Ann Thorac Surg 2008;85:178. doi:10.1016/j.athoracsur.2007.10.086
© 2008 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Juan V. Comas, MD, PhD
Paediatric Heart Institute, Hospital Universitario "12 de Octubre", Carretera de Andalucía, km 5, 400, Edificio Materno-Infantil, 28041 Madrid, Spain
(Email: jvc{at}mi.madritel.es).
The management of truncus arteriosus has evolved, and results are now more consistent [1]. As has been well described, however, the primary approach to truncus arteriosus and to significant associated lesions, such as interrupted aortic arch and truncal valve insufficiency, remain the major risk factors for reoperation and mid to late survival rates. The initial management of truncal valve is a good example of the problems that arise when pediatric cardiac surgeons try to standardize therapy.
The lack of consensus on timing and surgical techniques for treatment of moderate or severe truncal valve insufficiency impacts mid- and long-term outcomes. Nowadays, rational analysis of specific lesions and possible solutions is recommended. The following are influential lesions that may impact results:
- 1 Truncal valve morphology that includes dysplastic, dysfunctional, and an abnormal number of leaflets; conal septal hypoplasia; and valve prolapse due to the ventricle septal defect (VSD) should be considered.
- 2 Aortic arch obstruction and anomalous coronary anatomy are important associated lesions.
- 3 Morphology of the pulmonary arteries and their relationship to the aorta should be inspected.
The following are some influential solutions that have contributed to improved results:
- 1 Use of direct anastomosis, patch interposition, or conduit to produce truncal valve/aorta continuity.
- 2 Improve truncal valve function by truncal valve replacement, commissuroplasty, external or internal annuloplasty, truncal valve reduction, creating a functional tricuspid semilunar valve, or attachment of edges of prolapsed leaflets.
- 3 VSD closure using appropriate right ventriculotomy and patch size.
I have found the following procedures and guidelines to be helpful:
- 1 For moderate to severe truncal valve insufficiency, truncal valve repair is the most desirable and first choice.
- 2 Multiple leaflets (more than three) require careful attention.
- 3 Carefully consider the efficacy of different valvuloplasty alternatives.
- 4 Avoid valve replacement as a first option.
- 5 Prevent injury to truncal valve commissures during dissection of pulmonary arteries.
- 6 Try to construct an ascending aorta of uniform diameter, usually by using a direct anastomosis to reestablish truncal valve–aortic continuity.
- 7 Limit the incision distance of your right ventriculotomy through the truncal valve orifice.
- 8 Close the VSD with a large patch that is a larger size than the truncal valve orifice.
- 9 Assess the function of the truncal valve using an infusion of cardioplegia through the ascending aorta; view the valve from the right ventricle before finishing the VSD closure.
- 10 Take advantage of a perioperative transesophageal echocardiographic evaluation, and remember that truncus arteriosus is a challenging disease so repair.
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References
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- Henaine R, Azarnoush K, Belli E, et al. Fate of the truncal valve in truncus arteriosus Ann Thorac Surg 2008;85:172-178.[Abstract/Free Full Text]
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Fate of the Truncal Valve in Truncus Arteriosus
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