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Malyshev M, Safuanov A, Malyshev A, Rostovykh A, Sinyukov D, Rostovykh N. Pulmonary valve reconstruction by allograft replacement of underdeveloped anterior leaflet in case of late combined pulmonary restenosis after early primary repair. Int J Surg Case Rep 2021; 87:106410. [PMID: 34560590 PMCID: PMC8473756 DOI: 10.1016/j.ijscr.2021.106410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/11/2021] [Accepted: 09/11/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction The native pulmonary valve (PV) reconstruction is an attractive alternative to a replacement but is challenging due to the systematic underdevelopment of the valve structures in congenital heart diseases. The partial replacement of underdeveloped parts of the valve and saving of well-developed may have advantages versus replacing the whole valve in terms of durability and patient outgrowth of the prosthesis. Case presentation This report describes a case of the PV reconstruction by allograft replacement of an underdeveloped anterior leaflet in an adolescent patient who previously corrected pulmonary stenosis during the first year of her life. The normal anatomy of the right and left leaflets was revealed. The rudimental anterior leaflet determined the annular restenosis. The monocusp with the related supporting aortic wall was sewn instead of the anterior leaflet. The Z-score of the pulmonary annulus changed from minus 3, 9 before to +0.8 after the procedure. The excellent function of the PV was observed in 1-year follow-up. Discussion Valve deterioration over time will have a less negative impact on the function when it occurs in a limited area. The annular dilatation becomes unlikely if the annulus predominantly consists of natural tissues. The procedural effectiveness allows the transcatheter valve-in-valve therapy in case of late dysfunction. The expected feature of the procedure described is that the growth of the PV remains possible. Conclusion If allograft replacement of the PV is scheduled and allograft is available, the partial replacement may be superior to replacement of the whole valve in terms of durability and patient outgrowth of the prosthesis. A pulmonary valve (PV) repair is an attractive surgical option because an ideal replacement device is still not developed. A PV repair is a challenge due to the systematic underdevelopment of the valve structures in congenital heart diseases. The partial replacement of the PV structures may be more beneficial in terms of durability vs whole valve replacement. The PV leaflets at the primary operation should be saved and handled carefully. They may used for valve repair in the future.
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Affiliation(s)
- Michael Malyshev
- Center of Cardiac Surgery (OOO), Chelyabinsk, Russian Federation.
| | | | - Anton Malyshev
- Center of Cardiac Surgery (OOO), Chelyabinsk, Russian Federation
| | - Andrey Rostovykh
- Center of Cardiac Surgery (OOO), Chelyabinsk, Russian Federation
| | - Dmitry Sinyukov
- Center of Cardiac Surgery (OOO), Chelyabinsk, Russian Federation
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Fedevych O, Dhannapuneni R, Guerrero R, Lotto A. Native Pulmonary Valve Restoration Late Following Transannular Patch Repair of Tetralogy of Fallot. World J Pediatr Congenit Heart Surg 2021; 12:677-679. [PMID: 33947283 DOI: 10.1177/2150135120981056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We present a surgical case of native pulmonary valve (PV) restoration in a 16-year-old boy with a previous history of transannular patch repair of tetralogy of Fallot in infancy. The PV was restored by approximation of split anterior commissure in the presence of developed and pliable leaflets well preserved after initial surgery. Postoperative echocardiogram showed a competent valve with peak velocity of 2.8 m/s. At six-week follow-up, the patient remained well, and echocardiogram demonstrated a competent PV with decreased velocity of 2.1 m/s across it. We encourage a mindful preservation of PV leaflets whenever it is possible at time of initial repair to implement this relatively easy operation to restore PV function later in life.
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Affiliation(s)
- Oleg Fedevych
- Cardiac Services, 4593Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, United Kingdom
| | - Ramana Dhannapuneni
- Cardiac Services, 4593Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, United Kingdom
| | - Rafael Guerrero
- Cardiac Services, 4593Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, United Kingdom
| | - Attilio Lotto
- Cardiac Services, 4593Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, United Kingdom.,Faculty of Health, Liverpool John Moores University, Kingsway House, Liverpool, United Kingdom
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Adamson GT, McElhinney DB, Lui G, Meadows AK, Rigdon J, Hanley FL, Maskatia SA. Secondary repair of incompetent pulmonary valves after previous surgery or intervention: Patient selection and outcomes. J Thorac Cardiovasc Surg 2019; 159:2383-2392.e2. [PMID: 31585750 DOI: 10.1016/j.jtcvs.2019.06.110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/12/2019] [Accepted: 06/30/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Pulmonary valve (PV) regurgitation (PR) is common after intervention for a hypoplastic right ventricular outflow tract. Secondary PV repair is an alternative to replacement (PVR), but selection criteria are not established. We sought to elucidate preoperative variables associated with successful PV repair and to compare outcomes between repair and PVR. METHODS Patients who underwent surgery for secondary PR from 2010 to 2017 by a single surgeon were studied. The PV annulus and leaflets were measured on the preoperative echocardiogram and magnetic resonance images, and the primary predictor variable was leaflet area indexed to ideal PV annulus area (iPLA) by magnetic resonance imaging. PV repair and PVR groups were compared using multivariable logistic regression, and with a conditional inference tree. Freedom from PV dysfunction and from reintervention were assessed with Kaplan-Meier survival analyses. RESULTS Of 85 patients, 31 (36%) underwent PV repair. By multivariable analysis, longer PV total leaflet length (cm/m2) (β = 3.00, standard error [SE] = 0.82, P < .001), larger PV z score (β = 1.34, SE = 0.39, P = .001), and larger iPLA (β = 8.13, SE = 2.62, P = .002) were associated with repair. iPLA of 0.90 or greater was 91% sensitive and 83% specific for achieving PV repair. At a median of 4.1 years follow-up, there was greater freedom from significant PR in the PV repair group (log rank P = .008). CONCLUSIONS Patients with an iPLA >0.9, and those with an iPLA between 0.7 and 0.9 with a PV annulus z score >0 should be considered for a native PV repair. At midterm follow-up, patients with a PV repair were not more likely to develop PR or to require reintervention when compared with patients undergoing PVR.
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Affiliation(s)
- Gregory T Adamson
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif.
| | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - George Lui
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif; Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, Calif
| | - Alison K Meadows
- Department of Cardiology, Kaiser San Francisco Medical Center, San Francisco, Calif
| | - Joseph Rigdon
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, Calif
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Shiraz A Maskatia
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, Calif
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Parikh KN, Shah NC, Clark JB, Myers JL. Pulmonary valve restitution following transannular patch repair of tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2017; 25:985-986. [PMID: 29049532 DOI: 10.1093/icvts/ivx215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/30/2017] [Indexed: 11/13/2022] Open
Abstract
Chronic pulmonary insufficiency following transannular patch repair of tetralogy of Fallot may mandate restoration of a competent pulmonary valve. Pulmonary valve leaflets that are preserved at initial surgery may grow and develop normal morphology and subsequent valve repair may be possible. We reviewed our experience with native pulmonary valve restitution following transannular patch repair (2001-15). The cohort included 9 patients with a median age of 18.7 (range 10.6-31.3) years. Operative technique involved reapproximation of the anterior commissure of the pulmonary valve. Median length of stay was 3 days, and there were no deaths. At median follow-up of 2.0 (0.4-13.5) years, pulmonary insufficiency was graded as ≤mild (n = 4), mild-moderate or moderate (n = 4) and moderate-severe (n = 1); pulmonary stenosis was ≤mild (n = 8) and moderate (n = 1), with median peak gradient of 21 (16-64) mmHg. No patient required reintervention. At reoperation to treat pulmonary insufficiency in repaired TOF, if residual leaflets are found with favourable anatomy, restitution of the native valve should be considered. This valve-preserving technique avoids the certain failure of a bioprosthesis and is associated with favourable early outcomes. The viability of this option may influence surgeons to leave the pulmonary leaflets in situ at the time of initial repair.
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Affiliation(s)
- Khushboo N Parikh
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Nishant C Shah
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA
| | - Joseph B Clark
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Children's Hospital, Hershey, PA, USA
| | - John L Myers
- Department of Pediatrics, Penn State Children's Hospital, Hershey, PA, USA.,Department of Surgery, Penn State Children's Hospital, Hershey, PA, USA
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Said SM, Mainwaring RD, Ma M, Tacy TA, Hanley FL. Pulmonary Valve Repair for Patients With Acquired Pulmonary Valve Insufficiency. Ann Thorac Surg 2016; 101:2294-301. [PMID: 27083251 DOI: 10.1016/j.athoracsur.2016.01.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/27/2015] [Accepted: 01/04/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pulmonary valve (PV) insufficiency is often an acquired condition after treatment for pulmonary stenosis. It is recognized that PV insufficiency has serious deleterious effects. Although surgical replacement of the PV is efficacious, artificial valves inevitably fail and require re-intervention. The purpose of this study was to summarize our experience with PV repair in patients with acquired PV insufficiency. METHODS This was a retrospective review of 16 patients with marked PV insufficiency who underwent PV repair. Thirteen of these patients were born with tetralogy of Fallot (TOF) and had undergone a previous transannular patch repair. Three patients were born with critical pulmonary stenosis and had a surgical valvotomy or balloon valvuloplasty. RESULTS The 13 patients with TOF had resection of their previously placed transannular patch with re-approximation of the anterior commissure. All 13 patients experienced a marked reduction in the degree of pulmonary insufficiency. None of these patients have experienced any increase in insufficiency during follow-up. The 3 patients with critical pulmonary stenosis had a variety of pathologic findings identified at the surgical procedure. One patient had a large gap between a commissure and underwent closure of that commissure. The second and third patients had torn leaflets repaired with pericardial and Gore-Tex patches (Gore, Inc, Flagstaff, AZ). The degree of PV insufficiency was decreased to mild in all 3 patients. However, 2 of these 3 patients have subsequently had an increase in the degree of pulmonary insufficiency. CONCLUSIONS Patients with TOF who underwent a previous transannular patch may be candidates for bicuspidization of their native PV, and the results of this procedure have been quite stable at follow-up. PV repair for torn leaflets was effective in the short term but was less stable over time.
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Affiliation(s)
- Sameh M Said
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California
| | - Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California.
| | - Michael Ma
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California
| | - Theresa A Tacy
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital/Stanford University, Stanford, California
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, California
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Pulmonary valve replacement after repair of tetralogy of Fallot: Evolving strategies. J Thorac Cardiovasc Surg 2016; 151:623-625. [DOI: 10.1016/j.jtcvs.2015.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 02/03/2023]
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Shin YR, Park HK, Park YH, Jung JW, Kim YJ, Shin HJ. Pulmonary Valve Cusp Augmentation for Pulmonary Regurgitation After Repair of Valvular Pulmonary Stenosis. Ann Thorac Surg 2015; 99:e57-8. [DOI: 10.1016/j.athoracsur.2014.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 11/22/2014] [Accepted: 12/02/2014] [Indexed: 12/01/2022]
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Abstract
Despite tremendous advances in surgical treatment of tetralogy of Fallot, augmenting the small right ventricular outflow tract remains a challenge. Transannular patch augmentation revolutionised surgical management, but did so at the expense of rendering patients with pulmonary insufficiency and the resulting problems associated therewith. Recent surgical efforts have focused on pulmonary valve preservation at initial correction and pulmonary valve restoration after transannular patching, with favourable results. In this manuscript, we review methods of pulmonary valve preservation and restoration.
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Mavroudis C, Mavroudis CD, Frost J. Native Pulmonary Valve Restoration After Remote Tetralogy of Fallot Repair. World J Pediatr Congenit Heart Surg 2013; 4:422-6. [DOI: 10.1177/2150135113505296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Methods to repair tetralogy of Fallot have evolved from large ventriculotomy, large transannular patch placement techniques to smaller, transatrial approaches with valve-sparing strategies in select patients. Despite these advances, there continue to be patients in whom transannular patch is inevitable, and the management of the resulting pulmonary insufficiency that develops from this has been the source of considerable discussion. Techniques aimed at restoring pulmonary valve competence utilizing the remaining valve leaflets after transannular patch placement have recently been proposed for very select patient populations. We review the technical aspects of the operation including removal of the transannular patch and bicuspidization of a formerly tricuspid pulmonary valve, which results in a competent, nonstenotic valve. This report confirms the feasibility of these operative details and highlights the importance of planning before initial repair of tetralogy of Fallot as a way to prepare for a future valve restoration procedure and therefore avoid prosthetic valve placement.
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Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, USA
| | | | - Jennifer Frost
- Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, USA
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Late Repair of the Native Pulmonary Valve in Patients With Pulmonary Insufficiency After Surgery for Tetralogy of Fallot. Ann Thorac Surg 2012; 93:677-9. [DOI: 10.1016/j.athoracsur.2011.09.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 09/01/2011] [Accepted: 09/02/2011] [Indexed: 11/19/2022]
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