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Ann Thorac Surg 1999;68:982
© 1999 The Society of Thoracic Surgeons
a Pediatric Cardiac Surgery, Hesperia Hospital, Via Arqua 80, 41100 Modena, Italy
Invited commentary
The 1
ventricle repair has introduced the basic principle by which a pulmonary ventricle guarded by an atrioventricular valve, even if hypoplastic or diminutive, should no longer be disregarded and simply included in the Fontan circulation.
To simplify this matter, complicated by the heterogeneity of the anomalies treatable by a double source of pulmonary blood flow, I would like to propose that the patient should be considered as belonging to one of two groups: (a) those with small tricuspid valve and annulus; or (b) those with normal or dilated tricuspid valve annulus.
Then, all those patients with a tricuspid valve diameter less than 75% than that of the inferior vena cava will have a ventricle of insufficient size to propel the entire cardiac output into the pulmonary arteries. Such hearts should be corrected with the support of a cavopulmonary anastomosis. Relative atrial pressure measurements after repair, with a precalibrated atrial communication left open or closed, will guide the decision regarding the need for allowing atrial decompression.
When, instead, the tricuspid valve diameter is normal or enlarged, the adjunct of a cavopulmonary anastomosis will find its indication based on right ventricle morphology and function. A hypertrophic right ventricle, exposed to long-lasting hypertension and cyanosis, will most likely benefit from the preload reduction secondary to a partial cavopulmonary connection. For particular cardiac malformations in which a surgically created large left ventricular aortic tunnel occupies a significant portion of the right ventricular cavity, a cavopulmonary anastomosis might prevent a frequently observed postoperative right ventricular failure. In both circumstances, a band on the right pulmonary artery proximal to the anastomosis is often necessary to protect from possible superior caval hypertension. On the other hand, when the right ventricle is dilated and poorly contracting because of chronic postoperative pulmonary insufficiency, the role of cavopulmonary connection in supporting the ventricle is still uncertain. Such a ventricle will simply benefit from a competent pulmonary valve, to be implanted shortly after the onset of symptomatic right ventricular dilation.
Although decisions in favor of a one and one-half ventricle repair assisted by a cavopulmonary anastomosis, with or without adjustable atrial septal defect, with or without proximal right pulmonary artery band to protect from later superior vena caval hypertension, might be not totally unanimous, none could deny that contributions such as the one presented by Mavroudis and associates add more hope for children with complex congenital heart malformations having a less than optimal right ventricle.
Related Article
Ann. Thorac. Surg. 1999 68: 976-981.
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