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Schulte LJ, Miller PC, Bhat AN, Carvajal-Dominguez HG, Chomat MR, Miller JR, Nath D, Eghtesady P. Evolution of Pulmonary Valve Management During Repair of Tetralogy of Fallot: A 14-year Experience. Ann Thorac Surg 2023; 115:462-469. [PMID: 35779602 DOI: 10.1016/j.athoracsur.2022.05.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal repair strategy for tetralogy of Fallot remains controversial. This report presents a 14-year evolution of management of the pulmonary valve (PV) from transannular patch to valve-sparing repair to neovalve creation using living right atrial appendage tissue. METHODS A retrospective review of 172 consecutive patients undergoing complete repair for TOF between January 2007 and June 2021 was performed. Clinical and follow-up data were analyzed by repair group. Neopulmonary valve (NPV) creation using right atrial appendage tissue was introduced in 2019. Failure of valve-sparing repair was defined as needing reintervention for recurrent right ventricular outflow tract obstruction (RVOTO). RESULTS Median age and weight at repair were 4.9 months and 6 kg, respectively. Median preoperative PV size and z-score were 6.4 mm (5.2-8.3 mm) and -3.2 (-4.1 to -2.1), respectively. Patients who underwent valve-sparing repair had larger PV size and z-score compared with patients who underwent transannular patch procedures (8 mm vs 5.6 mm; -2.1 vs -3.2; both P < .001). There were no hospital mortalities. Overall follow-up was 44 months. At last follow-up, 10% of patients who underwent valve-sparing repair had repeat intervention for recurrent RVOTO. Patients who had failed valve-sparing repair had significantly lower PV z-scores (-2.6 vs -1.9; P = .01). An NPV was used in 8 patients with a median PV z-score of -4 (-4.7 to -3.9). At 6 months, 6 patients (75%) had mild or trivial pulmonary insufficiency after NPV placement. CONCLUSIONS Repair of tetralogy of Fallot is a safe operation with excellent outcomes. Valve-sparing repair avoids right ventricular dilation but may fail for RVOTO at a PV z-score <-2. NPV creation offers an alternative option in patients with a small PV.
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Affiliation(s)
- Linda J Schulte
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | | | - Amrita N Bhat
- Washington University School of Medicine, St Louis, Missouri
| | - Horacio G Carvajal-Dominguez
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Michael R Chomat
- Division of Cardiology, Department of Pediatrics, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri
| | - Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri
| | - Dilip Nath
- Section of Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis Children's Hospital, St Louis, Missouri.
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Miller JR, Stephens EH, Goldstone AB, Glatz AC, Kane L, Van Arsdell GS, Stellin G, Barron DJ, d'Udekem Y, Benson L, Quintessenza J, Ohye RG, Talwar S, Fremes SE, Emani SM, Eghtesady P. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: Management of infants and neonates with tetralogy of Fallot. J Thorac Cardiovasc Surg 2023; 165:221-250. [PMID: 36522807 DOI: 10.1016/j.jtcvs.2022.07.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite decades of experience, aspects of the management of tetralogy of Fallot with pulmonary stenosis (TOF) remain controversial. Practitioners must consider newer, evolving treatment strategies with limited data to guide decision making. Therefore, the TOF Clinical Practice Standards Committee was commissioned by the American Association for Thoracic Surgery to provide a framework on this topic, focused on timing and types of interventions, management of high-risk patients, technical considerations during interventions, and best practices for assessment of outcomes of the interventions. In addition, the group was tasked with identifying pertinent research questions for future investigations. It is recognized that variability in institutional experience could influence the application of this framework to clinical practice. METHODS The TOF Clinical Practice Standards Committee is a multinational, multidisciplinary group of cardiologists and surgeons with expertise in TOF. With the assistance of a medical librarian, a citation search in PubMed, Embase, Scopus, and Web of Science was performed using key words related to TOF and its management; the search was restricted to the English language and the year 2000 or later. Articles pertaining to pulmonary atresia, absent pulmonary valve, atrioventricular septal defects, and adult patients with TOF were excluded, as well as nonprimary sources such as review articles. This yielded nearly 20,000 results, of which 163 were included. Greater consideration was given to more recent studies, larger studies, and those using comparison groups with randomization or propensity score matching. Expert consensus statements with class of recommendation and level of evidence were developed using a modified Delphi method, requiring 80% of the member votes with 75% agreement on each statement. RESULTS In asymptomatic infants, complete surgical correction between age 3 and 6 months is reasonable to reduce the length of stay, rate of adverse events, and need for a transannular patch. In the majority of symptomatic neonates, both palliation and primary complete surgical correction are useful treatment options. It is reasonable to consider those with low birth weight or prematurity, small or discontinuous pulmonary arteries, chromosomal anomalies, other congenital anomalies, or other comorbidities such as intracranial hemorrhage, sepsis, or other end-organ compromise as high-risk patients. In these high-risk patients, palliation may be preferred; and, in patients with amenable anatomy, catheter-based procedures may prove favorable over surgical palliation. CONCLUSIONS Ongoing research will provide further insight into the role of catheter-based interventions. For complete surgical correction, both transatrial and transventricular approaches are effective; however, the smallest possible ventriculotomy should be utilized. When possible, the pulmonary valve should be spared; and if unsalvageable, reconstruction can be considered. At the conclusion of the operation, adequate relief of the right ventricular outflow obstruction should be confirmed, and identification of a significant fixed anatomical obstruction should prompt further intervention. Given our current knowledge and the gaps identified, we propose several key questions to be answered by future research and potentially by a TOF registry: When to palliate or proceed with complete surgical correction, as well as the ideal type of palliation; the optimal surgical approach for complete repair for the best long-term preservation of right ventricular function; and the utility, efficacy, and durability of various pulmonary valve preservation and reconstruction techniques.
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Affiliation(s)
- Jacob R Miller
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Andrew B Goldstone
- Section of Congenital and Pediatric Cardiac Surgery, Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Andrew C Glatz
- Division of Pediatrics, Department of Pediatric Cardiology, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
| | | | - Glen S Van Arsdell
- Division of Cardiothoracic Surgery, Department of Surgery, UCLA Mattel Children's Hospital, Los Angeles, Calif
| | - Giovanni Stellin
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Lee Benson
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - James Quintessenza
- Department of Cardiovascular Surgery, Johns Hopkins All Children's Heart Institute, St Petersburg, Fla
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Sachin Talwar
- Department of Cariothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sitaram M Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, Mass.
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis/St Louis Children's Hospital, St Louis, Mo
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Yi K, Wang D, Xu J, Zhang X, Wang W, Gao J, Wang W, You T, Tian J. Surgical Strategies for Preservation of Pulmonary Valve Function in a Radical Operation for Tetralogy of Fallot: A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 9:888258. [PMID: 35911536 PMCID: PMC9326161 DOI: 10.3389/fcvm.2022.888258] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo evaluate the efficacy and safety of different surgical strategies to preserve pulmonary valve function. Surgical procedures evaluated include intraoperative balloon pulmonary valvuloplasty (IBPV), pulmonary valve reconstruction, and commissurotomy and pulmonary cusp augmentation (PCA) in patients who underwent a radical operation for Tetralogy of Fallot (ToF).Materials and MethodsThe five databases searched in the current study included the Cochrane Library, PubMed, China National Knowledge Infrastructure, VIP, and WanFang data. A systematic search for control trials was performed in each database from the start date of each database until December 2021. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of included studies.ResultsA total of 15 retrospective studies with a total number of 1,396 participants were included in this study. In subgroup 1 (IBPV vs. TAP), patients undergoing IBPV had a less degree of regurgitation at 1–2 years after the surgery. The reintervention rate increased in the IBPV group at 5 years. In subgroup 2 (pulmonary valve reconstruction vs. TAP), the degree of regurgitation decreased in the pulmonary valve reconstruction group at 1 month after the surgery. In subgroup 3 (valve-sparing operation vs. TAP), the comparison demonstrated decreased rates for surgical mortality and reintervention at 5–10 years after the surgery.ConclusionWe proposed that pulmonary valve function in a radical operation for ToF was preserved. IBPV, pulmonary valve reconstruction, and commissurotomy and PCA can be performed during the surgical procedure based on the developmental status and anatomical characteristics of the right ventricular outflow tract (RVOT), pulmonary valve, and pulmonary artery.Systematic Review Registration[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022300987].
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Affiliation(s)
- Kang Yi
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
| | - Dan Wang
- Department of Geriatric Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jianguo Xu
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xin Zhang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenxin Wang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First School of Clinical Medicine, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jie Gao
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Wei Wang
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- The First Clinical Medical College, Lanzhou University, Lanzhou, China
| | - Tao You
- Department of Cardiovascular Surgery, Gansu Provincial Hospital, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- Tao You,
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Gansu International Scientific and Technological Cooperation Base of Diagnosis and Treatment of Congenital Heart Disease, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou University, Lanzhou, China
- *Correspondence: Jinhui Tian,
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Huang SW, Hsu WF, Li HY, Hwang B, Wu FY, Weng ZC, Chuang CM, Chen SJ, Wang CC, Wang DS, Lee PC. Implantation of monocusp valve prolongs the duration of chest tube drainage in children with tetralogy of fallot after corrective surgery. J Chin Med Assoc 2022; 85:364-368. [PMID: 34670223 DOI: 10.1097/jcma.0000000000000641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Right ventricular outflow tract obstruction relief is one of the major procedures during the total correction of tetralogy of Fallot (TOF). Pulmonary insufficiency (PI) is usually inevitable after a transannular incision with a patch repair is performed. Therefore, some surgeons advocate to place a monocusp valve within the transannular patch (TAP) in order to decrease the severity of the PI. However, the monocusp valve seemed not be very effective in some patients who underwent the complete TOF repair. METHODS Patients who had the classic form of TOF between January 2009 and January 2017 and underwent the corrective surgery with a TAP by the same cardiovascular surgeon were identified for further analysis. Clinical information including demographics at operation, perioperative data, and postoperative outcome were collected retrospectively and compared between the group with and without a monocusp valve. RESULTS A total of 24 TOF cases were included in the final analysis, and 16 (66.7%) patients received a monocusp valve placement. The patients' characteristics before and during the surgery were similar between the two groups. The median duration of chest tube drainage after the total correction in the monocusp group was longer than those without the valve (p = 0.04). There was no difference in the immediate postoperative data, including the inflammation/infection status, the duration of mechanical ventilation, and the length of ICU and hospital stay. CONCLUSION Implantation of a monocusp valve during the total TOF correction using a TAP did not bring benefit to improve the immediate postoperative outcomes, especially the duration of the pleural drainage. Further study with a prospective design and a larger number of cases is needed.
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Affiliation(s)
- Shao-Wei Huang
- Division of Pediatric cardiology, Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Division of Pediatric Cardiology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Wan-Fu Hsu
- Division of Pediatric cardiology, Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Division of Pediatric Cardiology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Hsing-Yuan Li
- Division of Pediatric Cardiology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Betau Hwang
- Division of Pediatric Cardiology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Pediatrics, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Pediatric Cardiology, Tung's Taichung MetroHarbor Hospital, Taichung, Taiwan, ROC
| | - Fei-Yi Wu
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Zen-Chung Weng
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Chieh-Mao Chuang
- Division of Pediatric Cardiology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shyi-Jou Chen
- Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chih-Chien Wang
- Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Der-Shiun Wang
- Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Pi-Chang Lee
- Division of Pediatric Cardiology, Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, Tri-Service General Hospital, Taipei, Taiwan, ROC
- Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan, ROC
- Department of Pediatrics, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
- Division of Pediatric Cardiology, Mackay Children's Hospital, Taipei, Taiwan, ROC
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Waqar T, Ansari MZA, Khan K. Clinical outcome of right ventricle outflow tract management for repair of Tetralogy of Fallot with three contemporary surgical strategies. Pak J Med Sci 2021; 37:1313-1318. [PMID: 34475904 PMCID: PMC8377931 DOI: 10.12669/pjms.37.5.3961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/04/2021] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare the early operative outcome of TOF repair with three contemporary repair strategies of RVOTO repair i.e. TAP, Mono-cusp construction (MC) in TAP and pulmonary valve repair. Methods: Study is performed at Punjab Institute of Cardiology, Lahore from May 2016 to April 2020. Retrospective analysis of data was performed for patient who underwent TOF repair by three different strategies of RVOT repairs during TOF surgery based on z scoring for pulmonary valve annulus. Group-I underwent trans-annular patch repair, while Group-II and III underwent Mono-cusp repair with autologous pericardium and pulmonary valve repair respectively. Analysis of Variance (ANOVA) and Pearson Chi-Square (PCS) statistics were used to compare the three groups for numeric and categorical variables respectively. Post-hoc t-test and Bonferroni correction were performed for numeric data to compare two groups with each other. Chi-square test was used to perform comparison between groups for categorial variables. Results: ANOVA for aortic cross clamp time, total CPB time, Post-operative mechanical ventilation time, ICU stay and hospital stay showed statistical difference among all three group with p-value less than 0.05 however post hoc T-test showed this variation is limited to post-operative mechanical ventilation only when groups compared with each other. PCS showed there was difference for incidence of difficult weaning from CPB when all three groups compared while there was no difference in operative mortality with p-value of 0.15. However, Group-II comparison with Group-I showed that weaning from CPB was superior in-Group-II with p-value of 0.016. Group-III showed the best statistics for all operative outcome variables among all three groups. Comparison of incidence of post-operative moderate pulmonary regurgitation before discharge between Group-II and Group-III showed significant difference with p-value of 0.0052. Conclusion: PV repair strategy should be employed for RVOT repair of TOF whenever feasible. MC repair showed fewer hours of postoperative mechanical ventilation and higher incidence of easy weaning from CPB when compared to TAP, however its impacts over ICU stay, Hospital stay and operative mortality is not profound in our TOF repair population.
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Affiliation(s)
- Tariq Waqar
- Tariq Waqar, (FCPS, FRCS), Associate Professor, Pediatric Cardiac Surgery, Punjab Institute of Cardiology, Lahore, Pakistan
| | - M Zubair Ahmed Ansari
- M. Zubair Ahmed Ansari, (FCPS), Assistant Professor, Cardiac Surgery, Cardiac Centre, Bahawalpur, QMC, Bahawalpur, Pakistan
| | - Kamran Khan
- Kamran Khan, (MS), Medical Officer, Punjab Institute of Cardiology, Lahore, Pakistan
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Amirghofran A, Edraki F, Edraki M, Ajami G, Amoozgar H, Mohammadi H, Emaminia A, Ghasemzadeh B, Borzuee M, Peiravian F, Kheirandish Z, Mehdizadegan N, Sabri M, Cheriki S, Arabi H. Surgical repair of tetralogy of Fallot using autologous right atrial appendages: short- to mid-term results. Eur J Cardiothorac Surg 2021; 59:697-704. [PMID: 33164039 DOI: 10.1093/ejcts/ezaa374] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The prevention of pulmonary insufficiency (PI) is a crucial part of the tetralogy of Fallot repair. Many techniques have been introduced to construct valves from different materials for the right ventricular outflow tract, including the most commonly constructed monocusp valves. We are introducing a new bicuspid valve made intraoperatively using the autologous right atrial appendage (RAA) to prevent PI in these patients. METHODS The RAA valve was constructed and used in 21 patients with tetralogy of Fallot. The effective preservation of the native valve was impossible in all patients because of either a severe valve deformity or a small annulus. The RAA valve was created after ventricular septal defect closure and right ventricular outflow tract myectomy and was covered with a bovine transannular pericardial patch. The perioperative data were evaluated, and the echocardiography results were assessed immediately after operations and in follow-up with a median of 10.5 months. The data were retrospectively compared with 10 other patients with similar demographic data but with only transannular patches. RESULTS The mean age of the patients was 13.3 months. No mortality or related morbidity occurred after repair using the RAA valve. The PI severity early after the operation was trivial or no PI in 18 patients, and mild PI was observed in 3 patients, which progressed to moderate PI in one of them in the mean 12-month follow-up period. Fifteen patients had mild or no pulmonary stenosis, while moderate pulmonary stenosis was observed in 6 others. Compared with the other 10 patients with only transannular patches, the RAA valve patients had prolonged operative and clamping times, but no difference in postoperative course and shorter hospital stays. The degree of PI was, of course, significantly less in the RAA valve patients, but pulmonary stenosis was the same. CONCLUSIONS The RAA valve construction is a safe and effective technique to prevent PI after the tetralogy of Fallot repair, at least in terms of short- and mid-term results. A longer follow-up period is needed to confirm if this new valve can eliminate or significantly delay the need for pulmonary valve replacement in these patients.
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Affiliation(s)
| | | | - Mohammadreza Edraki
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Gholamhossein Ajami
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Amoozgar
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Mohammadi
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abbas Emaminia
- Inova Heart and Vascular Institute, Fall Church, VA, USA
| | - Bahram Ghasemzadeh
- Cardiac Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Borzuee
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farah Peiravian
- Pediatric Department, Faculty of Medicine, Islamic Azad University, Kazerun Branch, Kazerun, Iran
| | - Zahra Kheirandish
- Pediatric Department, Faculty of Medicine, Islamic Azad University, Kazerun Branch, Kazerun, Iran
| | - Nima Mehdizadegan
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | | | - Hamid Arabi
- Shiraz University of Medical Sciences, Shiraz, Iran
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Rawat S, Jaswal V, Thingnam SKS, Singh H, Mahajan S, Kynta RL, Puri GD, Rohit MK. Short-term outcome of Polytetrafluoroethylene Membrane Valve versus Transannular Pericardial patch Reconstruction of Right Ventricular Outflow Tract in Tetralogy of Fallot: a Randomized Controlled Trial. Braz J Cardiovasc Surg 2021; 36:39-47. [PMID: 32759096 PMCID: PMC7918384 DOI: 10.21470/1678-9741-2020-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Reconstruction of right ventricular outflow tract during primary repair of tetralogy of Fallot often requires the placement of a transannular patch which results in pulmonary regurgitation (PR). We compared the short-term outcomes of bicuspid polytetrafluoroethylene membrane valve versus transannular pericardial patch reconstruction of the right ventricular outflow tract. METHODS Thirty consecutive patients undergoing primary repair of tetralogy of Fallot were randomly allocated to two groups - polytetrafluoroethylene valve (PTFEV) group (n=15) and transannular pericardial patch (TAP) group (n=15). The two groups had similar preoperative demographic characteristics. We compared the short-term clinical and echocardiographic outcomes between these groups. The transthoracic echocardiographic follow-up was performed at one week, one month and six months after surgery. RESULTS The PTFEV group had significantly lower central venous pressure in the immediate postoperative period compared to the TAP group (7.60±2.06 vs. 10.13±1.73, P=0.002). Extubation time was significantly shorter in the PTFEV group compared to the TAP group (12.93±7.55 hrs vs. 22.23±15.11 hrs, P=0.04). PR in the PTFEV group was absent in five patients at 24 hours post-surgery. At the study endpoint, PR was absent in six, trivial in one and mild in eight patients in the PTFEV group compared to TAP group, where all 15 patients had severe PR. CONCLUSION The bicuspid polytetrafluoroethylene membrane valves significantly decrease the central venous pressure in the immediate postoperative period, facilitate early extubation and, thus, prevent ventilator-related comorbidities. They achieve a high degree of pulmonary competence and do not increase the right ventricular outflow tract gradient in short-term follow-up.
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Affiliation(s)
- Sanjib Rawat
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vivek Jaswal
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Shyam Kumar Singh Thingnam
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harkant Singh
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sachin Mahajan
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Reuben Lamiaki Kynta
- Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Critical Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manoj Kumar Rohit
- Department of Cardiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Temur B, Aydın S, Suzan D, Kırat B, Demir IH, Erek E. Comparison of different pulmonary valve reconstruction techniques during transannular repair of tetralogy of fallot. J Card Surg 2020; 36:56-61. [PMID: 33124733 DOI: 10.1111/jocs.15133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/26/2020] [Accepted: 10/07/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Transannular patch, which results in pulmonary insufficiency (PI), is usually required during repair of tetralogy of fallot (TOF). In this study, we compared three types of pulmonary valve reconstruction techniques during transannular repair of TOF. METHODS Between February 2014 and January 2018, 50 patients with TOF underwent primary repair with transannular patch. These patients were divided into three groups. In Group 1, (n = 15), a single gluteraldehyde-treated autologous pericardial patch (standard method) was reconstructed as monocusp. In Group 2, (n = 16) Nunn's bileaflet pulmonary valve reconstruction technique was used with pericardial patch. In Group 3, (n = 19), Nunn's bileaflet technique was performed with expanded polytetrafluoroethylene membrane. The outcomes of the patients and early and midterm competency of the pulmonary valves were analyzed. RESULTS These techniques were significantly effective in early postoperative period. Freedom from moderate to severe PI were 73.3%; 100% and 89.4%, respectively. Mortality, duration of intensive care unit and hospital stay were similar between the groups. The mean follow-up period was 17.5 ± 13.0 (3-57) months. Freedom from moderate to severe PI decreased to 40%; 81.2% and 73.7%, respectively at the end of the follow-up period. Presence of moderate to severe PI was significantly higher in Group 1 (p = .018 between Groups 1 and 2, p = .048 between Groups 1 and 3). CONCLUSION All three pulmonary valve reconstruction techniques provided competent pulmonary valves. Nunn's bileaflet technique had better outcome at midterm. It has a potential to delay right ventricular dysfunction at long-term.
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Affiliation(s)
- Bahar Temur
- Department of Cardiovascular Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Selim Aydın
- Department of Cardiovascular Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Dilek Suzan
- Department of Cardiovascular Surgery, Gaziosmanpaşa Hospital, Yeni Yüzyıl University, Istanbul, Turkey
| | - Barış Kırat
- Department of Anesthesiology and Reanimation, Istanbul Florence Nightingale Hospital, Istanbul, Turkey
| | - Ibrahim Halil Demir
- Department of Pediatric Cardiology, Istanbul Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ersin Erek
- Department of Cardiovascular Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
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Wankhade PR, Aggarwal N, Joshi RK, Agarwal M, Joshi R, Mehta A, Kar S. Short-term clinical and echocardiographic outcomes after use of polytetrafluoroethylene bicuspid pulmonary valve during the repair of tetralogy of Fallot. Ann Pediatr Cardiol 2019; 12:25-31. [PMID: 30745766 PMCID: PMC6343384 DOI: 10.4103/apc.apc_51_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Application of transannular patch (TAP) during the repair of tetralogy of Fallot (TOF) leads to the development of pulmonary regurgitation (PR). This PR is known to cause right ventricular (RV) volume overload and dysfunction which in turn leads to increase in both morbidity and mortality both in immediate and long-term periods. Here, we sought to analyze the effects of polytetrafluoroethylene (PTFE) pulmonary bicuspid valve on the early outcome of patients with TOF repair where TAP is needed. Subjects and Methods: This is a retroprospective, observational study where PTFE bicuspid pulmonary valve was incorporated in all consecutive patients undergoing repair of TOF involving the application of TAP. Postoperative inhospital course was assessed, and patients were followed till 6 months for the status of PR and peak RV outflow tract (RVOT) gradient. Results: 38 patients were enrolled in the study. The mean age of participants was 53.66 ± 78.67 months. Extubation in operating room was done in 31 (81.58%) patients. Duration of ventilator support was 10.48 ± 24.22 h, and duration of hospital stay was 7.95 ± 3.08 days. These data were compared with three recent studies where only TAP was applied. Extubation in operating room, mechanical ventilation time, and hospital stay were significantly improved in the present study. Out of 37 live patients, four (10.81%) patients had no PR, 28 (75%) had mild, 1 (2.7) had moderate, and 4 (10.81%) had severe PR. Average RVOT peak gradient was 18.8 ± 8.1 mmHg. Conclusion: Incorporation of PTFE bicuspid pulmonary valve during the repair of TOF appears to facilitate early extubation and thus reduces ventilator-associated comorbidities. Study needs further long-term follow-up to look for behavior of PTFE bicuspid valve.
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Affiliation(s)
| | - Neeraj Aggarwal
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, Delhi, India
| | | | - Mridul Agarwal
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, Delhi, India
| | - Raja Joshi
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, Delhi, India
| | - Ashwani Mehta
- Department of Cardiology, Sir Ganga Ram Hospital, Delhi, India
| | - Sibashankar Kar
- Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, Delhi, India
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10
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The impact of pulmonary valve-sparing techniques on postoperative early and midterm results in tetralogy of Fallot repair. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:370-374. [PMID: 32082766 DOI: 10.5606/tgkdc.dergisi.2018.15499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 03/15/2018] [Indexed: 11/21/2022]
Abstract
Background In this study, we analyzed the impact of pulmonary valve-sparing techniques on early and midterm postoperative results of tetralogy of Fallot repair. Methods A total of 64 patients diagnosed with tetralogy of Fallot, who underwent total correction operation by the same surgeon between November 2010 and September 2015 were included in this retrospective study. Mean age of the patients was 20.0±14.2 months (5.5-96 months). Forty patients (62.5%) were male. Thirty two of the patients (50%) were under one year of age. Pulmonary valve-sparing techniques were performed in 29 patients (Group 2), while transannular patch was applied in the remaining 35 patients (Group 1). Pericardial monocusp valve was constructed in 15 patients in Group 1. In Group 2, pulmonary valve-sparing techniques were transatrial repair in nine patients; transatrial-transpulmonary in eight, infundibular patch in eight, and infundibular-pulmonary patch in four patients. Results There was no early postoperative mortality in Group 2. Five patients (14.2%) in Group 1 died in the early postoperative period (p=0.058). Pulmonary monocusp insertion was performed in 2 (13.3%) of these patients (p=1). The causes of mortality were sudden cardiac arrest (n=2), multiorgan failure (n=1), low cardiac output (n=1), and neurological complications (n=1). Five patients in Group 1 required extracorporeal membrane oxygenation support (ECMO). Three of them were separated from ECMO and two of the patients that were separated were discharged uneventfully. Total postoperative morbidity rate was significantly higher in Group 1 (51.4% vs. 6.8%) (p=0.0001). Morbidity rate was significantly lower in patients with pulmonary monocusp insertion than patients in the same group without a monocusp (p=0.0176). Forty nine (83%) of the patients were followed up for a median of 6.5 (1-24) months. While free pulmonary regurgitation was detected in all non-monocusp patients in Group 1, pulmonary regurgitation was absent or mild in Group 2. Twelve (80%) of the patients in Group 1 who had monocusp insertion were followed up. Only two of these patients had free pulmonary regurgitation (16.6%). The rest of them had mild (n=6) or mildmoderate pulmonary regurgitation (n=4). Conclusion Mortality and morbidity rates are lower when pulmonary valvesparing techniques are used in repair of tetralogy of Fallot. Monocusp pulmonary valve insertion may improve results in patients who require transannular patch repair. It is suggested that every effort should be made to achieve a competently working pulmonary valve during repair.
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11
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Wang Q, Wang Z, Wu C, Pan Z, Xiang L, Liu H, Jin X, Tong K, Fan S, Jin X. Potential association of long noncoding RNA HA117 with tetralogy of Fallot. Genes Dis 2018; 5:185-190. [PMID: 30258948 PMCID: PMC6148707 DOI: 10.1016/j.gendis.2018.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 03/01/2018] [Indexed: 02/01/2023] Open
Abstract
Tetralogy of Fallot (TOF) is a congenital heart disease characterized by abnormal cardiomyocyte differentiation in the right ventricular outflow tract (RVOT), and HA117 is a novel long noncoding RNA (lncRNA) with anti-differentiation roles. To investigate the potential association of HA117 with TOF, we collected 84 RVOT tissues from patients with TOF. We determined the expression of HA117 in RVOT samples from TOF patients and collected clinical data to conduct a cross-sectional and short-term follow-up study. McGoon ratio, Nakata index, and left ventricular end-diastolic volume index (LVEDVI) were negatively correlated with the expression of HA117 based on subgroup analysis, correlation analysis and logistic regression analysis. Additionally, cardiopulmonary bypass (CPB) time and ICU stay were longer in patients with higher expression of HA117 than in patients with lower expression of HA117. Furthermore, percentage improvement in SPO2 was significantly reduced in patients with increased HA117 expression at 6 months after surgery. Our results suggested that the increased expression of the novel lncRNA HA117 is a risk factor for unfavorable McGoon ratio, Nakata index and LVEDVI in TOF patients. Additionally, an increased expression of HA117 might lead to adverse short-term outcomes in TOF patients.
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Affiliation(s)
- Quan Wang
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhili Wang
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chun Wu
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengxia Pan
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Xiang
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hang Liu
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xin Jin
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Kerong Tong
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Shulei Fan
- Renal Department and Nephrology Institute, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xianqing Jin
- Ministry of Education, Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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12
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Pulmonary valve cusp augmentation for pulmonary regurgitation after percutaneous balloon pulmonary valvuloplasty of valvular pulmonary stenosis. Cardiol Young 2018; 28:507-510. [PMID: 29307316 DOI: 10.1017/s1047951117002694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pulmonary valvular stenosis is a relatively common disorder, accounting for approximately 10% of all CHDs. Pulmonic valvular disease can get clinically detected at different ages of life. The more severe the obstruction, the earlier detected the valvular abnormality. Surgical pulmonary valvotomy has been available as a treatment since 1956. This article is about a case of pulmonary annular and valvular stenosis in a 1-year-old child, and it also explores surgical operation of this condition. Transannular patches are usually used within the 1st year of age in pulmonary annular and valvular stenosis. In recent years, anterior leaflet augmentation has been preferred for annulus enlargements. In our 1-year-old case, we expanded the annulus by the anterior leaflet expansion technique and we also augmented other leaflets by polytetrafluoroethylene patch.
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Sayyed EHN, Rana SS, Anand KM, Eram A, Harkant S. Monocusp pulmonary valve reconstruction in childhood and adult TOF repairs: does a single cusped valve work? Indian J Thorac Cardiovasc Surg 2016. [DOI: 10.1007/s12055-016-0457-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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14
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Jang WS, Cho JY, Lee JU, Lee Y. Surgical Results of Monocusp Implantation with Transannular Patch Angioplasty in Tetralogy of Fallot Repair. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:344-349. [PMID: 27733993 PMCID: PMC5059119 DOI: 10.5090/kjtcs.2016.49.5.344] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 11/22/2015] [Accepted: 12/01/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Monocusp reconstruction with a transannular patch (TAP) results in early improvement because it relieves residual volume hypertension during the immediate postoperative period. However, few reports have assessed the long-term surgical outcomes of this procedure. The purpose of the present study was to evaluate the mid-term surgical outcomes of tetralogy of Fallot (TOF) repair using monocusp reconstruction with a TAP. METHODS Between March 2000 and March 2009, 36 patients with a TOF received a TAP. A TAP with monocusp reconstruction (group I) was used in 25 patients and a TAP without monocusp reconstruction (group II) was used in 11 patients. We evaluated hemodynamic parameters using echocardiography during the follow-up period in both groups. RESULTS At the most recent follow-up echocardiography (mean follow-up, 8.2 years), the mean pulmonary valve velocities of the patients in group I and group II were 2.1±1.0 m/sec and 0.9±0.9 m/sec, respectively (p=0.001). Although the incidence of grade 3-4 pulmonary regurgitation (PR) was not significantly different between the two groups (group I: 16 patients, 64.0%; group II: 7 patients, 70.0%; p=0.735) during the follow-up period, the interval between the treatment and the incidence of PR aggravation was longer in group I than in group II (group I: 6.5±3.4 years; group II: 3.8±2.2 years; p=0.037). CONCLUSION Monocusp reconstruction with a TAP prolonged the interval between the initial treatment and grade 3-4 PR aggravation. Patients who received a TAP with monocusp reconstruction to repair TOF were not to progress to pulmonary stenosis during the follow-up period as those who received a TAP without monocusp reconstruction.
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Affiliation(s)
- Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine
| | - Joon Yong Cho
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine
| | - Jong Uk Lee
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine
| | - Youngok Lee
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, Kyungpook National University School of Medicine
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