0.001), RVESVi (121.19 ± 51.47 vs. 83.94 ± 20.43, P = 0.001), RVSVi (67.19 ± 19.87 vs. 106.31 ± 33.44, P = 0.001), and RVEF (40.90 ± 8.73 vs. 54.63 ± 4.76, P = 0.001). The increased RVEDVi, RVESVi and RVSVi and decreased RVEF have significant correlation with Ea/Emax. Ea/Emax was also found positively correlated with RVEDVi (P = < 0.05, r = 0.35), RVESVi (P = < 0.001, r = 0.41) and negatively correlated with RVSVi (P = < 0.05, r = 0.22) and RVEF (P = < 0.05, r = 0.78). Conclusions Unfavorable RV-PA coupling is present in post operative TOF patients and it is affected by several factors. Our results explain a new concept of RV-PA interactions as a contributing mechanism for the observed decline in RV function.

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