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• W2043138853 abstract "The optimal repair for tetralogy of Fallot is challenged by the management of the small right ventricular outflow tract (RVOT), which was initially solved by John Kirklin who determined that the absence of the pulmonary valve could be well tolerated owing to low pulmonary artery pressure and preserved right ventricular function.1Kirklin J.W. Ellis Jr, F.H. McGoon D.C. et al.Surgical treatment for tetralogy of Fallot by open intracardiac repair.J Thorac Surg. 1959; 37: 22-51PubMed Google Scholar This assumption was affirmed in a significant number of patients who tolerated the persistent effects of right ventricular volume overload for many years. In a significant number of postoperative patients, however, long-term complications of pulmonary regurgitation, residual ventricular septal defects (VSD), distal pulmonary artery stenosis, right ventricular dysfunction, atrial or ventricular arrhythmias, and exercise intolerance2Karamlou T. McCrindle B.W. Williams W.G. Surgery insight: Late complications following repair for tetralogy of Fallot and related surgical strategies for management.Nat Clin Prac Cardiovasc Med. 2006; 3: 611-621Crossref PubMed Scopus (57) Google Scholar, 3Ammash N.M. Dearani J.A. Burkhart H.M. et al.Pulmonary regurgitation after tetralogy of Fallot repair: Clinical features, sequelae, and timing of pulmonary valve replacement.Congenit Heart Dis. 2007; 2: 386-403Crossref PubMed Scopus (68) Google Scholar, 4Gatzoulis M.A. Balaji S. Webber S.A. et al.Risk factors of arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: Multicentre study.Lancet. 2000; 356: 975-981Abstract Full Text Full Text PDF PubMed Scopus (1365) Google Scholar, 5Kane C. Kogon B. Pernetz M. et al.Left ventricular function improves after pulmonary valve replacement in patients with previous right ventricular outflow tract reconstruction and biventricular dysfunction.Tex Heart Inst J. 2011; 38: 234-237PubMed Google Scholar required further operative intervention to address the residual defects, perform concomitant arrhythmia surgery, and pulmonary valve insertion. Valve-sparing strategies at the initial reparative operation started to emerge in succeeding decades with efforts to retain the native pulmonary valve with extensive valvotomy techniques and acceptance of high intraoperative right ventricular to left ventricular pressure ratios of 0.7 or less.6Jonas R. Early primary repair of tetralogy of Fallot.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2009; 12: 39-47Abstract Full Text Full Text PDF Scopus (53) Google Scholar, 7Karl T.R. Sano S. Pornviliwan S. Tetralogy of Fallot: Favorable outcome of nonneonatal transatrial transpulmonary repair.Ann Thorac Surg. 1992; 54: 903-907Abstract Full Text PDF PubMed Scopus (170) Google Scholar, 8Stewart R.D. Backer C.L. Young L. et al.Tetralogy of Fallot: Results of a pulmonary valve-sparing strategy.Ann Thorac Surg. 2005; 80: 1431-1438Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 9Rao V. Kadletz M. Hornberger L.K. et al.Preservation of the pulmonary valve complex in tetralogy of Fallot: How small is too small?.Ann Thorac Surg. 2000; 69: 176-180Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 10Ilbawi M.N. Idriss F.S. DeLeon S.Y. et al.Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair, surgical implications.J Thorac Cardiovasc Surg. 1987; 93: 36-44PubMed Google Scholar Transannular patches, when necessary, involved a strategy of transatrial RVOT resection, transatrial VSD closure, and limited ventriculotomy, oftentimes not extending the incision more than 1-2 cm. Under these circumstances, transannular patches were intentionally downsized and reconstructed to result in right ventricular gradients of approximately 20 mm Hg.11Latus H. Gummel Rupp S. Valeske K. et al.Beneficial effects of residual right ventricular outflow tract obstruction on right ventricular volume and function in patients after repair of tetralogy of Fallot.Pediatr Cardiol. 2013; 34: 424-430Crossref PubMed Scopus (33) Google Scholar, 12Hua Z. Li S. Wang L. et al.A new pulmonary valve cusp plasty technique markedly decreases transannular patch rate and improves midterm outcomes of tetralogy of Fallot repair.Eur J Cardiothorac Surg. 2011; 40: 1221-1226PubMed Google Scholar More comprehensive valve-sparing techniques that included a supravalvar pantaloon autologous pericardial patch for supravalvar pulmonary stenosis were highlighted by several authors.8Stewart R.D. Backer C.L. Young L. et al.Tetralogy of Fallot: Results of a pulmonary valve-sparing strategy.Ann Thorac Surg. 2005; 80: 1431-1438Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 9Rao V. Kadletz M. Hornberger L.K. et al.Preservation of the pulmonary valve complex in tetralogy of Fallot: How small is too small?.Ann Thorac Surg. 2000; 69: 176-180Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 10Ilbawi M.N. Idriss F.S. DeLeon S.Y. et al.Factors that exaggerate the deleterious effects of pulmonary insufficiency on the right ventricle after tetralogy repair, surgical implications.J Thorac Cardiovasc Surg. 1987; 93: 36-44PubMed Google Scholar These techniques permitted an increased incidence of pulmonary valve preservation during initial repair in up to 70% of patients8Stewart R.D. Backer C.L. Young L. et al.Tetralogy of Fallot: Results of a pulmonary valve-sparing strategy.Ann Thorac Surg. 2005; 80: 1431-1438Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar compared with 40% or less in other reports.13Hirsch J.C. Mosca R.S. Bove E.L. Complete repair of tetralogy of Fallot in the neonate: Results in a modern era.Ann Surg. 2000; 232: 508-514Crossref PubMed Scopus (166) Google Scholar, 14Pigula F. Khalil P. Mayer J. et al.Repair of tetralogy of Fallot in neonates and young infants.Circulation. 1999; 100: II-157-II-161Google Scholar The following drawings highlight the technique of pulmonary valve preservation by supravalvar pantaloon pericardial patch pulmonary artery arterioplasty(Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8).Figure 2The vertical incision is commenced superior to the pulmonary valve, and the incisions are extended into the sinuses of Valsalva in the event that there is an anterior-posterior orientation of a bicuspid pulmonary valve or into the 2 facing sinuses if there is a tricuspid pulmonary valve. If the pulmonary valve is bicuspid and oriented in a horizontal position, a linear incision into the facing sinus of Valsalva is performed. The incisions are extended to approximately 1-2 mm from the pulmonary valve annulus.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Once the pulmonary valve is exposed, careful anterior and posterior and strategic valvotomies are performed to open the orifice but not cause significant distortion that can result in regurgitation. Local detachment of the commissural attachments is avoided because of the associated and resultant regurgitation that this maneuver can cause as well. A subvalvar, transpulmonary artery muscle resection to compliment the already performed muscle resection through the right atrium and tricuspid valve can be accomplished. The RVOT can now be measured by sized dilators, which should be introduced carefully to avoid valvar injury by excessive dilatation. An autologous pericardial patch is cut to size and in a pantaloon configuration. Three interrupted sutures are placed at the incised portion of the pericardial patch and tied. The purpose of these interrupted sutures is to prepare for a subsequent transannular patch across the reconstruction without suture line disruption in the event that the resultant right ventricular pressure proves excessive.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Once the interrupted sutures are placed in the incised portion of the pericardium, a running suture technique is commenced to augment the respective and incised sinuses of Valsalva. At this point of the operation and after the VSD and atrial septal defect are closed, the cross clamp can be removed and the patient can be rewarmed. The left ventricular vent is allowed to drain and the vena cava catheters are allowed to capture the right atrial return without caval tapes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Rather than tapering the superior portion of the pericardial patch to the estimated exact size and risk resultant supravalvar stenosis, the pericardial patch is left in a redundant size and the suture line technique is performed by gathering the pericardium to match up with the extant pulmonary artery wall.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Artist’s representation of the complete repair.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7In the event that right ventricular hypertension attends the completed repair after separation from cardiopulmonary bypass, resumption of cardiopulmonary bypass can be instituted and a transannular patch can be performed. One or 2 interrupted sutures can be removed without disrupting the entire extant pulmonary reconstruction. The incision across the anterior commissure is performed carefully to allow the valvar attachments to remain in place and maintain competency. Recent reports have extolled the virtue of this maneuver in the event that future operations for pulmonary insufficiency might be necessary.15Mainwaring R. Pirolli T. Punn R. et al.Late repair of the native pulmonary valve in patients with pulmonary insufficiency after surgery for tetralogy of Fallot.Ann Thorac Surg. 2012; 93: 677-679Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 16Prêtre R. Rosser B. Mueller C. et al.Recycling of the pulmonary valve: An elegant solution for secondary pulmonary regurgitation in patients with tetralogy of Fallot.Ann Thorac Surg. 2012; 94: 850-853Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 18Mavroudis C. Mavroudis C.D. Frost J.L. Native pulmonary valve restoration after remote tetralogy of Fallot repair: How to do it.World J Pediatr Cong Heart Surge. 2013; 4: 422-426Crossref PubMed Scopus (5) Google Scholar Growth of these leaflets might allow restoration of the pulmonary valve by bicuspidization thereby avoiding the placement of a homograft, heterograft, or polytetrafluoroethylene pulmonary valve at the subsequent operation. A limited right ventriculotomy with extension in the pericardial patch can then be performed as noted to prepare for the RVOT reconstruction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Artist’s representation of the completed RVOT reconstruction with a patch-on-patch configuration.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The described technique herein shows how the pantaloon pericardial patch arterioplasty can be performed in the presence of a bicuspid pulmonary valve oriented in an anterior-posterior position. With some adjustments, the same can be accomplished in a tricuspid pulmonary valve. In the case of a bicuspid pulmonary valve oriented in a horizontal position, a pericardial pulmonary artery arterioplasty into the anterior sinus of Valsalva can be completed without the pantaloon adaptation. One could add a separate pericardial arterioplasty for the posterior sinus of Valsalva; however, the technical challenge and possibility of bleeding complications have mitigated against this strategy for the time being. The basic strategy for this operation is to relieve the supravalvar stenosis, preserve the function of the pulmonary valve, and allow for the possibility of somatic growth. Usually the supravalvar pulmonary artery arterioplasty is performed after VSD and atrial septal defect or patent foramen ovale closure during cardioplegic arrest. This allows careful suture placement especially at the pulmonary annulus and sinuses of Valsalva. The surgeon has the option of removing the cross clamp at any time during this reconstruction if the ischemic arrest time becomes excessive. Relief of subvalvar stenosis is an important part of the RVOT reconstruction as any stenosis below the valve will mask the success of the valve preservation operation. Oftentimes, a separate prosthetic patch will be necessary to ensure an unobstructed pathway to the pulmonary annulus. In general, the only stenosis of the RVOT that should be tolerated in this situation is at the pulmonary valve annulus. Although this valve preservation strategy would be successful for most patients, there are some patients who would require a transannular patch as noted in Figure 7, Figure 8. Recent advances in native pulmonary valve intervention late after tetralogy of Fallot repair have highlighted various techniques that can restore the function of the pulmonary valve 15Mainwaring R. Pirolli T. Punn R. et al.Late repair of the native pulmonary valve in patients with pulmonary insufficiency after surgery for tetralogy of Fallot.Ann Thorac Surg. 2012; 93: 677-679Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 16Prêtre R. Rosser B. Mueller C. et al.Recycling of the pulmonary valve: An elegant solution for secondary pulmonary regurgitation in patients with tetralogy of Fallot.Ann Thorac Surg. 2012; 94: 850-853Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 17Bacha E. Valve-sparing options in tetralogy of Fallot surgery.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2012; 15: 24-26Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 18Mavroudis C. Mavroudis C.D. Frost J.L. Native pulmonary valve restoration after remote tetralogy of Fallot repair: How to do it.World J Pediatr Cong Heart Surge. 2013; 4: 422-426Crossref PubMed Scopus (5) Google Scholar, 19Quintessenza J.A. Jacobs J.P. Chai P.J. et al.Polytetrafluoroethylene bicuspid pulmonary valve implementation experience 126 patients.World J Pediatr Congenit Heart Surg. 2010; 1: 20-27Crossref PubMed Scopus (47) Google Scholar, 20Park C.S. Lee C.-H. Lee Y.O. et al.Pulmonary valve repair late after right ventricular outflow tract reconstruction in children and adolescents.Inter Cardiovasc Thorac Surg. 2010; 10: 906-909Crossref PubMed Scopus (11) Google Scholar without resorting to valve-replacement strategies.21Discigil B. Dearani J.A. Puga F.J. et al.Late pulmonary valve replacement after repair of tetralogy of Fallot.J Thorac Cardiovasc Surg. 2001; 121: 344-351Abstract Full Text Full Text PDF PubMed Scopus (238) Google Scholar, 22McElhinney D.B. Hellenbrand W.E. Zahn E.M. et al.Short- and medium-term outcomes after transcatheter pulmonary valve placement in the expanded multicenter US melody valve trial.Circulation. 2010; 122: 507-516Crossref PubMed Scopus (454) Google Scholar For these valve preservation strategies to be applicable, the conduct of pulmonary valve manipulation at the original operation is foundational. The original pulmonary valvar anatomy must be respected and includes maintenance of pulmonary valve commissural attachments during the transannular incision in anticipation of somatic growth and the possibility of future restoration. This is best accomplished when a bicuspid pulmonary valve oriented in an anterior-posterior position is encountered allowing for an accurate and pinpoint transannular incision at the point of the commissural attachments. The resultant incision would usually be centered in the RVOT away from the respective locations of the left anterior descending coronary artery and the right coronary artery, assuming of course that there are no anomalous coronary origins or courses. A horizontal orientation of the pulmonary valve that would require a transannular incision represents the most challenging situation of first-time management with the thought of future restoration. Some authors19Quintessenza J.A. Jacobs J.P. Chai P.J. et al.Polytetrafluoroethylene bicuspid pulmonary valve implementation experience 126 patients.World J Pediatr Congenit Heart Surg. 2010; 1: 20-27Crossref PubMed Scopus (47) Google Scholar have incised the anterior leaflet at its middle portion and augmented it with a polytetrafluoroethylene membrane patch in association with the transannular patch, the idea being that the remaining incised valve leaflets would be the substrate for future valve restoration. Although this technique is an attractive potential solution, no long-term reports of restoration have been published to date. Small tricuspid pulmonary valves that require a transannular patch represent complex solutions dependant on the extant anatomy and the respective sizes of the cusps. Oftentimes, the anterior cusp is small with a correspondingly small leaflet. In these situations, the anterior leaflet can be resected in association with a transannular patch with a reasonable possibility that the remaining valve leaflets, if not sacrificed, would be available for a valve restoration procedure by bicuspidization.18Mavroudis C. Mavroudis C.D. Frost J.L. Native pulmonary valve restoration after remote tetralogy of Fallot repair: How to do it.World J Pediatr Cong Heart Surge. 2013; 4: 422-426Crossref PubMed Scopus (5) Google Scholar The other theoretical options not yet reported are to incise the annulus at the medial or lateral commissure. This approach requires an off-center transannular incision owing to the location of the extant cusps, which endangers the respective coronary arteries and challenges the exposure for an adequate subvalvar muscle resection and relief of the RVOT obstruction. Practical wisdom and clinical experience would determine whether this approach would be attempted in the future. Valve-sparing techniques for repair of tetralogy of Fallot are being evaluated and are the subject of intense study for both the initial operation and any subsequent restorative procedures. Even so, there would always be patients who would require bioprosthetic alternatives. The search for a durable valve leaflet that can undergo appropriate somatic growth and maintain proper function over the long term is still the goal for those unfortunate patients who require a transannular patch." @default.
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• W2043138853 title "Pulmonary Valve Preservation Strategies for Tetralogy of Fallot Repair" @default.
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