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Ann Thorac Surg 2001;72:316-317
© 2001 The Society of Thoracic Surgeons

Correspondence

Classification of pulmonary atresia with ventricular septal defect: Reply

Christo I. Tchervenkov, MDa a Executive Advisory Committee, International Congenital Heart Surgery Nomenclature and Database Project, Director, Cardiovascular Surgery, The Montreal Children’s Hospital, Associate Professor of Surgery, McGill University, Montreal, Québec, Canada

e-mail: christo.tchervenko{at}muhc.mcgill.ca

To the Editor

I thank my friend, Dr Barbero-Marcial, for bringing to my attention his excellent article published in 1990 in the Seminars in Thoracic and Cardiovascular Surgery [1]. In the preparation of our manuscript, a MEDLINE search under "pulmonary atresia, ventricular septal defect (PA, VSD)," failed to pick up this article, probably because of the different terminology he used, namely tetralogy of Fallot with pulmonary atresia. It is noteworthy that experienced surgeons from different parts of the world have concluded independently that a classification for PA, VSD is necessary. As we try to weed out the numerous surgical options, it is essential to adopt a simple and consistent classification that allows us to make relevant comparisons. Despite the fact that Dr Barbero-Marcial published his classification 10 years ago, since then the major publications on the surgical experience with PA, VSD have not used it.

A comparison of the classification proposed by Dr Barbero-Marcial and the classification proposed by us is detailed in Table 1. Although the two classifications share many similarities, significant differences do exist. The classification of Dr Barbero-Marcial stipulates that all the bronchopulmonary segments must be supplied by the native pulmonary arteries (NPA) in Group A and that all are supplied exclusively by major aortopulmonary collateral arteries (MAPCA) in Group C. In what group do patients belong if they do not have all their segments supplied by one or the other source? Furthermore in Group B, some bronchopulmonary segments are supplied by NPA and others by MAPCA. What about segments with dual blood supply or supply by communicating MAPCA? Finally, in Group A, a source of pulmonary blood flow can be from MAPCA, as long as all the bronchopulmonary segments are supplied by the NPA.


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  		Table 1. Comparison of the Two Classification Systems

 
Our aim was to propose a classification as simple as possible, consistent with the extreme heterogeneity of patients with PA, VSD and not leaving any patients unaccounted for. Furthermore, we wanted the classification to be consistent with the current trend toward primary repair in type A and the single-stage unifocalization ± repair in types B and C, as well as with the traditional multistage approach. The fundamental basis of our classification is only the presence or absence of NPA and MAPCA as variables. Although simple, our proposed classification categorizes patients with PA, VSD into three broad types based on the nature of their pulmonary circulation, using straightforward anatomic criteria with fundamentally different surgical options. It is hoped that the use of a classification system will enable relevant comparisons of surgical series, strategies, and outcomes.

The contribution of Drs Barbero-Marcial and Jatene has to be applauded. I am grateful that their work was brought to my attention, because it lends strong support to the establishment and use of a classification system by the scientific community. It is up to the reader as an individual and the surgical community as a whole to decide which of the two classifications is more appropriate.

References

  1. Barbero-Marcial M., Jatene A.D. Surgical management of the anomalies of the pulmonary arteries in the tetralogy of Fallot with pulmonary atresia. Semin Thorac Cardiovasc Surg 1990;2:93-107.[Medline]
  2. Tchervenkov C.I., Roy N. Congenital Heart Surgery Nomenclature and Database Project: pulmonary atresia–ventricular septal defect. Ann Thorac Surg 2000;69:S97-S105.[Abstract/Free Full Text]

Related Article

Classification of pulmonary atresia with ventricular septal defect
Miguel Barbero-Marcial
Ann. Thorac. Surg. 2001 72: 316. [Extract] [Full Text] [PDF]




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