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Ann Thorac Surg 2009;87:1220-1226. doi:10.1016/j.athoracsur.2008.12.083
© 2009 The Society of Thoracic Surgeons
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Right arrow Congenital - cyanotic

Original Articles: Pediatric Cardiac

Surgical Treatment of Anomalies With Discontinuity Between the Right Ventricle and the Pulmonary Arteries Without Use of an Extracardiac Conduit

Ing-Sh Chiu, MD, PhDa,*, M. Diva,b,c, Shu-Chien Huang, MDa,b,c,d, Shye-Jao Wu, MDa,b,c,d, Meng-Luen Lee, MDg, En-Ting Wu, MDb, Shyh-Jye Chen, MDc, Ming-Ren Chen, MDe,f

a Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
b Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
c Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
d Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan
e Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
f Mackay Medicine, Nursing and Management College, Taipei, Taiwan
g Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan

Accepted for publication December 24, 2009.

* Address correspondence to Dr Chiu, Department of Surgery, National Taiwan University Hospital, No. 7 Chung-Shan S. Rd, Taipei, 100, Taiwan (Email: ingsh{at}ntu.edu.tw).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Background: Reoperation is usually inevitable for congenital cardiac patients after insertion of an extracardiac valved conduit. We sought to verify that a transannular patch on the autologous posterior wall with the common wall between the aorta and pulmonary artery can replace the conventional operation using an extracardiac conduit.

Methods: From August 1997 to October 2007, 31 patients (age 15 days to 19.3 years) underwent a procedure of autologous pulmonary floor with common wall between the great arteries and transannular patch to correct a right ventricle to pulmonary artery discontinuity at our hospital. The posterior pulmonary pathways were reconstructed by direct or indirect ventriculoarterial connection using tissue in situ or donated from the dominant aorta or truncus in all cases. The aorta or truncus was tailored transversely or longitudinally to donate the inner or outer wall to the pulmonary pathway as needed.

Results: There was no surgical mortality, and late noncardiac death occurred in 1 patient (3%). The postoperative systolic right ventricular to aortic pressure ratio was 0.48 ± 0.11 in the operating theater, and the central venous pressure was 9 ± 2 mm Hg. The follow-up duration was 5.5 ± 3.3 years (range, 6 months to 10.6 years). In the follow-up echocardiography, significant pulmonary stenosis (pressure gradient > 40 mm Hg) was noted in 4 patients (13%). Follow-up computerized tomograms (n = 9) showed growth of the common wall.

Conclusions: The tissue deficiency of the pulmonary outflow tract could be recruited from the outer wall or inner wall of the large aorta or truncus in this disease category. We recommend such an operation to correct a right ventricle to pulmonary artery discontinuity without using an extracardiac conduit.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 
Extracardiac valved conduit has been adopted for reconstruction of the discontinuity between the right ventricle and the pulmonary artery since its invention in 1965 [1–4], yet the choice of conduit or valve has remained in debate [5–7]. Calcification of the heterograft or homograft has been documented [8–10], and even the autologous pericardial leaflet in the pulmonary pathway can become calcified, especially in young patients [11, 12]. Thus redo is inevitable after insertion of an extracardiac valved conduit, even in the present era of various interventional therapies. In contrast, a secondary operation is rare in patients with tetralogy of Fallot who have undergone total correction with a transannular patch [13, 14]. Furthermore, neither the homograft nor the bovine jugular vein graft (Contegra) was available in our institute. In 1996 we began to use the concept of a common wall to switch the great arteries in their transposition [15–17], and the following is our experience in applying the common wall to reconstruct the pulmonary outflow tract for the other congenital defects that would conventionally have required an extracardiac valved conduit.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 Acknowledgments
 References
 
From August 1997 to October 2007, 31 patients at our hospital underwent transannular patch with a common wall to establish a right ventricle to pulmonary artery continuity after obtaining informed consent from their parents. This retrospective study was approved by the institutional research ethical committee. The cardiac defects and associated lesions are listed in Table 1, including pulmonary atresia and ventricular septal defect (VSD), double-outlet right ventricle, complete transposition of the great arteries (TGA) or congenitally corrected TGA with VSD plus pulmonary stenosis (PS), persistent or created truncus arteriosus, and aortic valve disease or Ross operation. Patient age ranged from 15 days to 19.3 years (median, 3.3 years), with 9 patients younger than 2 years of age. The male to female ratio was 15:16. Previous palliation included central or right ventricle to pulmonary artery shunt through a median sternotomy in 8 patients, and Blalock-Taussig shunt in 4 patients. Six patients had natural coarctation of the left pulmonary artery near the ductal insertion site; 5 of them had been repaired at previous palliation. In all cases with a central shunt, the exposed area was covered with a surgical membrane (Gore-Tex, Flagstaff, AZ). Major aortopulmonary collateral arteries were coil embolized after the central shunt if not interrupted in palliative operation.


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  		Table 1 Diagnostic Category of Patients
 
All patients underwent computerized tomography before total correction to obtain clear status of residual collaterals and pulmonary arteries. After surgical correction, 27 patients underwent computerized tomography 1 year after total correction for follow-up. Nine of them had two examinations after operation for comparison.

A transannular patch with a common wall between the aorta and pulmonary trunk and the autologous posterior pulmonary pathway by direct or indirect ventriculoarterial connection was used in all cases. A monocusp made by a Gore-Tex membrane was used when there was elevated pulmonary artery pressure. Under endotracheal general anesthesia and through a median sternotomy, the substernal tissue was dissected free. The Gore-Tex membrane was extracted, and the shunt was dissected. After aortic and bicaval cannulation, the shunt was clipped and divided. Cardiopulmonary bypass was then instituted with moderate hypothermia. Blood cardioplegic solution was infused through the aortic root after aortic cross-clamping.

The pulmonary artery was opened after removal of the distal shunt, and the stenotic part was also opened if present (Figs 1A and 2A). After longitudinal ventriculotomy, the VSD was repaired or rerouted to the systemic outflow with a patch. The main pulmonary artery was connected with the right ventricle directly (Fig 1B) or indirectly (Fig 2B) using a 6-0 synthetic absorbable Maxon suture (Davis-Geck, Cyanamid, Hampshire, UK). The posterior ridge along the posterior pulmonary outflow was smoothed if present. The outer wall of the ascending aorta, after being cleaned of its adventitia at the planned site of the pulmonary pathway, was used as the common wall to augment the pulmonary artery. Finally, a piece of fresh pericardium was harvested and sutured to cover the right ventricular outflow tract (Figs 1C and 2C). Injury of the proximal right coronary artery was carefully avoided during stitching. The aortic cross-clamp was released after removing air and closure of the interatrial communication. The right ventricular portion and then the right atrium were closed. The patient was weaned from bypass after checking with transesophageal echocardiography and measurement of right ventricular and systemic pressures.


Figure 1
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  		Fig 1. Operative procedures used in patients with adequate tissue for direct connection. (A) The pulmonary artery was incised just before the orifice of the left pulmonary artery (LPA); note that it was fashioned so that an anterior flap (marked by *) could be everted down to the ventriculotomy (dashed line) for direct connection, and then sutured to the * mark at the end of the right ventriculotomy. The proximal pulmonary trunk was incised along the dotted line until the atretic orifice. The right ventricle (RV) was opened accordingly from the mark and extended rightward until the atretic fibrous portion, and the annulus was opened if present. (B) The left caudal aspect of the pulmonary artery incision was attached to the cephalic portion of the right ventriculotomy using Maxon suture, and extended upward to attach the right aspect of the pulmonary artery incision to the left side of the aorta after cleaning it of adventitia. Thus the right ventricle and pulmonary artery were connected obliquely. (C) A transannular patch (TAP) of fresh pericardium was used to cover the pulmonary outflow tract, without insertion of a valve. (Ao = aorta; LA = left atrium; LV = left ventricle; RA = right atrium.)

 

Figure 2
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  		Fig 2. Operative procedures using indirect connection of the right ventricle (RV) to the pulmonary artery. (A) The pulmonary artery was incised from the insertion site of the central shunt until the stenotic orifice of the right pulmonary artery was cut open behind the aorta (Ao; arrow). (B) The opened right pulmonary artery was sutured to the back of the ascending aorta, thus enlarging its stenotic orifice. Then the suture was continued caudally to attach its lower edge to the fibrous roof of the right ventricle, on which reactive visceral epicardium to a previously implanted surgical membrane was present. The right ventricle was opened distally and the distal part was smoothed out, then both medial and lateral ends were sutured in a horizontal fashion. (C) The anterior part of the right ventricular outflow tract was covered with a generous patch of fresh pericardium. The left lateral and posterior wall of the ascending aorta acted as a common wall between the systemic and pulmonary pathways, and also as an augmentation flap. Note that injury of the proximal right coronary artery (arrowhead) should be avoided. (LA = left atrium; LPA = left pulmonary artery; LV = left ventricle; RA = right atrium; TAP = transannular patch.)

 
For truncus arteriosus, a transverse incision on the truncus was done first, followed by a vertical extension (Fig 3A) to ascertain the status of the truncal valve and location of coronary orifices (Fig 3A, inset). An instrument was passed into the truncal root to probe the planned site of ventriculotomy. After oblique ventriculotomy (Fig 3B), the truncal annulus was opened from above between the right coronary and pulmonary cuspid, along with the outlet septum below it, until the cephalic margin of the VSD that was enlarged by anterior cutback was reached. The truncal wall above the pulmonary cuspid was everted to the left (Fig 3B, inset). The pulmonary orifice in the truncal wall and the pulmonary trunk were opened near the right side (Fig 3C). The rudimentary pulmonary cuspid was excised and a new commissure created (Fig 3C, inset). The neoaorta was reconstructed by suturing the flap (marked with #) directly to the intimal side of the truncus to exclude the pulmonary orifice. The cardioplegia solution was infused into the aortic root to check whether aortic regurgitation was still significant, and the VSD was then closed with a Dacron patch. The caudal edge of the everted flap and also that of the incised pulmonary trunk were sutured to the cephalic margin of ventriculotomy (Fig 3D) to reconstruct the posterior pulmonary pathway. Finally, the anterior portion of the pulmonary pathway was roofed with Gore-Tex (as depicted by a transparent patch along the shallow dashed line). A common wall was thus shared between the neoaorta and the pulmonary pathway.


Figure 3
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  		Fig 3. Operative technique of concomitant truncal valve repair and pulmonary artery reconstruction. Please refer to the text for details. (A = aorta; A' = everted truncal wall; G = Gore-Tex; LCA = left coronary artery; os = outlet septum; P = pulmonary trunk; RCA = right coronary artery; TAP = transannular patch.)

 
For TGA with left ventricular outflow obstruction (Fig 4), the ascending aorta was then amputated, and a curved segment (18 mm x 6 mm) was harvested (Fig 4A) and then reconnected (Fig 4B). The VSD was rerouted to the systemic outflow with a patch. The pulmonary trunk was also divided, and the proximal stump was closed. The aortic free graft was sutured to the distal pulmonary trunk with the greater curvature on the left side (Fig 4B). The lengthened pulmonary trunk was then connected directly to the cephalic margin of the ventriculotomy. Finally, a piece of fresh pericardium was harvested and sutured to cover the right ventricular outflow tract (Fig 4C).


Figure 4
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  		Fig 4. Operative technique of pulmonary artery reconstruction for transposition of the great arteries with irreparable left ventricular outflow obstruction. Please refer to the text for details. (Ao = aorta; Ao graft = short segment of free graft from the ascending aorta; LA = left atrium; LPA = left pulmonary artery; LV = left ventricle; RA = right atrium; TAP = transannular patch; VSD patch = ventricular septal defect patch repair.)

 

   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 Acknowledgments
 References
 
All patients survived without early mortality. There was one late noncardiac death attributable to hypoxic encephalopathy. The mean aortic cross-clamp time was 86.9 ± 35.0 minutes, and the cardiopulmonary bypass time was 186.1 ± 57.0 minutes. Intraoperative transesophageal echocardiogram revealed a widely patent right ventricular outflow tract in all patients (Fig 5). The postoperative systolic right ventricular to aortic pressure ratio was 0.48 ± 0.11 in the operating theater. None of the patients exhibited a pressure gradient across the annulus. The central venous pressure was low (9 ± 2 mm Hg).


Figure 5
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  		Fig 5. Follow-up transesophageal echocardiogram showing a widely patent right ventricular outflow tract (RVOT).

 
The follow-up duration was 5.5 ± 3.3 years (range, 6 months to 10.6 years). In the follow-up echocardiography, significant PS (pressure gradient > 40 mm Hg) was noted in 4 patients (13%). Three patients with pulmonary atresia and VSD had stenosis of the orifices of branch pulmonary arteries. One patient with truncus arteriosus had residual ventricular defect and bilateral pulmonary artery stenosis; reoperation was suggested. The other cases of truncus and all TGA/VSD/PS did not have significant PS. Pulmonary regurgitation was noted in all patients, with mild to moderate degree. Neither thrombus nor embolic events were ever detected.

Three-dimensional images of the reconstructed right ventricular outflow tract by computerized tomography are shown in Figure 6. The right ventricular outflow tract was widely patent on follow-up; no shrinkage was noted on the pulmonary floor. The common wall between the great arteries became thinner and larger by comparing two computerized tomograms after correction between a mean duration of 3.3 years (n = 9).


Figure 6
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  		Fig 6. Three-dimensional computed tomogram of a 16-month-old girl who underwent valveless outflow reconstruction, showing a patent outflow tract from the right ventricle to the pulmonary trunk (PT) 1 year after correction (top). Through the transparent anterior wall of the right ventricular outflow tract, the common wall (yellow color) between the pulmonary trunk and ascending aorta (Ao) was identified (B, E). The size of the common wall grew up after a follow-up of 6.5 years (bottom). On transverse cut film (C, F), it was evident that the common wall (arrow) became thinner and larger. Note the natural spiral relationship between the aorta and pulmonary trunk after in situ reconstruction. (lpa = left pulmonary artery; rpa = right pulmonary artery; svc = superior vena cava.)

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 Acknowledgments
 References
 
In this study, we found the method using autologous tissue and common wall is effective to reconstruct the right ventricular outflow tract. With a median 5-year follow-up only 13% had significant PS, mainly on the orifice of the branch arteries. This method could be an alternative to using an extracardiac conduit to repair a right ventricle to pulmonary artery discontinuity.

We originally reconstructed the tri-semilunar valve in the right ventricular outflow tract in case of absent pulmonary valve syndrome [18], but changed to a nonvalved procedure owing to calcification of the autologous pericardial valve [19]. In this communication, the monocusp made by a Gore-Tex membrane was used only when there was pulmonary hypertension; otherwise no valve was used. The concept of a common wall was first used in reconstruction of an aortopulmonary window and interrupted aortic arch [20, 21], and was later applied to the arterial switch operation both for coronary and pulmonary arterial reconstruction [15]. We found it can also be helpful to switch the great arteries in spiral fashion in complete or congenitally corrected TGA [16, 17]. In this communication, we applied this concept to cases that conventionally would have needed an extracardiac valved conduit. By this concept, the outer wall of the dominant aorta was used to augment the pulmonary pathway. Because the adventitia of the outer aorta inside the pulmonary circulation may grow into an intraluminal fibrous formation [15, 16], we recommend cleaning all aortic adventitia inside the pulmonary pathway until the white wall appeared. Neither anticoagulant nor antiplatelet agent was necessary after adequate cleaning. It might be questioned whether the aorta will be dilated later after its adventitia is peeled off. This was not observed in our longer follow-up of cases of spiral arterial with partial removal of aortic adventitia (up to 10 years) [17], and also has not been reported to our knowledge. In this study, we only remove the adventitia of the aortic part of the common wall, not the whole circumference.

In our opinion, a central approach to create the palliative shunt is preferable to a peripheral shunt [19], allowing the reactive visceral epicardium and underlying tissue to act as the posterior pulmonary pathway to fill the gap between the pulmonary arteries and the ventriculotomy (Fig 2). This gap can also be filled with the flap from the anterior pulmonary trunk by tailoring it directly downward or obliquely downward (Fig 1). One-stage correction was used when direct connection of the right ventricle to the pulmonary artery was feasible (Fig 1). Besides the above method for indirect connection, we proposed the following idea. Some part of the dominant arterial trunk in cyanotic congenital cardiac defects should be recruited and shared with the nondominant pulmonary circulation, as shown in Figures 3 and 4. For persistent truncus arteriosus, it was shared in longitudinal fashion (Fig 3) along with the so-called pulmonary cuspid that originally belonged to the pulmonary circulation [22, 23]. For truncal regurgitation, we are not the first to omit one cuspid to make the truncal valve competent [24], but we now also use the truncal wall above the pulmonary cuspid along with this cuspid for augmentation of the pulmonary pathway [23]. In complete TGA with left ventricular outflow obstruction, a segment of the aorta was cut in transverse fashion and donated to the pulmonary circulation to establish the ventriculoarterial continuity (Fig 4). End-to-end anastomosis of the ascending aorta after excision of a segment also decreased the gap between the right ventriculotomy and the pulmonary artery, so that the aortic free graft could achieve its bridging effect equivalent to the conventional conduit of double length but without aortic shortening. This advantage of aortic shortening is also observed in patients undergoing the Nikaidoh operation with aortic shortening [25]. We agree with Metras and coworkers [26] that the Lecompte maneuver to mobilize the pulmonary bifurcation anterior to the aorta is unnecessary and not rational. This is because if the pulmonary bifurcation is left in situ as it is originally by nature, the chance for suprapulmonary stenosis is decreased [16, 17]. It is worth mentioning that our direction for the free graft of this curved aortic segment is opposite to that reported by Metras and associates [26].

The major concern of this technique is the presence of pulmonary regurgitation. The detrimental effect of pulmonary regurgitation was shown in the patients with repaired tetralogy of Fallot after long-term follow-up [27]. We recommend long-term follow-up of these patients with echocardiography, magnetic resonance imaging, and electrophysiologic study. Significant dilatation of the right ventricle (>3 times normal), sign of right ventricular failure, and ventricular arrhythmia were possible indications for pulmonary valve replacement. This was not necessary in the present series, but we emphasize that the importance of ensuring a competent tricuspid is indispensable in the valveless right ventricular outflow reconstruction. In addition, a smooth pulmonary pathway is also needed [28]. All our cases with a significant PS occurred at the origin of the branch pulmonary arteries from the pulmonary trunk.

The limitations of this study are that the number of cases and duration of follow-up are not enough. Long-term follow-up is mandatory to verify the results. It has been reported that the direct connection technique reduces the need for reoperation [12], and the Gore-Tex transannular patch hood over it had the lowest rate for catheter-based intervention [29]. A coronary crossing the right ventricular outflow tract would prevent our approach, and our approach would be modified. However, no such coronary pattern was encountered during our study period, nor did we use a conventional conduit to correct a right ventricle to pulmonary artery discontinuity.

In conclusion, the tissue deficiency of the pulmonary outflow tract could be recruited from the outer wall or whole flap of the larger arterial trunk in this disease category. We recommend a transannular patch with a common wall between the great arteries on the autologous floor by direct ventriculoarterial connection, or indirectly by local tissue or those donated from the dominant aorta or truncus (longitudinally or transversely). Long-term follow-up is mandatory for such an operation to correct a right ventricle to pulmonary artery discontinuity without using an extracardiac conduit.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
Acknowledgments
 References
 
DR JAMES S. TWEDDELL (Milwaukee, WI): Thank you, Dr Huang, that was an excellent presentation of an innovative technical approach to right ventricular outflow tract reconstruction. The authors have in some cases borrowed from the larger aorta to compensate for the smaller pulmonary artery. Doctor Chiu has called this the Robin Hood approach or perhaps in the current vernacular a redistributive approach.

You stated in your manuscript that all the patients underwent preoperative CT (computed tomography) scan, and I found this to be a very innovative approach to evaluating these patients. You also discussed a little bit about the potential for pulmonary hypertension in some of these patients, and I just wanted to know if they also underwent a preoperative cardiac catheterization.

DR HUANG: Almost all patients underwent CT scan in this category in our hospital. For the cardiac catheterization, some of them did have cardiac catheterization before operation and some of them did not have cardiac catheterization before operation. In our institute the CT scan could show the detail of the pulmonary artery as well as the existence of coronary artery anomaly or not, and even the airway condition. The radiologist made the construction 3-D (three-dimensional) for us for better surgical planning. So the CT scan is usually performed for this category of patient.

DR TWEDDELL: In your manuscript you mentioned using a monocusp in patients with pulmonary hypertension. Was there a specific degree of pulmonary hypertension or elevation of pulmonary vascular resistance that would prompt you to use a monocusp immediately or did you assess each patient individually?

DR HUANG: Usually if we perform the operation in the neonate or early infancy we do use a monocusp. Otherwise if the pulmonary pressure is above like a mean of 25 mm Hg, we will consider putting a monocusp on the right ventricular outflow tract.

DR TWEDDELL: So for patients with truncus arteriosis you would routinely use a monocusp?

DR HUANG: These patients are operated on in the neonatal period, so, yes.

DR TWEDDELL: I thought the repair technique for the truncal valve and combining that with your outflow tract reconstruction was very innovative, but this reconstruction technique would limit truncal valve repair to resection of the so-called pulmonary cusp of the truncal valve. I wonder when using the cusp resection technique if the pulmonary cusp is always the one that is appropriate to resect. Perhaps one of the other cusps might be more hypoplastic and therefore more appropriate for resection. I know the group from Chicago has written about this technique in particular, and it seems to me that the surgeon must assess all four cusps to see which one is the smallest or the most rudimentary or thickened one. So has this approach been completely successful?

DR HUANG: We do not have many cases with truncus arteriosus in our institute, so we cannot say it could apply to all the patients. But for these few patients it seems to work, because we can see the four cusps on the preoperative echocardiography or CT scan to have a preoperative plan. It is also worth mentioning that from our studies and previous report [23], the sinus occupied by the pulmonary cuspid, usually devoid of coronary arterial orifice, was located on the left anterior lateral truncal circumferences.

DR TWEDDELL: What about the patient with a significant coronary that crosses over the outflow tract. How did you manage those cases and were there some cases where the coronary artery anatomy might prohibit you from using your approach?

DR HUANG: In this series the coronary artery crossing the RVOT (right ventricular outflow tract) was not encountered in this group. Most of these patients are pulmonary atresia with ventricular septal defect. So even if the coronary artery crosses the right ventricle, you can try to amputate the pulmonary trunk and make the continuity to the newly created ventriculotomy on the right ventricle, but that is not included in this series.

DR TWEDDELL: Well, your results are very good. You have avoided the mandatory reoperation associated with using an RV (right ventricle) to PA (pulmonary artery) conduit, but now you have patients with significant pulmonary insufficiency. For that group of patients, our criteria for intervening are a little less precise, and I was wondering how are you going to follow those patients and do you have criteria for reintervention on this group with pulmonary insufficiency?

It was an excellent talk and thank you very much for allowing me to discuss it.

DR HUANG: So far these patients were followed up with echocardiography, and for some patients we did an MR (magnetic resonance) image study for the pulmonary insufficiency, and the right ventricle function as well. And we did not have an absolute criteria for the pulmonary valve implantation in our institute yet, but in our discussions we think that the presence of ventricular arrhythmia or significant right ventricular dilatation such as right ventricular end diastolic volume over 150 mL/m2 and significant pulmonary regurgitation with sign of right ventricular failure are possible indicators for pulmonary valve replacement for these patients.

DR J. WILLIAM GAYNOR (Philadelphia, PA): I really enjoyed your talk. This is a very interesting technique. In the early 1990s before Tom Spray and I came to Philadelphia, Dr Norwood performed RV outflow tract reconstruction with a very similar technique using the outer aortic wall. As a note of caution, if you need to reoperate on these patients and get to the right pulmonary artery or to the main pulmonary artery bifurcation or cross-clamp the aorta, it can be very difficult. There is really no way to get around the aorta without entering the RV outflow tract. So you do create potential problems with this technique. Over their lifetime, these patients are probably going to come to reoperation. So you need to be very careful, and it can be a very, very difficult reoperation, because there is no way to separate the ascending aorta from the RV outflow tract.

I enjoyed your presentation.

DR HUANG: Thank you.

DR MICHAEL HINES (Winston-Salem, NC): I think that we recognize that this is a very clever way to deal with a problem in a country where you do not have allografts available, and we hope in 10 years you present a paper on how to reoperate these patients.

DR HUANG: Recently after operation we place a Gore-Tex strip around the ascending aorta so that we can have an easier reoperation, and recently we do place a Gore-Tex surgical membrane to close the pericardium. So we will be prepared for the next 10 years.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
References
 
This study was supported by a grant from the National Science Council (NSC95-2314-B-002-259). We are indebted to Wei-Te Lin, PhD, Chang-Ying Lin, and Ju-Hsiu Cheng for their assistance.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 Acknowledgments
 References
 

  1. Rastelli GC, Ongley PA, Davis GD, Kirklin JW. Surgical repair for pulmonary valve atresia with coronary-pulmonary artery fistula: report of case Mayo Clin Proc 1965;40:521-527.[Medline]
  2. McGoon DC, Rastelli GC, Ongley PA. An operation for the correction of truncus arteriosus JAMA 1968;205:69-73.[Abstract/Free Full Text]
  3. Rastelli GC. A new approach to "anatomic" repair of transposition of the great arteries Mayo Clin Proc 1969;44:1-12.[Medline]
  4. Ross DN, Somerville J. Correction of pulmonary atresia with a homograft aortic valve Lancet 1966;2:1446-1447.[Medline]
  5. O'Brien MF, Stafford EG, Gardner MAH, Pohlner PG, McGiffin DC. A comparison of aortic valve replacement with viable cryopreserved and fresh allograft valves, with a note on chromosomal studies J Thorac Cardiovasc Surg 1987;94:812-823.[Abstract]
  6. Sano S, Karl TR, Mee RB. Extracardiac valved conduits in the pulmonary circuit Ann Thorac Surg 1991;52:285-290.[Abstract/Free Full Text]
  7. Mohammadi S, Belli E, Martinovic I, et al. Surgery for right ventricle to pulmonary artery conduit obstruction: risk factors for further reoperation Eur J Cardiothorac Surg 2005;28:217-222.[Abstract/Free Full Text]
  8. Stark J, Bull C, Stajevic M, Jothi M, Elliott M, de Leval M. Fate of subpulmonary homograft conduits: determinants of late homograft failure J Thorac Cardiovasc Surg 1998;115:506-516.[Abstract/Free Full Text]
  9. Niwaya K, Knott-Craig CJ, Lane MM, Chandrasekaren K, Overholt ED, Elkins RC. Cryopreserved homograft valves in the pulmonary position: risk analysis for intermediate-term failure J Thorac Cardiovasc Surg 1999;117:141-146.[Abstract/Free Full Text]
  10. Hickey EJ, McCrindle BW, Blackstone EH, et al. Jugular venous valved conduit (Contegra) matches allograft performance in infant truncus arteriosus repair Eur J Cardiothorac Surg 2008;33:890-898.[Abstract/Free Full Text]
  11. Dearani JA, Danielson GK, Puga FJ, et al. Late follow-up of 1095 patients undergoing operation for complex congenital heart disease utilizing pulmonary ventricle to pulmonary artery conduits Ann Thorac Surg 2003;75:399-411.[Abstract/Free Full Text]
  12. Isomatsu Y, Shin'oka T, Aoki M, et al. Establishing right ventricle-pulmonary artery continuity by autologous tissue: an alternative approach for prosthetic conduit repair Ann Thorac Surg 2004;78:173-180.[Abstract/Free Full Text]
  13. Murphy JG, Gersh BJ, Mair DD, et al. Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot N Engl J Med 1993;329:593-599.[Medline]
  14. Kirklin JK, Kirklin JW, Blackstone EH, Milano A, Pacifico AD. Effect of transannular patching on outcome after repair of tetralogy of Fallot Ann Thorac Surg 1989;48:783-791.[Abstract/Free Full Text]
  15. Chiu IS, Chen SJ, Wu SJ, et al. Modified arterial switch operation by sharing the common wall between the great arteries J Formos Med Assoc 2001;100:77-82.[Medline]
  16. Chiu IS, Wu SJ, Chen MR, et al. Modified arterial switch operation by spiral reconstruction of the great arteries in transposition Ann Thorac Surg 2000;69:1887-1892.[Abstract/Free Full Text]
  17. Chiu IS, Wang JK, Wu MH. Spiral arterial switch operation in transposition of the great arteries J Thorac Cardiovasc Surg 2002;124:1050-1052.[Free Full Text]
  18. Chiu IS, Chao SF, Wu MH, et al. Reconstruction of right ventricular outflow tract by autologous pericardial tri-semilunar valve with sinus of Valsalva: report of a case with absent pulmonary valve J Formos Med Assoc 1989;88:718-721.
  19. Chiu IS, Chen MR, Chen SJ, et al. Valveless outflow reconstruction using autologous tissue as a posterior wall for pulmonary atresia with ventricular septal defect J Formos Med Assoc 2001;100:162-167.[Medline]
  20. Chiu IS, Wang JK, Wang MJ, Wang CC. One-stage repair of aortopulmonary septal defect and interrupted aortic arch Ann Thorac Surg 1994;58:1529-1532.[Abstract/Free Full Text]
  21. Chiu IS, Wu SJ, Lee ML. One-stage repair of interrupted aortic arch and aortopulmonary window with an autologous arterial flap J Card Surg 1999;14:306-309.[Medline]
  22. Van Praagh R, Van Praagh S. The anatomy of common aorticopulmonary trunk (truncus arteriosus communis) and its embryologic implications: a study of 57 necropsy cases Am J Cardiol 1965;16:406-425.[Medline]
  23. Chiu IS, Wu SJ, Chen MR, Chen SJ, Wang JK. Anatomic relationship of the coronary orifice and truncal valve in truncus arteriosus and their surgical implication J Thorac Cardiovasc Surg 2002;123:350-352.[Free Full Text]
  24. Mavroudis C, Backer CL. Surgical management of severe truncal insufficiency: experience with truncal valve remodeling techniques Ann Thorac Surg 2001;72:396-400.[Abstract/Free Full Text]
  25. Morell VO, Wearden PD. Nikaidoh operation for transposition of the great arteries with a ventricular septal defect and pulmonary stenosis. Multimedia Manual of Cardiothoracic Surgery doi:10.1510/mmcts.2006.002337.[Abstract/Free Full Text]
  26. Metras D, Kreitmann B, Riberi A, et al. Extending the concept of the autograft for complete repair of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction: a report of ten cases of a modified procedure J Thorac Cardiovasc Surg 1997;114:746-753.[Abstract/Free Full Text]
  27. Ammash NM, Dearani JA, Burkhart HM, Connolly HM. Pulmonary regurgitation after tetralogy of Fallot repair: clinical features, sequelae, and timing of pulmonary valve replacement Congenital Heart Dis 2007;2:386-403.
  28. Godart F, Houyel L, Lacour-Gayet F, et al. Absent pulmonary valve syndrome: surgical treatment and considerations Ann Thorac Surg 1996;62:136-142.[Abstract/Free Full Text]
  29. Chen JM, Glickstein JS, Davies RR, Mercando ML, Hellenbrand WE, Mosca RS. The effect of repair technique on postoperative right-sided obstruction in patients with truncus arteriosus J Thorac Cardiovasc Surg 2005;129:559-568.[Abstract/Free Full Text]



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I.-S. Chiu, M.-R. Chen, S.-C. Huang, M.-L. Lee, H.-E. Tsai, S.-J. Chen, and H.-C. Lue
Restoration of Transposed Great Arteries to Nature
World Journal for Pediatric and Congenital Heart Surgery, April 1, 2011; 2(2): 287 - 295.
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