Ann Thorac Surg 2003;75:303-305
© 2003 The Society of Thoracic Surgeons
How to do it
Pulmonic valve annular enlargement with valve repair in tetralogy of Fallot
Si Chan Sung, MDa,b*,
Siho Kim, MDa,b,
Jong Soo Woo, MDa,b,
Young Seok Lee, MDa,b
a Departments of Thoracic and Cardiovascular Surgery, Dong-A University Hospital, Pusan, South Korea
b Department of Pediatrics, Dong-A University Hospital, Pusan, South Korea
Accepted for publication June 20, 2002.
* Address reprint requests to Dr Sung, Department of Thoracic and Cardiovascular Surgery, Dong-A University Hospital, 3-1 Dongdaeshin-Dong, Seo-Gu, Pusan 602-715, South Korea.
e-mail: scsung{at}mail.donga.ac.kr
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Abstract
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We present an operative technique of pulmonic valve annular enlargement with concomitant valve repair using two pericardial patches to reduce pulmonary regurgitation after complete repair of tetralogy of Fallot. We have used this technique in 18 patients with tetralogy of Fallot with excellent results.
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Introduction
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Surgical repair of tetralogy of Fallot (TOF) with small pulmonic valve (PV) annulus requires the destruction of the PV and annulus. The resultant pulmonary regurgitation (PR) may lead to acute and late functional deterioration of right ventricular performance [1, 2]. A monocusp ventricular outflow patch has been used to reduce PR [3, 4]. However, when we enlarge the PV annulus using a monocusp ventricular outflow patch or a simple patch, we cannot use the patient’s own destroyed valve tissue, which will become nonfunctional or obstructive. We repaired a divided PV during transannular enlargement in complete repair of TOF.
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Technique
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The main pulmonary artery (MPA) is opened longitudinally, and the valve is inspected after induction of cardioplegia. The most frequent finding is a bicuspid valve with varying degree of commissural fusion and tethering to the MPA wall. The first step of our technique is a precise division of the commissural fusion if there is any. If there are significant tetherings of valve cusps to the MPA wall, only the posterior cusp is released from the tethering by scalpel to improve cusp excursion. The tethering of the anterior cusp to the MPA is left untouched to preserve hinge function of the newly created large anterior cusp. At this time, we have to decide whether to enlarge the PV annulus or not. If the annulus is not large enough in size to be preserved, a small separate vertical incision is made at the right ventricular outflow tract (RVOT) free wall. The two incisions at the MPA and RVOT are extended toward each other, and they meet at the nadir of the anterior PV cusp. Then the anterior PV cusp is evenly divided (Fig 1, A).
The next step is extensive infundibulectomy through the small ventriculotomy incision and tricuspid valve. The ventricular septal defect is closed through the tricuspid valve in all cases except in doubly committed juxtaarterial defect. Pulmonary valve reconstruction is then carried out in the arrested heart. The extent of annular enlargement is decided by probing the PV with a Hegar dilator. Our target annular size in the arrested heart is 2 mm larger than the mean normal sized pulmonary annulus. The glutaraldehyde-treated autologous pericardium is adequately designed in the rectangular shape. The width of the patch is tailored according to the fraction of the Hegar dilator circumference exposed at the annulus during RVOT calibration. The patch is placed between the divided valve cusps with continuous over-and-over suture technique using a 6-0 monofilament suture. Then the RVOT incision is subsequently covered with the same patch (Fig 1, B). We think that it is important for the patch to be placed at the endocardial side of the incised myocardium at the upper half of the RVOT incision. This maneuver might be useful to maintain good valve function because the valve structure is a continuation of the endocardium. When the anterior cusp is very small or dysplastic, or the bicuspid PV has anterior and posterior commissures, the PV division is performed near either commissure to preserve the remaining valve tissue as much as possible, and one of two sides of the pericardial patch is anchored to the incised MPA wall instead of valve tissue at the same level of the commissure. After completion of PV reconstruction and covering of the RVOT incision, the aortic clamp is removed with procedures for removal of air first. The incision at the MPA is then covered with a second ovoid glutaraldehyde-treated bovine pericardial patch, which is connected to the middle or lower part of the first RVOT patch. The patch is placed to the epicardial side of the incised RVOT wall. As a result, a large anterior pulmonary cusp with a large sinus is created (Fig 1C).
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Fig 1. (A) The anterior pulmonic valve cusp is evenly divided after a small ventriculotomy is performed. (B) The rectangularly shaped patch is placed between the divided valve cusps, and the ventriculotomy incision was subsequently covered with the same patch. (C) The incision at the main pulmonary artery is then covered with a second ovoid glutaraldehyde-treated bovine pericardial patch, which is connected to the middle or lower part of the first patch used in valve repair, covering the ventriculotomy incision. A large anterior pulmonic valve cusp with a large sinus is created.
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Results
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Since April 2000, we have used this technique on 18 TOF patients with small PV annulus. All patients except 2 had a small bicuspid PV with varying degree of commissural fusion and tethering. The median age of these patients was 13.8 months (range, 9.7 to 35.6 months). The mean body weight was 10.7 kg (range, 8.3 to 14 kg). There was no operative mortality. No patient had significant pleural effusion or other postoperative complication. Two-dimensional echocardiography at discharge showed excellent valve motion with absent or mild PR in all patients (Fig 2).
The mean pressure gradient across the PV was 6.6 mm Hg (range, 3 to 10 mm Hg). Fifteen patients had the same degree of PR during the mean follow-up period of 10.6 months (range, 6 to 18.8 months). In 2 patients, PR had been aggravated from mild to moderate with good valve motion, and 1 patient improved from mild to trivial PR. All patients had excellent valve motion without thickening of the repaired PV and no significant increase of the mean pressure gradient through the valve at the last follow-up.
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Fig 2. Postoperative echocardiography shows a well-functioning large anterior pulmonic valve cusp. (LPA = left pulmonary artery; LVOT = left ventricular outflow tract; RPA = right pulmonary artery; RVOT = right ventricular outflow tract.)
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Comment
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Although the incidence of transannular RVOT reconstruction in repair of TOF varies among different centers, a certain portion of patients with TOF have been known to require a transannular patch. It has been well known that severe PR can adversely affect early and late outcomes of TOF repair [5, 6]. The transannular patching with a monocusp ventricular outflow patch has been a main operative technique to deal with the problem, but there have been some controversies about its effectiveness [3, 4].
We developed a simple technique to reduce PR by augmentation of a PV cusp during transannular enlargement. One of two important advantages of this technique over monocusp ventricular outflow patch is preservation of the hinge function of the native PV cusp, which provides better PV function. The second is its better versatility. It can be applicable even when only a small enlargement of the PV annulus is required, which is somewhat difficult when a monocusp ventricular outflow patch is used. Moreover, we hope that the reconstructed PV can keep its function for a long time because the functioning native PV tissue can grow. We have confirmed continuing excellent valve function without significant pressure gradient in most patients so far, even though the follow-up duration was not very long.
A major limitation of our technique is that it cannot be used in patients with very small and dysplastic PVs. However, it is not our policy to repair TOF in early infancy to avoid the need of transannular enlargement of PV at that age. We usually perform elective repair of TOF at approximately 1 year of age when the PV is usually sizable for reconstruction.
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References
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- Ellison R.G., Brown W.J., Jr, Yeh T.J., Hamilton T.J. Surgical significance of acute and chronic pulmonary valvular insufficiency. J Thorac Cardiovasc Surg 1970;60:549-558.[Medline]
- Helbing W.A., Niezen R.A., Le Cessie S., van der Geest R.J., Ottenkamp J., de Roos A. Right ventricular diastolic function in children with pulmonary regurgitation after repair of tetralogy of Fallot: volumetric evaluation by magnetic resonance velocity mapping. J Am Coll Cardiol 1996:1827-1835.
- Gundry S.R., Razzouk A.J., Boskind J.F., Bansal R., Bailey L.L. Fate of the pericardial monocusp pulmonary valve for right ventricular outflow tract reconstruction: early function, late failure without obstruction. J Thorac Cardiovasc Surg 1994;107:908-912.[Abstract/Free Full Text]
- Bigras J.L., Boutin C., McCrindle B.W., Rebeyka I.M. Short-term effect of monocuspid valves on pulmonary insufficiency and clinical outcome after surgical repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 1996;112:33-37.[Abstract/Free Full Text]
- Kirklin J.K., Kirklin J.W., Blackstone E.H., Milano A., Pacifico A.D. Effect of transannular patching on outcome after repair of tetralogy of Fallot. Ann Thorac Surg 1989;48:783-791.[Abstract]
- Carvalho J.S., Shinebourne E.A., Busst C., Rigby M.L., Redington A.N. Exercise capacity after complete repair of tetralogy of Fallot: deleterious effects of residual pulmonary regurgitation. Br Heart J 1992;67:470-473.[Abstract/Free Full Text]
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Abstract
Introduction
