Right Ventricular Outflow Tract Reconstruction Using Transannular Patch with Pericardial Monocusp in Patients with Tetralogy of Fallot
Keywords:Right ventricular outflow tract reconstruction, Tetralogy of Fallot, Transannular patch, Monocusp
Background: Tetralogy of Fallot is the most common cyanotic heart disease in Thailand. Many patients have stenosis involving the pulmonic valve (PV) annulus which requires complex surgical procedures to relieve the obstruction at this level, especially by using a transannular patch (TAP). We analyzed the early results of TAP with pericardial monocusp, and compared this with the results of non-TAP operations.
Methods: A retrospective medical record review was conducted which included 69 patients who underwent definitive cardiac repair between January 2009 to December 2018. The results of patients who underwent TAP with the pericardial monocusp technique were compared to those who underwent the non-TAP technique.
Results: There were 30 patients in the non-TAP group (mean age 92.6 months) and 39 patients in the TAP group (mean age 90.4 months). Most patients in both groups had favorable and comparable preoperative characteristics, except the mean PV annulus diameter in the TAP group was smaller than that in the non-TAP group (mean z-score in the TAP group, -2.2, in the Non-TAP group, 0.6, p-value < 0.001). Bypass times were longer in the TAP group (non-TAP group 107± 42 mins, TAP group 138 ± 37 mins, p-value 0.002). Cross-clamp times were longer as well (Non-TAP group 79 ± 27 mins, TAP group 102 ± 27 mins, p-value 0.001). In-hospital mortality rate was higher in the TAP group (Non-TAP group 7%, TAP group 23%). Overall survival was 88.4 % at 2 years (96.7% in non-TAP group, and 82.1% in TAP group). After exclusion of in-hospital deaths from both groups, freedom from at least moderate pulmonary stenosis or regurgitation at 2 years was 93.3 % in the non-TAP group, and 61.1 % in the TAP group, whereas freedom from re-intervention was excellent and comparable in both groups (Non-TAP group 100%, TAP group 96.4%).
Conclusion: TAP with monocusp technique can adequately relieve PV stenosis with good valvular function at least in the early period after surgery. Although the in-hospital mortality was higher with TAP, increasing experience should eventually reduce the mortality rate.
2. Olenchock S. Kirklin/Barratt-Boyes cardiac surgery . 3rd ed. Curr Surg. 2004
3. Rygg IH, Olesen K, Boesen I. The life history of tetralogy of Fallot. Dan Med Bull. 1971;18.
4. Blalock A, Taussig HB. The surgical treatment of malformations of the heart: In which there is pulmonary stenosis or pulmonary atresia. J Am Med Assoc. 1945;128(3):189-202.
5. Potts WJ, Smith S, Gibson S. Anastomosisof the Aorta to A Pulmonary Artery: Certain Types in Congenital Heart Disease. J Am Med Assoc [Internet]. 1946 Nov 16;132(11):627–31.
6. de Leval MR, McKay R, Jones M, Stark J, Macartney FJ. Modified Blalock-Taussig shunt. Use of subclavian artery orifice as flow regulator in prosthetic systemic-pulmonary artery shunts. J Thorac Cardiovasc Surg. 1981;81(1):112-119.
7. Lillehei CW, Cohen M, Warden HE, et al. Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentalogy of Fallot, and pulmonary atresia defects; report of first ten cases. Ann Surg. 1955;142(3):418-442.
8. Kirklin JW, Blackstone EH, Pacifico AD, Brown RN, Bargeron LM. Routine primary repair vs two-stage repair of tetralogy of Fallot. Circulation. 1979;60(2):373–86.
9. Kirklin JW, Blackstone EH, Jonas RA, et al. Morphologic and surgical determinants of outcome events after repair of tetralogy of Fallot and pulmonary stenosis: A two-institution study. In: Journal of Thoracic and Cardiovascular Surgery. 1992;103(4):706-773.
10. Kirklin JW, Ellis FH, McGoon DC, Dushane JW, Swan. Surgical treatment for the tetralogy of Fallot by open intracardiac repair. J Thorac Surg. 1959;37(1):22-51.
11. Fuster V, McGoon DC, Kennedy MA, Ritter DG, Kirklin JW. Long-term evaluation (12 to 22 years) of open heart surgery for tetralogy of fallot. Am J Cardiol. 1980;46(4):635-642.
12. Gundry SR, Razzouk AJ, Boskind JF, et al. Fate of the pericardial monocusp pulmonary valve for right ventricular outflow tract reconstruction: Early function, late failure without obstruction. J Thorac Cardiovasc Surg. 1994;107(3):908–13.
13. Sluysmans T, Colan SD. Structural Measurements and Adjustment for Growth. In: Echocardiography in Pediatric and Congenital Heart Disease: From Fetus to Adult. 2009.
14. Colan SD. Normal Echocardiographic Values for Cardiovascular Structures. In: Echocardiography in Pediatric and Congenital Heart Disease. 2016.
15. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017;30(4):303‐371.
16. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic Assessment of Valve Stenosis: EAE/ASE Recommendations for Clinical Practice. Journal of the American Society of Echocardiography. 2009 May;22(5):442]. J Am Soc Echocardiogr. 2009;22(1):1‐102.
17. van der Ven JPG, van den Bosch E, Bogers AJCC, Helbing WA. Current outcomes and treatment of tetralogy of Fallot. F1000Research. 2019; 8:F1000 Faculty Rev-1530.
18. Austen WG, Greenfield LJ, Ebert PA, Morrow AG. Experimental study of right ventricular function after surgical procedures involving the right ventricle and pulmonic valve. Ann Surg. 1962; 155(4):606‐613.
19. Carvalho JS, Shinebourne EA, Busst C, Rigby ML, Redington AN. Exercise capacity after complete repair of tetralogy of Fallot: Deleterious effects of residual pulmonary regurgitation. Br Heart J. 1992;67(6):470–3.
20. Roest AAW, Helbing WA, Kunz P, et al. Exercise MR imaging in the assessment of pulmonary regurgitation and biventricular function in patients after tetralogy of fallot repair. Radiology. 2002; 223(1):204‐211.
21. Gatzoulis MA, Balaji S, Webber SA, et al. Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: A multicentre study. Lancet. 2000; 356(9234):975‐981.
22. Awori MN, Leong W, Artrip JH, O’Donnell C. Tetralogy of fallot repair: Optimal z-score use for transannular patch insertion. Eur J Cardio-thoracic Surg. 2013; 43(3):483‐486.
23. Gustafson RA, Murray GF, Warden HE, Hill RC, Rozar EJ. Early Primary Repair of Tetralogy of Fallot. Ann Thorac Surg. 1988;45(3):235–41.
24. Touati GD, Vouhe PR, Amodeo A, et al. Primary repair of tetralogy of Fallot in infancy. J Thorac Cardiovasc Surg. 1990;99(3):396–403.
25. Knott-Craig CJ, Elkins RC, Lane MM, Holz J, McCue C, Ward KE. A 26-year experience with surgical management of tetralogy of fallot: Risk analysis for mortality or late reintervention. Ann Thorac Surg. 1998;66(2)506-510.
26. Anagnostopoulos P, Azakie A, Natarajan S, Alphonso N, Brook MM, Karl TR. Pulmonary valve cusp augmentation with autologous pericardium may improve early outcome for tetralogy of Fallot. J Thorac Cardiovasc Surg. 2007;133(3):640–7.
27. Sasson L, Houri S, Sternfeld AR, et al. Right ventricular outflow tract strategies for repair of tetralogy of Fallot: Effect of monocusp valve reconstruction. Eur J Cardio-thoracic Surg. 2013;43(4):743–51.
28. Kirklin JW, Blackstone EH, Pacifico AD, Kirklin JK, Bargeron J, R. LM. Risk Factors for Early and Late Failure after Repair of Tetralogy of Fallot, and their Neutralization. Thorac Cardiovasc Surg. 1984;32:208–14.
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