How We Do It
Native Pulmonary Valve Restoration After Remote Tetralogy of Fallot Repair: How To Do It
World Journal for Pediatric and Congenital Heart Surgery 4(4) 422-426 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135113505296 pch.sagepub.com
Constantine Mavroudis, MD1, Constantine D. Mavroudis, MD, MSc2, and Jennifer Frost, MPAS1
Abstract Methods to repair tetralogy of Fallot have evolved from large ventriculotomy, large transannular patch placement techniques to smaller, transatrial approaches with valve-sparing strategies in select patients. Despite these advances, there continue to be patients in whom transannular patch is inevitable, and the management of the resulting pulmonary insufficiency that develops from this has been the source of considerable discussion. Techniques aimed at restoring pulmonary valve competence utilizing the remaining valve leaflets after transannular patch placement have recently been proposed for very select patient populations. We review the technical aspects of the operation including removal of the transannular patch and bicuspidization of a formerly tricuspid pulmonary valve, which results in a competent, nonstenotic valve. This report confirms the feasibility of these operative details and highlights the importance of planning before initial repair of tetralogy of Fallot as a way to prepare for a future valve restoration procedure and therefore avoid prosthetic valve placement. Keywords congenital heart disease, tetralogy of Fallot, pulmonary insufficiency Submitted July 26, 2013; Accepted August 25, 2013.
Introduction Techniques for repair of tetralogy of Fallot have undergone many revisions from the original large ventricular incision, transventricular septal defect closure, and large transannular patch.1 Although these early methods proved successful in correcting a debilitating congenital heart defect, long-term complications such as pulmonary regurgitation, right ventricular dysfunction, tricuspid regurgitation, atrial/ventricular arrhythmias, and eventually left ventricular dysfunction developed.2-4 Surgical improvements were centered on valve-sparing strategies for those patients who were undergoing initial repair.5,6 In subsequent eras, there was a movement toward pulmonary valve-sparing operations despite resultant high right ventricular pressure.7,8 When transannular patches were necessary, they were configured to result in mild stenosis of approximately 20 mm Hg gradients with the expectation that mild stenosis coupled with regurgitation would be better tolerated in the long term.9,10 Extensive pulmonary valve-sparing techniques were proposed by several authors7,8,11 by employing transatrial right ventricular outflow tract (RVOT) resection, limited subvalvar ventriculotomy when necessary, and a pantaloon supravalvar pulmonary artery reconstruction after pulmonary valve valvotomy. This set of techniques allowed the greatest possibility of pulmonary valve sparing during repair and resulted in
pulmonary valve preservation in up to 70% of the patients,7 comparing favorably with other reports.12,13 Despite these technical advances, there continue to be patients who undergo complete repair with transannular patches and resultant severe pulmonary regurgitation. Pulmonary valve homografts, stented bioprosthetic valves, and polytetrafluoroethylene (PTFE) valves,14-16 among other solutions have been used to recreate pulmonary valve competence and avoid further deterioration of right ventricular dysfunction.17 The introduction of transcatheter bioprosthetic valves has proved to be successful in a subset of patients, but long-term outcomes are still being accrued.18 Recent studies by Papadopoulos et al,19 Mainwaring et al,14 and Pretre et al20 have introduced native pulmonary valve restoration late after transannular repair when the extant pulmonary valves have not been resected and remain amenable to reconstruction and restoration as competent bicuspid valves. We review the operative techniques of 1 Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, USA 2 Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
Corresponding Author: Constantine Mavroudis, Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, 32804, USA. Email: [email protected]
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
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Figure 1. Artist’s representation of reoperation on a patient with remote tetralogy of Fallot repair with indications for pulmonary valve insertion owing to significant pulmonary regurgitation, right ventricular distention, and exercise intolerance. Aortobicaval cardiopulmonary bypass is established with aortic cross-clamping and cardioplegic arrest. The dotted line shows the area where the incision is to be made in the extant transannular patch that had been placed during the original reparative operation.
Figure 3. The transannular patch which is oftentimes calcified is totally removed thereby exposing the competent posterior leaflets and the opened redundant right ventricular outflow tract. Assessment of the remaining leaflets can now be made by noting the leaflet mobility, coaptation level, and size.
Figure 2. The incision in the original transannular patch is being performed, and the right and left posterior pulmonary valve leaflets are exposed. On close inspection, both leaflets are well formed with attached commissures and coapt at the same level.
pulmonary valve restoration by bicuspidization after remote repair of tetralogy of Fallot by a transannular patch and preservation of the 2 posterior valve leaflets.
Operative Technique After uncomplicated resternotomy, aortobicaval cannulation, mild hypothermic cardiopulmonary bypass (34 C), and
cardioplegic arrest (Figure 1), the RVOT is incised in the midline and longitudinally through the entire length of the RVOT transannular patch (Figure 2). The patch is sharply removed (Figure 3) to eliminate calcified edges, allow RVOT visualization, and permit evaluation of the remaining pulmonary valve leaflets. Although preoperative echocardiography may guide the surgeon with respect to potential valve function, visual inspection and assessment of pulmonary valve z score will determine whether the resultant restored valve could be expected to be competent and free of significant stenosis. Assuming that the original valve was tricuspid with the anterior leaflet incised, bicuspidization can be performed by apposition of the two anterior pulmonary valve commissures using one or two pledgeted sutures (only one pledgeted suture is demonstrated in the drawing) to form a competent bicuspid valve (Figure 4). Once the sutures are tied, and the commissure is created, a piece of biologic or prosthetic material is cut to size and used to close and isolate the supravalvar pulmonary artery reconstruction (Figure 5). The pulmonary artery back flow will serve as a volume-testing mechanism to test the newly
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
424
World Journal for Pediatric and Congenital Heart Surgery 4(4)
Figure 4. A pledgeted suture is being placed to approximate the right posterior and left posterior pulmonary commissures in order to form a competent bicuspid valve. A second pledgeted suture, not shown in the drawing, can be placed to reinforce the newly formed commissure if necessary.
formed valve much the way that one instills saline through a valve using a saline-filled bulb syringe (Figure 6). Leaks can be evaluated and repaired at this time. In addition, sized dilators can be used to serially measure the new valve to measure the z score and predict valve function. Primary closure of the RVOT is achieved by longitudinal running suture technique (Figure 7). Alternatively, a biologic or prosthetic patch can be used. Primary closure of a residual patent foramen ovale or atrial septal defect is performed through a right atriotomy when appropriate. The crossclamp is removed after all air maneuvers are employed, and the patient can be separated from cardiopulmonary bypass in sinus rhythm, without difficulty, and without pressor agents. Postoperative transesophageal echocardiography is used to assess neopulmonary valve function.
Discussion Our experience with the technique described here confirms other reports14,20 that have demonstrated the feasibility of restoring the pulmonary valve by bicuspidization after remote transannular repair of tetralogy of Fallot as long as the two posterior leaflets were not resected at the original operation. Patients who are fortunate enough to undergo this operation may be spared future
Figure 5. A piece of biologic or prosthetic material is cut to size and used to augment the supravalvar pulmonary artery using running suture technique. This maneuver will isolate the supravalvar pulmonary artery reconstruction and force the pulmonary artery back flow to test the competency of the pulmonary valve which can be assessed by visual inspection through the RVOT. RVOT indicates transatrial right ventricular outflow tract.
operations for RVOT reconstruction. Clearly, the opportunity to perform such a procedure requires a valve leaflet preservation strategy at the original reparative operation that maintains pulmonary valve integrity with commissural attachments even in the circumstances of transannular patching. This procedural detail at the original operation requires a careful assessment of the valve anatomy and transannular incision to divide the pulmonary annulus at one of the commissures with the intent of preserving the valvar function for a future date when somatic growth might allow for pulmonary valve restoration. The original anatomy and valve orientation play a major role in this preparatory procedure. The valve-sparing transannular incision is best accomplished in a bicuspid pulmonary valve that is oriented in an anterior–posterior position thereby making the commissural/transannular incision optimally positioned in the center of the RVOT. This allows for the incision to be placed away from the course of the left anterior descending coronary artery on the left and the orifice of the right coronary artery on the right. When the pulmonary valve is positioned in a horizontal configuration requiring a transannular incision, a valve-sparing procedure with the thought of future bicuspidization is virtually impossible as the anterior leaflet will require incision at its midpoint. Others21 have incised the anterior pulmonary leaflet with a concomitant transannular incision and inserted a PTFE
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
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Figure 6. The newly reconstructed bicuspid pulmonary valve is shown through the RVOT. The competency can be determined by visual inspection owing to pulmonary artery back flow which can pinpoint any leaks that could be rerepaired as necessary. This same view can also be used to measure the orifice by serially sized dilators to determine the z score and assess the potential pulmonary valve pressure gradient. RVOT indicates transatrial right ventricular outflow tract.
membrane patch to enlarge the leaflet much the same way that a monocusp is employed, the difference being that the two sides of the incised anterior leaflet are still attached to their respective commissures and offer the possibility of somatic growth. To date, no valve restoration has been reported using this technique. In the case of a small tricuspid pulmonary valve, there are a number of potentially successful delayed pulmonary valve restoration techniques. The first, as noted in this report, is resection of the anterior leaflet, transannular patch, and preservation of the two posterior leaflets with the expectation that somatic growth will allow future bicuspidization. Another option is transannular incision at one of the anterior commissures of the anterior leaflet. The anatomic dangers with this maneuver are noteworthy. Aside from proximity of the two aforementioned coronary arteries is the difficulty in performing an adequate RVOT resection, as the approach is not in the center of the RVOT. The authors have not attempted this approach, and it remains theoretical until anatomic cadaver studies are performed, and clinical application is assessed. Despite the advances in valve-sparing techniques for primary repair of tetralogy of Fallot, inevitably there will be
Figure 7. The subvalvar RVOT is closed using running suture technique. Alternatively, a biologic or prosthetic patch can be used. After rewarming, separation from cardiopulmonary bypass and transesophageal echocardiographic assessment will determine whether further intervention will be necessary. RVOT indicates transatrial right ventricular outflow tract.
patients in whom such techniques will fail. In these cases, valve restoration techniques will become more important to delay or eliminate pulmonary valve replacement. Other studies have demonstrated that, while feasible, these valve-restoration techniques are for the minority of patients with tetralogy of Fallot because of the damage done to the valve at the time of original procedure. It is our hope that by continuing to demonstrate the feasibility of these valve-preserving techniques, surgeons will become more focused on leaflet preservation and on selecting those patients who may ultimately benefit from valve restoration in the future. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
426
World Journal for Pediatric and Congenital Heart Surgery 4(4)
References 1. Karamlou T, McCrindle BW, Williams WG. Surgery insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management. Nat Clin Pract Cardiovasc Med. 2006;3(11): 611-622. 2. Ammash NM, Dearani JA, Burkhart HM, Connolly HM. Pulmonary regurgitation after tetralogy of Fallot repair: clinical features, sequelae, and timing of pulmonary valve replacement. Congenit Heart Dis. 2007;2(6): 386-403. 3. Gatzoulis MA, Balaji S, Webber SA, et al. Risk factors of arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: multicentre study. Lancet. 2000;356(9234): 975-981. 4. Kane C, Kogon B, Pernetz M, et al. Left ventricular function improves after pulmonary valve replacement in patients with previous right ventricular outflow tract reconstruction and biventricular disfunction. Tex Heart Inst J. 2011;38(3): 234-237. 5. Jonas R. Early primary repair of tetralogy of Fallot. Semin Thorac Cardiovasc Surg Pediatr Pediatric Card Surg Annu. 2009;12: 39-47. 6. Karl TR, Sano S, Pornviliwan S, Mee RBB. Tetralogy of Fallot: favorable outcome of non neonatal transatrial transpulmonary repair. Ann Thorac Surg. 1992;54(5): 903-907. 7. Stewart RD, Backer CL, Young L, Mavroudis C. Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg. 2005;80(4): 1431-1438. 8. Rao V, Kadletz M, Hornberger LK, Freedom RM, Black MD. Preservation of the pulmonary valve complex in tetralogy of Fallot: how small is too small? Ann Surg. 2000;69(1): 176-180. 9. Ilbawi MN, Idriss FS, DeLeon SY, et al. Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair, surgical implications. J Thorac Cardiovasc Surg. 1987;93(1): 36-44. 10. Latus H, Gummel D, Rupp S, et al. Beneficial effects of residual right ventricular outflow tract obstruction on right ventricular volume and function in patients after repair of tetralogy of Fallot. Pediatr Cardiol. 2013:34(2): 424-430. 11. Hua Z, Li S, Wang L, Hu S, Wang D. A new pulmonary valve cusp plasty technique markedly decreases transannular patch rate
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
and improves midterm outcomes of tetralogy of Fallot repair. Eur J Cardiothorac Surg. 2011;40(5): 1221-1226. Hirsch JC, Mosca RS, Bove EL. Complete repair of tetralogy of Fallot in the neonate: results in a modern era. Ann Surg. 2000; 232(4): 508-514. Pigula F, Khalil P, Mayer J, Del Nido P, Jonas R. Repair of tetralogy of Fallot in neonates and young infants. Circulation. 1999; 100(19 suppl): II157-II161. Mainwaring RD, Pirolli T, Punn R, Hanley FL. Late repair of the native pulmonary valve in patients with pulmonary insufficiency after surgery for tetralogy of Fallot. Ann Thorac Surg. 2012;93(2): 677-679. Quintessenza JA, Jacobs JP, Chai PJ, Morrell VO, Lindberg H. Polytetrafluoroethylene bicuspid pulmonary valve implementation experience 126 patients. World J Pediatr Congenit Heart Surg. 2010;1(1): 20-27. Park CS, Lee C-H, Lee YO, Kim G-B, Kim J-T, Kim YJ. Pulmonary valve repair late after right ventricular outflow tract reconstruction in children and adolescents. Interact Cardiovasc Thorac Surg 2010;10(6): 906-909. Discigil B, Dearani JA, Puga FJ, et al. Late pulmonary valve replacement after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg. 2001;121(2): 344-351. McElhinney DB, Hellenbrand WE, Zahn EM, et al. Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial. Circulation. 2010;122(5): 507-516. Papadopoulos N, Esmaeili A, Zierer A, Bakhtiary F, Ozaslan F, Moritz A. Secondary repair of incompetent pulmonary valves. Ann Thorac Surg. 2009;87(6): 1879-1884. Preˆtre R, Rosser B, Mueller C, Kretschmar O, Dave H. Recycling of the pulmonary valve: an elegant solution for secondary pulmonary regurgitation in patients with tetralogy of Fallot. Ann Thorac Surg. 2012;94(3): 850-853. Bacha E. Valve-sparing options in tetralogy of Fallot surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2012; 15(1): 24-26.
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
Native Pulmonary Valve Restoration After Remote Tetralogy of Fallot Repair: How To Do It
World Journal for Pediatric and Congenital Heart Surgery 4(4) 422-426 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135113505296 pch.sagepub.com
Constantine Mavroudis, MD1, Constantine D. Mavroudis, MD, MSc2, and Jennifer Frost, MPAS1
Abstract Methods to repair tetralogy of Fallot have evolved from large ventriculotomy, large transannular patch placement techniques to smaller, transatrial approaches with valve-sparing strategies in select patients. Despite these advances, there continue to be patients in whom transannular patch is inevitable, and the management of the resulting pulmonary insufficiency that develops from this has been the source of considerable discussion. Techniques aimed at restoring pulmonary valve competence utilizing the remaining valve leaflets after transannular patch placement have recently been proposed for very select patient populations. We review the technical aspects of the operation including removal of the transannular patch and bicuspidization of a formerly tricuspid pulmonary valve, which results in a competent, nonstenotic valve. This report confirms the feasibility of these operative details and highlights the importance of planning before initial repair of tetralogy of Fallot as a way to prepare for a future valve restoration procedure and therefore avoid prosthetic valve placement. Keywords congenital heart disease, tetralogy of Fallot, pulmonary insufficiency Submitted July 26, 2013; Accepted August 25, 2013.
Introduction Techniques for repair of tetralogy of Fallot have undergone many revisions from the original large ventricular incision, transventricular septal defect closure, and large transannular patch.1 Although these early methods proved successful in correcting a debilitating congenital heart defect, long-term complications such as pulmonary regurgitation, right ventricular dysfunction, tricuspid regurgitation, atrial/ventricular arrhythmias, and eventually left ventricular dysfunction developed.2-4 Surgical improvements were centered on valve-sparing strategies for those patients who were undergoing initial repair.5,6 In subsequent eras, there was a movement toward pulmonary valve-sparing operations despite resultant high right ventricular pressure.7,8 When transannular patches were necessary, they were configured to result in mild stenosis of approximately 20 mm Hg gradients with the expectation that mild stenosis coupled with regurgitation would be better tolerated in the long term.9,10 Extensive pulmonary valve-sparing techniques were proposed by several authors7,8,11 by employing transatrial right ventricular outflow tract (RVOT) resection, limited subvalvar ventriculotomy when necessary, and a pantaloon supravalvar pulmonary artery reconstruction after pulmonary valve valvotomy. This set of techniques allowed the greatest possibility of pulmonary valve sparing during repair and resulted in
pulmonary valve preservation in up to 70% of the patients,7 comparing favorably with other reports.12,13 Despite these technical advances, there continue to be patients who undergo complete repair with transannular patches and resultant severe pulmonary regurgitation. Pulmonary valve homografts, stented bioprosthetic valves, and polytetrafluoroethylene (PTFE) valves,14-16 among other solutions have been used to recreate pulmonary valve competence and avoid further deterioration of right ventricular dysfunction.17 The introduction of transcatheter bioprosthetic valves has proved to be successful in a subset of patients, but long-term outcomes are still being accrued.18 Recent studies by Papadopoulos et al,19 Mainwaring et al,14 and Pretre et al20 have introduced native pulmonary valve restoration late after transannular repair when the extant pulmonary valves have not been resected and remain amenable to reconstruction and restoration as competent bicuspid valves. We review the operative techniques of 1 Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, USA 2 Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
Corresponding Author: Constantine Mavroudis, Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, 32804, USA. Email: [email protected]
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
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Figure 1. Artist’s representation of reoperation on a patient with remote tetralogy of Fallot repair with indications for pulmonary valve insertion owing to significant pulmonary regurgitation, right ventricular distention, and exercise intolerance. Aortobicaval cardiopulmonary bypass is established with aortic cross-clamping and cardioplegic arrest. The dotted line shows the area where the incision is to be made in the extant transannular patch that had been placed during the original reparative operation.
Figure 3. The transannular patch which is oftentimes calcified is totally removed thereby exposing the competent posterior leaflets and the opened redundant right ventricular outflow tract. Assessment of the remaining leaflets can now be made by noting the leaflet mobility, coaptation level, and size.
Figure 2. The incision in the original transannular patch is being performed, and the right and left posterior pulmonary valve leaflets are exposed. On close inspection, both leaflets are well formed with attached commissures and coapt at the same level.
pulmonary valve restoration by bicuspidization after remote repair of tetralogy of Fallot by a transannular patch and preservation of the 2 posterior valve leaflets.
Operative Technique After uncomplicated resternotomy, aortobicaval cannulation, mild hypothermic cardiopulmonary bypass (34 C), and
cardioplegic arrest (Figure 1), the RVOT is incised in the midline and longitudinally through the entire length of the RVOT transannular patch (Figure 2). The patch is sharply removed (Figure 3) to eliminate calcified edges, allow RVOT visualization, and permit evaluation of the remaining pulmonary valve leaflets. Although preoperative echocardiography may guide the surgeon with respect to potential valve function, visual inspection and assessment of pulmonary valve z score will determine whether the resultant restored valve could be expected to be competent and free of significant stenosis. Assuming that the original valve was tricuspid with the anterior leaflet incised, bicuspidization can be performed by apposition of the two anterior pulmonary valve commissures using one or two pledgeted sutures (only one pledgeted suture is demonstrated in the drawing) to form a competent bicuspid valve (Figure 4). Once the sutures are tied, and the commissure is created, a piece of biologic or prosthetic material is cut to size and used to close and isolate the supravalvar pulmonary artery reconstruction (Figure 5). The pulmonary artery back flow will serve as a volume-testing mechanism to test the newly
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
424
World Journal for Pediatric and Congenital Heart Surgery 4(4)
Figure 4. A pledgeted suture is being placed to approximate the right posterior and left posterior pulmonary commissures in order to form a competent bicuspid valve. A second pledgeted suture, not shown in the drawing, can be placed to reinforce the newly formed commissure if necessary.
formed valve much the way that one instills saline through a valve using a saline-filled bulb syringe (Figure 6). Leaks can be evaluated and repaired at this time. In addition, sized dilators can be used to serially measure the new valve to measure the z score and predict valve function. Primary closure of the RVOT is achieved by longitudinal running suture technique (Figure 7). Alternatively, a biologic or prosthetic patch can be used. Primary closure of a residual patent foramen ovale or atrial septal defect is performed through a right atriotomy when appropriate. The crossclamp is removed after all air maneuvers are employed, and the patient can be separated from cardiopulmonary bypass in sinus rhythm, without difficulty, and without pressor agents. Postoperative transesophageal echocardiography is used to assess neopulmonary valve function.
Discussion Our experience with the technique described here confirms other reports14,20 that have demonstrated the feasibility of restoring the pulmonary valve by bicuspidization after remote transannular repair of tetralogy of Fallot as long as the two posterior leaflets were not resected at the original operation. Patients who are fortunate enough to undergo this operation may be spared future
Figure 5. A piece of biologic or prosthetic material is cut to size and used to augment the supravalvar pulmonary artery using running suture technique. This maneuver will isolate the supravalvar pulmonary artery reconstruction and force the pulmonary artery back flow to test the competency of the pulmonary valve which can be assessed by visual inspection through the RVOT. RVOT indicates transatrial right ventricular outflow tract.
operations for RVOT reconstruction. Clearly, the opportunity to perform such a procedure requires a valve leaflet preservation strategy at the original reparative operation that maintains pulmonary valve integrity with commissural attachments even in the circumstances of transannular patching. This procedural detail at the original operation requires a careful assessment of the valve anatomy and transannular incision to divide the pulmonary annulus at one of the commissures with the intent of preserving the valvar function for a future date when somatic growth might allow for pulmonary valve restoration. The original anatomy and valve orientation play a major role in this preparatory procedure. The valve-sparing transannular incision is best accomplished in a bicuspid pulmonary valve that is oriented in an anterior–posterior position thereby making the commissural/transannular incision optimally positioned in the center of the RVOT. This allows for the incision to be placed away from the course of the left anterior descending coronary artery on the left and the orifice of the right coronary artery on the right. When the pulmonary valve is positioned in a horizontal configuration requiring a transannular incision, a valve-sparing procedure with the thought of future bicuspidization is virtually impossible as the anterior leaflet will require incision at its midpoint. Others21 have incised the anterior pulmonary leaflet with a concomitant transannular incision and inserted a PTFE
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
Mavroudis et al
425
Figure 6. The newly reconstructed bicuspid pulmonary valve is shown through the RVOT. The competency can be determined by visual inspection owing to pulmonary artery back flow which can pinpoint any leaks that could be rerepaired as necessary. This same view can also be used to measure the orifice by serially sized dilators to determine the z score and assess the potential pulmonary valve pressure gradient. RVOT indicates transatrial right ventricular outflow tract.
membrane patch to enlarge the leaflet much the same way that a monocusp is employed, the difference being that the two sides of the incised anterior leaflet are still attached to their respective commissures and offer the possibility of somatic growth. To date, no valve restoration has been reported using this technique. In the case of a small tricuspid pulmonary valve, there are a number of potentially successful delayed pulmonary valve restoration techniques. The first, as noted in this report, is resection of the anterior leaflet, transannular patch, and preservation of the two posterior leaflets with the expectation that somatic growth will allow future bicuspidization. Another option is transannular incision at one of the anterior commissures of the anterior leaflet. The anatomic dangers with this maneuver are noteworthy. Aside from proximity of the two aforementioned coronary arteries is the difficulty in performing an adequate RVOT resection, as the approach is not in the center of the RVOT. The authors have not attempted this approach, and it remains theoretical until anatomic cadaver studies are performed, and clinical application is assessed. Despite the advances in valve-sparing techniques for primary repair of tetralogy of Fallot, inevitably there will be
Figure 7. The subvalvar RVOT is closed using running suture technique. Alternatively, a biologic or prosthetic patch can be used. After rewarming, separation from cardiopulmonary bypass and transesophageal echocardiographic assessment will determine whether further intervention will be necessary. RVOT indicates transatrial right ventricular outflow tract.
patients in whom such techniques will fail. In these cases, valve restoration techniques will become more important to delay or eliminate pulmonary valve replacement. Other studies have demonstrated that, while feasible, these valve-restoration techniques are for the minority of patients with tetralogy of Fallot because of the damage done to the valve at the time of original procedure. It is our hope that by continuing to demonstrate the feasibility of these valve-preserving techniques, surgeons will become more focused on leaflet preservation and on selecting those patients who may ultimately benefit from valve restoration in the future. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Downloaded from pch.sagepub.com at PURDUE UNIV LIBRARY TSS on May 30, 2015
426
World Journal for Pediatric and Congenital Heart Surgery 4(4)
References 1. Karamlou T, McCrindle BW, Williams WG. Surgery insight: late complications following repair of tetralogy of Fallot and related surgical strategies for management. Nat Clin Pract Cardiovasc Med. 2006;3(11): 611-622. 2. Ammash NM, Dearani JA, Burkhart HM, Connolly HM. Pulmonary regurgitation after tetralogy of Fallot repair: clinical features, sequelae, and timing of pulmonary valve replacement. Congenit Heart Dis. 2007;2(6): 386-403. 3. Gatzoulis MA, Balaji S, Webber SA, et al. Risk factors of arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: multicentre study. Lancet. 2000;356(9234): 975-981. 4. Kane C, Kogon B, Pernetz M, et al. Left ventricular function improves after pulmonary valve replacement in patients with previous right ventricular outflow tract reconstruction and biventricular disfunction. Tex Heart Inst J. 2011;38(3): 234-237. 5. Jonas R. Early primary repair of tetralogy of Fallot. Semin Thorac Cardiovasc Surg Pediatr Pediatric Card Surg Annu. 2009;12: 39-47. 6. Karl TR, Sano S, Pornviliwan S, Mee RBB. Tetralogy of Fallot: favorable outcome of non neonatal transatrial transpulmonary repair. Ann Thorac Surg. 1992;54(5): 903-907. 7. Stewart RD, Backer CL, Young L, Mavroudis C. Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg. 2005;80(4): 1431-1438. 8. Rao V, Kadletz M, Hornberger LK, Freedom RM, Black MD. Preservation of the pulmonary valve complex in tetralogy of Fallot: how small is too small? Ann Surg. 2000;69(1): 176-180. 9. Ilbawi MN, Idriss FS, DeLeon SY, et al. Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair, surgical implications. J Thorac Cardiovasc Surg. 1987;93(1): 36-44. 10. Latus H, Gummel D, Rupp S, et al. Beneficial effects of residual right ventricular outflow tract obstruction on right ventricular volume and function in patients after repair of tetralogy of Fallot. Pediatr Cardiol. 2013:34(2): 424-430. 11. Hua Z, Li S, Wang L, Hu S, Wang D. A new pulmonary valve cusp plasty technique markedly decreases transannular patch rate
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
and improves midterm outcomes of tetralogy of Fallot repair. Eur J Cardiothorac Surg. 2011;40(5): 1221-1226. Hirsch JC, Mosca RS, Bove EL. Complete repair of tetralogy of Fallot in the neonate: results in a modern era. Ann Surg. 2000; 232(4): 508-514. Pigula F, Khalil P, Mayer J, Del Nido P, Jonas R. Repair of tetralogy of Fallot in neonates and young infants. Circulation. 1999; 100(19 suppl): II157-II161. Mainwaring RD, Pirolli T, Punn R, Hanley FL. Late repair of the native pulmonary valve in patients with pulmonary insufficiency after surgery for tetralogy of Fallot. Ann Thorac Surg. 2012;93(2): 677-679. Quintessenza JA, Jacobs JP, Chai PJ, Morrell VO, Lindberg H. Polytetrafluoroethylene bicuspid pulmonary valve implementation experience 126 patients. World J Pediatr Congenit Heart Surg. 2010;1(1): 20-27. Park CS, Lee C-H, Lee YO, Kim G-B, Kim J-T, Kim YJ. Pulmonary valve repair late after right ventricular outflow tract reconstruction in children and adolescents. Interact Cardiovasc Thorac Surg 2010;10(6): 906-909. Discigil B, Dearani JA, Puga FJ, et al. Late pulmonary valve replacement after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg. 2001;121(2): 344-351. McElhinney DB, Hellenbrand WE, Zahn EM, et al. Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial. Circulation. 2010;122(5): 507-516. Papadopoulos N, Esmaeili A, Zierer A, Bakhtiary F, Ozaslan F, Moritz A. Secondary repair of incompetent pulmonary valves. Ann Thorac Surg. 2009;87(6): 1879-1884. Preˆtre R, Rosser B, Mueller C, Kretschmar O, Dave H. Recycling of the pulmonary valve: an elegant solution for secondary pulmonary regurgitation in patients with tetralogy of Fallot. Ann Thorac Surg. 2012;94(3): 850-853. Bacha E. Valve-sparing options in tetralogy of Fallot surgery. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2012; 15(1): 24-26.
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