Ann Thorac Surg 2009;87:1884. doi:10.1016/j.athoracsur.2009.03.055
© 2009 The Society of Thoracic Surgeons
Original Articles: Pediatric Cardiac
Invited Commentary
Glenn J. Pelletier, MD
St. Christophers Hospital for Children, Erie Ave at Front St, Philadelphia, PA 19134
(Email: gpelleti{at}drexelmed.edu).
Surgical repair of pulmonary stenosis, particularly with the use of a transannular patch, often leads to pulmonary regurgitation (PR) because the pulmonary valve is rendered incompetent. With time, the resultant volume load on the right ventricle (RV) causes enlargement and dysfunction of this chamber and produces heart failure, ventricular arrhythmias, and even sudden death. Generally this process evolves for decades after the primary repair, and is frequently compensated for much of that time. However, much attention has recently been made to identify specific, objective indicators of RV dysfunction, or more broadly biventricular failure that can identify patients who may benefit from timely therapeutic intervention for the PR. Measurements such as RV end-diastolic or end-systolic volumes, RV stroke volume, left ventricular stroke volume, left ventricular end-diastolic volume, PR fraction, RV ejection fraction, and RV dilatation index have been applied to this situation. For example, an indexed RV end-diastolic volume of approximately 160 mL/m2 is accepted by some as a threshold for recommending surgery to restore valvar competence in the right ventricular outflow tract.
Once the decision is made to intervene for severe pulmonary regurgitation, the choices become the method to use and the type of valve to construct or implant. Historically, pulmonary valve replacement with a homograft or stented prosthesis has been the mainstay of surgical therapy. These operations are often successful at eliminating the pulmonary regurgitation, facilitating RV remodeling, and ameliorating signs and symptoms of heart failure. The introduction of stentless xenografts provided an alternative source for valves that expanded the surgeon's armamentarium. Recently, a percutaneous pulmonary valve implantation technique was developed, and with it came a less invasive method for pulmonary valve replacement that may be better suited for some patients. Regardless of the type of pulmonary valve replacement chosen, the long-term durability of the implanted valve is not infinite. Therefore, a strategy to repair the native pulmonary valve, albeit after the valve has been surgically made incompetent, is intriguing. Papadopoulos and colleagues [1] present a series of 7 patients, all of whom had severe PR with accompanying RV dilation or dysfunction as a consequence of a previous procedure to relieve pulmonary stenosis. Their techniques are resourceful and creative, and have produced good, short-term results. Curiously, enough native valve tissue was present in these patients to afford the opportunity for valve repair. Insofar as these valve repair techniques may be widely applied to patients with acquired PR after prior surgery to relieve pulmonary stenosis, time will provide the evidence. Furthermore, the long-term durability of "secondary repair of incompetent pulmonary valves" remains uncertain. However, this work may stimulate other surgeons to perform these valve reparative operations more frequently to help clarify its role in the treatment of severe PR with RV dysfunction.
 |
References
|
|---|
- Papadopoulos N, Esmaeili A, Zierer A, Bakhtiary F, Özaslan F, Moritz A. Secondary repair of incompetent pulmonary valves Ann Thorac Surg 2009;87:1879-1884.[Abstract/Free Full Text]
Related Article
-
Secondary Repair of Incompetent Pulmonary Valves
- Nestoras Papadopoulos, Anoosh Esmaeili, Andreas Zierer, Farhad Bakhtiary, Feyzan Özaslan, and Anton Moritz
Ann. Thorac. Surg. 2009 87: 1879-1884.
[Abstract]
[Full Text]
[PDF]
Top
References