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Ann Thorac Surg 2001;71:505-506
© 2001 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, John Colloton Pavilion, Room 1602-A, 200 Hawkins Dr, Iowa City, IA 52242, USA
e-mail: douglas-behrendt{at}uiowa.edu
Techniques for reconstruction of the right ventricular outflow tract that will result in long-term freedom from reoperation remain an elusive goal for surgeons treating right ventricle-pulmonary artery discontinuity. Prosthetic conduits and allografts impose the subsequent certainty of reoperation, especially in growing infants, and there are occasional problems of finding space for them under the sternum in the mediastinum. This has led to a search for better ways to bridge the gap by utilizing autologous tissue. In 1981, LeCompte described mobilizing the pulmonary arteries and translocating them anterior to the aorta to permit direct anastomosis to the right ventricle. Barbero-Marcial in 1990 described several patients with truncus in whom he utilized flaps of pulmonary artery to create the floor of an RV-PA connection, the roof consisting of a pericardial patch containing a monocusp valve. Others have borrowed this concept for correcting conditions such as tetralogy with an absent main pulmonary artery as well as for bridging over an anomalous coronary artery crossing the RV outflow tract.
In 1 patient, Barbero-Marcial found, "because of the distance between the left pulmonary artery and the ventriculostomy, the left atrial appendage was utilized to construct the posterior wall of a new pulmonary trunk artery." This appears to be the genesis of the technique described herein.
In all of these techniques, it is assumed that the autologous tissue floor of the RV-PA connection will grow. Unfortunately, in no case has long-term follow-up data been provided to prove this point. Because the roof is created from pericardial tissue, pulmonary regurgitation and RV volume overload are inevitable, even when a monocusp valve is used. Some, therefore, may require pulmonary valve replacements later in life. So, one of the principle objectives of these techniques, which is to reduce the need for reoperation, remains unproved.
Because the epicardial surface of the left atrial appendage becomes part of the blood flow pathway, another concern is whether thrombosis will occur. As the authors point out, there is no evidence for this in the short follow-up reported herein, nor has this proven to occur in patients with Senning repairs in whom the epicardium is left inside the heart.
Despite these reservations, this technique may prove useful in dealing with unusual situations, especially in small infants, and we look forward to learning of the long-term results.
Related Article
Ann. Thorac. Surg. 2001 71: 501-505.
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