The transannular patch tap repair used in the correction of tetralogy of fallot tof inevitably causes pulmonary regurgitation. Longterm outcome in patients undergoing surgical repair of. Commissurotomy was performed whenever pulmonary valve stenosis was present. Surgical management of patients with pulmonary valve dysplasia. Devyani chowdhury is a pediatric cardiologist in lancaster, pa. They usually result in an insufficient amount of oxygenated blood reaching the body. If the obstruction is due to thickened muscle tissue below the pulmonary valve. Careful attention must be taken to prevent transannular leak at this level. Involves closure of the vsd and resection of the infundibular stenosis, with placement of a pericardial patch to enlarge the rvot. Pulmonary valve leaflets that are preserved at initial surgery may grow and develop normal morphology and subsequent valve repair may be possible. Pulmonary atresia with intact ventricular septum paivs is a rare congenital cardiac lesion characterized by heterogeneous right ventricular development, an imperforate pulmonary valve, and possible extensive ventriculocoronary connections.
There were seven deaths before surgery and one posttransannular patch repair. On multivariate logistic regression, smva was independently associated with the absence of transannular patch p0. The prosthesis is positioned over the diseased pulmonary valve and a balloon is inflated, deploying the prosthetic valve in place. Fresh autologous pericardium to reconstruct the pulmonary valve. We highlight our retrospective analysis for the last 10 years.
Pdf transannular pulmonary enlargement and bioprostheses. There were seven deaths before surgery and one post transannular patch repair. The new shelhigh injectable stented pulmonic valve shelhigh inc, union, nj allows implantation without cardiopulmonary bypass. A transannular patch is sewn in place supplemental fig j, and the patient is weaned from cardiopulmonary bypass. Prognosis and management depend on the degree of right ventricular hypoplasia including tricuspid val. In tof, there can be narrowing beneath the pulmonary valve. A pulmonary homograft valved conduit is the replacement of choice. To report on our initial experience with the implantation of a pulmonary valve using nunns technique in association with a transannular patch for the complete repair of the tetralogy of fallot. It is also the first cyanotic heart disease to have a total and successful. There is great variability in the dimensions of the tetralogy right ventricular outflow tract, main pulmonary artery and branch pulmonary arteries, both between patients and within the same patient.
Oct 18, 2016 the bovine pericardial patch is sutured to the pulmonary artery, and the suture line is carried at the level of the valve on both sides. Material and methods from july, 1975, through july, 1985, 21 patients 12 boys and 9 girls underwent operations for relief of pulmo nary stenosis due to pulmonary valve dysplasia. However, if there is also a need to widen the outflow tract of the right ventricle, a transannular patch may be required. We report herein the results of a longterm followup study conducted on 50 patients who had undergone a tap repair 2029 years earlier to evaluate the influence of pulmonary regurgitation on their late outcome and quality of life. Transannular patch tap repair of tetralogy of fallot tof is correlated to poor late outcome, 30% need reoperation due to pulmonary regurgitation pr. Management of pentalogy of cantrell with complete ectopia. Myocardial damage, invasiveness, and the risks of pulmonary valve replacement pvr therefore need to be minimized. Monocusp valve placement in children with tetralogy of fallot. This patch covers part of the wall of the right ventricle as well as widening the pulmonary artery and pulmonary valve. The pulmonary valve stenosis is also repaired early with a patch and or valvoplasty. A new pulmonary valve cusp plasty technique markedly decreases transannular patch rate and improves midterm outcomes of tetralogy of fallot repair.
Lecompte maneuver in surgical correction of absent pulmonary. Outcomes of prenatally diagnosed tetralogy of fallot. Late pulmonary valve placement after tetralogy repair with a. The aim of this protocol is to assess the efficacy, safety and performance of venus pvalve. Free pulmonary valve regurgitation due to previously performed transannular patch plastic was found. Transannular incision through the pulmonary valve and patching is sometimes necessary to relieve. A patch across the pulmonary valve annulus a transannular patch is often required in order to adequately relieve right ventricular outflow tract obstruction. Pulmonary valve implantation with the new shelhigh injectable. Pulmonary regurgitation pr occurs frequently after tetralogy of fallot tof repair, impairing longterm prognosis and necessitating reinterventions. Percutaneous pulmonary valve implantation with the venus p. Fresh autologous pericardium to reconstruct the pulmonary valve at the. The narrowing in the pulmonary valve is also repaired with the transannular patch to improve blood flow to the lungs.
Pbpv, percutaneous balloon pulmonary valvuloplasty. If a patch is inserted, it may be used to widen the pulmonary artery from the valve upward. Alternatives to this repair include a transannular patch without a homograftconduit valve, especially if the respiratory symptoms are not severe. Use of a pulmonary neovalve with a transannular patch for. In some repairs, the patch may extend across the pulmonary valve annulus transannular patch, making the. Angiography and hemodynamic evaluations are repeated. Jul 21, 2012 valvectomy with or without transannular patch valvectomy is the surgical removal of the valve and the widening of the outflow patch to improve blood flow from the right ventricle into the pulmonary artery.
Early versus late pulmonary valve replacement in patients with transannular patchrepaired tetralogy of fallot. Pulmonary valve stenosisvalvectomy with transannular patch. A single suture may provide hemostasis at the venous access. Tetralogy of fallot is a combination of four congenital abnormalities. We then narrow the transannular patch with the use of a series of clips under echocardiographic guidance to reduce the amount of pulmonary insufficiency without creating a gradient of more than 15 mm hg supplemental fig k. Valvesparing surgery for tetralogy of fallot procedure. Surgical management of patients with pulmonary valve. Although right ventricular dilation and dysfunction are important late consequences of free pulmonary regurgitation, there is evidence that failure to insert a tap when one is. The catheter is removed and pressure is applied to stop bleeding at the access site. Devyani chowdhury, pediatric cardiologist in lancaster. Rightsided valve disease deserves a little more respect. Placement of a transannular patch is necessary in some patients during tetralogy repair but this results in pulmonary regurgitation.
Twentysix underwent valvesparing repair median age 5. In some repairs, the patch may extend across the pulmonary valve annulus transannular patch, making the pulmonary valve incompetent. Currently, timing of pvr is based on the patients symptoms and rv size and function. Although many patients tolerate this indefinitely, 30% to 40% will require later valve placement.
Valvesparing surgery for tetralogy of fallot procedure details. The majority 95% of pulmonary stenosis ps cases are related to congenital or genetic disorders. Close the vsd with a patch so that the aorta comes from the left ventricle 2. Transcatheter pulmonary valve implantation medical clinical. Transannular patching was used in 99 patients 52%, patch closure of a right. Development of a novel hybrid strategy for transcatheter pulmonary valve placement in patients following transannular patch repair of tetralogy of fallot. Affect the pulmonary valve tpv therapy can help adults and children who have had previous surgery to help repair or replace a pulmonary valve that was damaged by a chd.
In the z patch is inserted, it may be used to widen the pulmonary artery from the valve upward. The goal of pulmonary valve replacement pvr is to prevent these complications and reverse the process of rv dilatation 2, 3, 68. Tof repair, ventriculotomy, transannular patch 370. Noonan syndrome, an autosomal dominant disorder, is commonly associated with ps. The patch is folded and the ring of the valve is fixed to the transannular patch at the level of the fold. The longterm influence of pulmonary valve regurgitation. However, controversy remains as to the optimal time to implant a competent pulmonary valve 3, 710. These patients will do poor if there is any type of rvoto obstruction. The right ventricular outflow tract appeared without stenosis. Used in adolescents and adults to treat pulmonary valve leaking regurgitation. Av block in 6 patients, sick sinus syndrome in 1, and unknown in the last. The integrity of the pulmonary valve annulus is spared whenever possible to maintain pulmonary valve competence.
If your doctor has considered tpv as treatment option for you, you may have had one of the following pulmonary valve conditions or surgical treatments. A new pulmonary valve cusp plasty technique markedly. Morphologic features of the stenotic pulmonary valve vary and include a the domeshaped valve and b the dysplastic myxomatous valve. Pulmonary valve restitution following transannular patch. The data are also relevant to the recent upsurge of interest in using semi lunar valve allografts rather than transannular patches when the pulmonary annulus is hypoplastic. Pulmonary valve disease japan pdf ppt case reports. Right ventricular outflow tract obstruction radiology key. Transcatheter pulmonary valve implantation, percutaneous approach, including prestenting of the valve delivery site, when performed. Early versus late pulmonary valve replacement in patients. Patients between 1860 years with rvot stenosis and moderate to severe pulmonary regurgitation. Transannular patching is a valid alternative for tetralogy of. Pulmonary regurgitation in congenital heart disease. He is now almost 7 years old and is presenting with significant backflow to the right ventricle due to having no pulmonary valve.
Longterm survival of patients with tetralogy of fallot with or without a patch up to or through the pulmonary annulus who survived the immediate postoperative period. Severe stenosis at both pulmonary annulus and the right ventricle outflow impose the tap. In the case of transannular patch tap repair, once the valve is opened and a tap is placed. Recent evidence indicates, however, that use of a transannular patch can cause pulmonary insufficiency, or weakness in the pulmonary valve that allows backflow of blood into the right ventricle. Right ventricular outflow tract obstruction was relieved by a transannular patch in 14 cases 42%, with a ptfe monocusp in 4 cases, by an infundibular patch with preservation of the pulmonary valve in 7 cases 21%, and a right ventricletopulmonary artery valved conduit interposition was used in 11 cases 33%.
The most common morphology is the domeshaped, tricuspid pulmonary valve with thickened, fused commissures, a narrow central opening pinhole to several millimeters, preserved leaflet mobility, and poststenotic dilatation of the pulmonary artery. Chronic pulmonary insufficiency following transannular patch repair of tetralogy of fallot may mandate restoration of a competent pulmonary valve. One patient required a transannular patch repair after the. Use of a pulmonary neovalve with a transannular patch for repair. Pulmonary stenosis congenital heart disease cove point. The abnormal pulmonary valve pv may be classified as acommisural, unicommissural, bicuspid, or dysplastic. The four defects include a ventricular septal defect vsd, pulmonary valve stenosis, a misplaced aorta and a thickened right ventricular wall right ventricular hypertrophy. Complete repair usually performed in the first year of life.
Nevin, phillip shah, avni olshove, vincent garg, ruchira and zahn, evan m. Hcpcs codes not covered for indications listed in the cpb. Efficacy and safety of venus pvalve to treat rvot stenosis. Cardiovascular disease in noonan syndrome archives of. Pulmonary valve diseases are the least common heart valve disease in adults. Tetralogy of fallot is a common form of congenital heart disease amenable to full surgical repair. Coexistence of abnormal systolic motion of mitral valve in a. Truncus pulmonalis and pulmonary arteries appeared enlarged without affected pulmonary artery perfusion. Chowdhurys phone number, address, insurance information, hospital affiliations and more. Primary surgical repair for valvar ps was performed in 35 patients with either a pulmonary valvotomy n28 or transannular patch n7, at an average age of 6. Human or porcine pig tissue valve is used to replace the original pulmonary valve.
A traditional procedure involves closing the ventricular septal defect and placing a transannular patch a patch across the pulmonary valve connective tissue to. Conclusions in this series of adult tof patients, we describe a novel finding of a high prevalence of systolic mitral valve abnormalities. Once tetralogy of fallot is diagnosed, the immediate management focuses on determining whether the childs oxygen levels are in a safe range. Remove extrathick muscle in the right ventricle below the valve 3. In cases where the bronchial compression cannot be ameliorated by pulmonary reduction arterioplasty, the addition of the lecompte maneuver to the repair has been shown to provide substantial relief. No rhythm disturbances were electrocardiographically detected. Tetralogy of fallot repair assumes vsd closure and relief of pulmonary stenosis at one or more levels, with use of a ventriculotomy incision and placement of a transpulmonary annulus patch. Twentysix underwent valve sparing repair median age 5. Although transannular patch repair has a good shortterm outcome, there is mounting concern that longstanding severe pulmonary insufficiency may lead to progressive rightsided heart failure, reduced functional status and reduced life expectancy. A diminutive pulmonary artery and right ventricular outflow tract in a 46yearold woman with a 10year history of carcinoid syndrome required transannular pulmonary patch enlargement to allow.
Effect of transannular patching on outcome after repair of. The bovine pericardial patch is sutured to the pulmonary artery, and the suture line is carried at the level of the valve on both sides. Pulmonary valve replacement in adult congenital cardiac surgery. Pulmonary valve replacement in adult congenital cardiac. Use of a pulmonary neovalve with a transannular patch for repair of. The most common reason for patients to return as adults after tof repair is for pulmonary valve regurgitation.