Bioprosthetic pulmonary valve replacement yasuhiro kotani, md, phd and shingo kasahara, md, phd an increasing number of patients will require pulmonary valve replacement following repair of tetralogy of fallot. Ventricular septal defect a hole in the wall of the heart septum. A functioning pulmonary valve does not improve immediate postsurgical outcomes. Pulmonary valve replacement in adult congenital cardiac surgery. At the time of corrective surgery, the pulmonary annulus was considered large enough to avoid a transannular patch in 69% of the infants. Pulmonary valve stenosisvalvectomy with transannular patch. Monocusp valve placement in children with tetralogy of fallot. Pulmonary valve stenosis a narrowed or completely blocked pulmonary valve, which restricts blood flow from the valve to the lungs. Nevertheless, the majority of patients in need of a valve have a native, nonobstructive right. This facilitates early recovery after surgery, and benefits can persist in the medium to long term.
Transannular patching is a valid alternative for tetralogy of. Pitkanen, eero jokinen, heikki sairanen, need of transannular patch in tetralogy of fallot surgery carries a higher risk of reoperation but has no impact on late survival. The need to insert a transannular patch during reconstruction surgery of the right ventricular outflow results in pulmonary insufficiency which, associated with other residual defects interventricular communication, obstruction in the pulmonary branches, creates volume overload, ventricular dysfunction requiring subsequent reinterventions. Tetralogy of fallot tof is one of the most common congenital heart diseases for which patients are referred for postoperative magnetic resonance mr imaging evaluation. Reprinted with permission from annals of thoracic surgery, vol 93, mainwaring rd, pirolli t, punn r, hanley fl. Early balloon dilatation of the pulmonary valve in infants.
Pulmonary valve replacement in adult congenital cardiac. Early and 1year outcome and predictors of adverse outcome. During the past several decades, several groups have favored the use of either a limited tap, or the use of an infundibular sparring approach. The problems related with primary repair for tetralogy of. Mar 30, 2017 tetralogy of fallot tof with pulmonary stenosis is the common form of tetralogy of fallot, and it is the focus of this article. Since then, several operative techniques have been re ported, including transatrial repair of the vsd and. The most common surgical procedures for tof repair include infundibulectomy, transannular pulmonary artery patch repair, and right ventriclepulmonary artery conduit placement. The operative repair of rvot obstruction generally requires either resection of the dysplastic valve or widening of the pulmonary valve annulus using a transannular patch. Tetralogy of fallot is a conotruncal defect resulting from anterior malalignment of the infundibular septum. The transannular patch technique was used to relieve the obstruction at the level of the annulus, which lead to the wellknown, longterm problems associated with free pulmonary valve regurgitation pr, including right ventricular dilation and dysfunction. Objectives to identify predictors of morbidity and mortality in patients undergoing either transcatheter pulmonary valve replacement tpvr or surgical pulmonary valve replacement spvr in an effort to quantify any early benefit of tpvr over spvr.
This insufficiency progressed over time and eventually resulted in right ventricular enlargement. Transannular patching was reported to be a significant risk factor for reoperation by kirklin et al. Tetralogy of fallot with pulmonary stenosis treatment. Early outcomes in patients undergoing transcatheter versus. At our institution we have made a conscious effort to avoid the use of transannular patching to preserve a functional pulmonary valve. Patients were analyzed on the basis of diagnosis and the method of right ventricular outflow tract reconstruction.
This patch covers part of the wall of the right ventricle as well as widening the pulmonary artery and pulmonary valve. Effect of transannular patching on outcome after repair of. Jun 29, 20 tetralogy of fallot tof is one of the most common congenital heart diseases for which patients are referred for postoperative magnetic resonance mr imaging evaluation. Most of these patients have a history of surgical repair with a transannular patch ie, pulmonary valve not preserved. If the pulmonary valve is too small for surgical or balloon valvuloplasty, it may be. Pulmonary valve stenosis a narrowed or completely blocked pulmonary valve, which restricts blood flow from the. Tetralogy of fallot tof with pulmonary stenosis is the common form of tetralogy of fallot, and it is the focus of this article.
Transesophageal echocardiography is utilized to help assess adequacy of repair. Valvesparing surgery for tetralogy of fallot cleveland clinic. Need of transannular patch in tetralogy of fallot surgery carries a. Because of the presence of the pulmonary valve dysplasia, a transannular patch to enlarge the narrowed right ventricular outflow tract and pulmonary artery is required. To correct pulmonary regurgitation, the use of bioprosthesis is the first choice at our center. Reoperation, most commonly a pulmonary valve replacement, was performed for 121 patients. Transcatheter pulmonary valve implantation medical clinical. Iorio, gianluca oricchio, roberta iacobelli, antonio amodeo, roberto m.
Fresh autologous pericardium to reconstruct the pulmonary. Need of transannular patch in tetralogy of fallot surgery. Use of a pulmonary neovalve with a transannular patch for repair. The integrity of the pulmonary valve annulus is spared whenever possible to maintain pulmonary valve competence.
Value of pulmonary annulus area index in predicting. The surgeon cuts across the abnormal pulmonary valve, removes the abnormal valve and places a patch to create an open connection between the right ventricle and pulmonary artery. Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of fallot petros anagnostopoulos, anthony azakie, shobha natarajan, nelson alphonso, michael m. Tetralogy of fallot with absent pulmonary valve syndrome.
Consecutive patients who underwent icr with transannular patch and monocuspid valve reconstruction of rvot for tof for a 6month period from 1 may 2011 were included in the study after obtaining their informed consent. The main concern for this transannular patch is that the integrity of pulmonary valve will be damaged, which results in postoperative pulmonary regurgitation. Isthmus 1 is located between the tricuspid annulus and right ventricular rv outflow tract rvot patchrv incision, isthmus 2 between rvot patchrv incision and pulmonary valve, isthmus 3 between pulmonary valve and ventricular septal. Monocusp valve placement in children with tetralogy of fallot undergoing repair with transannular patch. Pulmonary stenosis congenital heart disease cove point. A new pulmonary valve cusp plasty technique markedly. Jan 17, 2017 3d lifeprints, with alder hey surgeon rafael guerrero and giuseppe pelella, simulate the process of applying a transannular patch to the pulmonary artery of a 3d printed silicon model supplied by. In patients with tetralogy of fallot tof, use of transannular patch tap may be required in order to relieve significant right ventricular outflow tract obstruction, subsequently resulting in pulmonary insufficiency pi. Recent evidence indicates, however, that use of a transannular patch can cause pulmonary insufficiency, or weakness in the pulmonary valve that allows backflow of blood into the right ventricle. Pulmonary valve restitution following transannular patch repair of. However, if there is also a need to widen the outflow tract of the right ventricle, a transannular patch may be required. Valvesparing surgery for tetralogy of fallot procedure details. Careful attention must be taken to prevent transannular leak at this level. A traditional procedure involves closing the ventricular septal defect and placing a transannular patch a patch across the pulmonary valve connective tissue to.
Chronic pulmonary insufficiency following transannular patch repair of tetralogy of fallot may mandate restoration of a competent pulmonary valve. However patch augmentation of pulmonary valve alone leads to pulmonary insufficiency which causes right ventricle volume overload, right ventricle failure and fatal arrhythmias. A simple method to obtain pulmonary competence in cases requiring a transannular patch tap for surgical correction is the implantation of an expanded polytetrafluoroethylene ptfe monocusp valve. Percutaneous pulmonary valve implantation ppvi in non. We then narrow the transannular patch with the use of a series of clips under echocardiographic guidance to reduce the amount of pulmonary insufficiency without creating a gradient of more than 15 mm hg supplemental fig k. Among 814 patients undergoing repair of tetralogy of fallot with pulmonary stenosis between 1967 and may 1986, transannular patching in the current era was a weak risk factor for death early postoperatively predicted 30day mortality, 4% with a transannular patch and 1. Tetralogy of fallot and pulmonary valve replacement. A transannular patch is sewn in place supplemental fig j, and the patient is weaned from cardiopulmonary bypass. Surgery for congenital heart defect, third edition.
We hypothesized that the pulmonary annulus area index paai, the pulmonary. Total repair of tetralogy of fallot requires cardiopulmonary bypass and aortic. Methods using a riskadjusted propensity score model, we compare early major morbidity and mortality between patients undergoing spvr and tpvr. Precisely evaluating the need for transannular patch tap placement is very important in the surgical treatment of tetralogy of fallot. Pulmonary valve restitution following transannular patch. If a patch is inserted, it may be used to widen the pulmonary artery from the valve upward. Mar 15, 2018 transcatheter pulmonary valve replacement tpvr is one of the most exciting recent developments in the treatment of chd and has evolved to become an attractive alternative to surgery in patients with right ventricular outflow tract rvot dysfunction. The valve leaflets are tucked in place with the ring. Five patients with initial pulmonary valve sparing operations required reoperation for residual stenoses. Valvesparing surgery for tetralogy of fallot procedure. The word tetralogy means a group of 4, and in tetralogy of fallot, there are 4 heart defects that occur in combination.
A novel predictive value for the transannular patch enlargement in. The monocusp valve has been used to temporarily reduce insufficiency in hopes to improve short and midterm outcomes. Jun 11, 20 because of the presence of the pulmonary valve dysplasia, a transannular patch to enlarge the narrowed right ventricular outflow tract and pulmonary artery is required. Transannular patch repair of doubleoutlet right ventricle. A commissurotomy is performed for a tight valve stenosis. An increasing number of patients will require pulmonary valve replacement following repair of tetralogy of fallot.
Transannular goretex patch with pericardial unicusp for. Bioprosthetic pulmonary valve replacement sciencedirect. Approval for the study was obtained from the institutional ethical committee. The narrowing in the pulmonary valve is also repaired with the transannular patch to improve blood flow to the lungs.
Bioprosthetic pulmonary valve replacement operative. Pulmonary valve cusp augmentation with autologous pericardium. The authors concluded that transcatheter pulmonary valve implantation using the melody valve within bpvs can be accomplished with a high rate of success, low procedurerelated morbidity and mortality, and excellent shortterm results. Pulmonary atresia university of maryland childrens hospital.
Tetralogy of fallot with absent pulmonary valve syndrome is a form of tetralogy of fallot with a severely dysplastic pulmonary valve and markedly dilated pulmonary arteries. Transcatheter pulmonary valve replacement tpvr is one of the most exciting recent developments in the treatment of chd and has evolved to become an attractive alternative to surgery in patients with right ventricular outflow tract rvot dysfunction. Ten to twenty years after the initial repair, severe pulmonary regurgitation results in right ventricular dilation and dysfunction. The need to insert a transannular patch during reconstruction surgery of the right. Cardiovascular mr imaging after surgical correction of. Pulmonary valve leaflets that are preserved at initial surgery may grow and develop normal morphology and subsequent valve repair may be possible. Pulmonary valve restitution following transannular patch repair of tetralogy of fallot. When corrective surgery for tetralogy of fallot was accomplished through the use of a transannular goretex patch with a pericardial unicusp, the rightventricular enddiastolic volumes of all. Use of a pulmonary neovalve with a transannular patch for.
A traditional procedure involves closing the ventricular septal defect and placing a transannular patch a patch across the pulmonary valve connective tissue to enlarge the pulmonary annulus the ring of tissue that supports the valve leaflets, which helps blood flow from the pulmonary valve. Use of a dacron annular sparing versus limited transannular patch with nominal pulmonary annular expansion in. These include right ventricular outflow tract muscle resection or infundibular patch augmentation, pulmonary valvotomy, patch augmentation of the main or branch pulmonary arteries. All transannular incisions were closed with a patch. Transannular patching is a valid alternative for tetralogy of fallot and complete atrioventricular septal defect repair gianluca brancaccio, guido michielon, sergio filippelli, gianluigi perri, duccio di carlo, fiore s. To this end we have used a strategy of transatrial, transpulmonary repair of tof with aggressive pulmonary valve commissurotomy, extensive subvalvar resection. Following adequate rewarming, the patient is weaned from cardiopulmonary bypass. Pulmonary regurgitation can occur after transannular patch or valvesparing repairs. Mar 30, 2017 tetralogy of fallot with absent pulmonary valve syndrome.
Optimal pulmonary valve positioning within the rvot. Some surgeons will place a monocusp valve or utilize valve repair techniques such as leaflet augmentation. He is now almost 7 years old and is presenting with significant backflow to the right ventricle due to having no pulmonary valve. Oct 18, 2016 the bovine pericardial patch is sutured to the pulmonary artery, and the suture line is carried at the level of the valve on both sides. Longterm results of right ventricular outflow tract. Unfortunately, the large transannular patch designed to relieve obstruction also resulted in significant pulmonary valve insufficiency. Treatment of fallot tetralogy with a transannular patch. From august 2006 through may 2010, 9 consecutive patients underwent repair of tetralogy of fallot at a median age of 6. Transannular patch of the pulmonary artery simulation on a 3d. The anterior commissure had been split during the original repair, and a transannular patch was placed with retention of the pulmonary valve leaflets. Ptfe monocusp valve for rvot reconstruction ctsnet. A transannular incision was used in 99 patients 52%. The data are also relevant to the recent upsurge of interest in using semi lunar valve allografts rather than transannular patches when the pulmonary annulus is hypoplastic. Five patients with initial pulmonary valvesparing operations required reoperation for residual stenoses.
Percutaneous pulmonary valve implantation ppvi has been established as a safe and effective alternative to surgery treating patients with a failing pulmonary valve conduit. Cardiac repair with transannular patch enlargement of the pulmonary outflow was planned. A patch across the pulmonary valve annulus a transannular patch is often. The valve leaflets are cut to loosen the valve slightly, allowing blood to pass easily. The patient selected for this procedure would be one for whom the surgeon would consider either a transannular patch or a pulmonary valve insertion at the time of initial tetralogy of fallot repair, or a patient having a reoperation after initial transannular patch or valved conduit placement. A, lateral view of the optimal position for pulmonary valve in the right ventricular outflow tract with a transannular patch demonstrating the laminar flow of blood into the pulmonary arteries. Impact of surgery on presence and dimensions of anatomical. This represented a 30% to 40% reduction in the need for a transannular patch compared with the incidence of transannular patch expected before balloon dilatation. Methods one hundred and fortytwo postmortem tof specimens 8458 correcteduncorrected were studied for isthmus presence. A patch across the pulmonary valve annulus a transannular patch is often required in order to adequately relieve right ventricular outflow tract obstruction.
Isthmus 1 is located between the tricuspid annulus and right ventricular rv outflow tract rvot patch rv incision, isthmus 2 between rvot patch rv incision and pulmonary valve, isthmus 3 between pulmonary valve and ventricular septal defect patch, isthmus 4 between. Pulmonary valve repair for patients with acquired pulmonary. At surgery, a longitudinal incision was made in the right side of the main pulmonary artery and extended 4 cm into the right ventricle, equidistantly from the rca and right atrioventricular groove fig. This relatively rare lesion represents only 35% of all cases of tetralogy of fallot. The problems related with primary repair for tetralogy of fallot, especially about transannular patch repair since the initial surgical correction of tetralogy of fallot tof in 1954, advances in management have helped reduce early surgical mortality to less than 2% 1. Tetralogy of fallot often requires reconstruction of the right ventricular outflow tract with a transannular patch tap, but this renders the pulmonary valve incompetent and eventually leads to ri.
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