B, lateral view of improper position for pulmonary valve in the right ventricular outflow tract with a transannular patch demonstrating the. The transannular patching with a monocusp ventricular outflow patch has been a. In the past few decades, surgery has proved successful, but most patients require repeat imaging throughout their lives. The patient selected for this procedure would be one for whom the surgeon would consider either a transannular patch or a pulmonary valve insertion at the time of initial tetralogy of fallot repair, or a patient having a reoperation after initial transannular patch or valved conduit placement. Objectives we sought to determine if early primary repair of acyanotic tetralogy of fallot tof can be performed safely with low requirement for transannular patching tap and thereafter allow normal right ventricular outflow tract rvot growth. Since then, several operative techniques have been re ported, including transatrial repair of the vsd and.
Department of cardiac surgery, university hospital of gent, gent, belgium. Limited transannular patch with nominal pulmonary annular expansion in. Ptfe monocusp valve for rvot reconstruction ctsnet. On the other hand, in some limited institutions such as pusan national university yangsan hospital, transannular patch repair was avoided whenever judged possible, resulting in a low rate of tape only 32. Transannular patch repair of tetralogy of fallot leads to pulmonary insufficiency and progressive right ventricular dilatation responsible for a decreased exercise capacity. Native pulmonary valve restoration after remote tetralogy. Although recent literature has focused on the deleterious effects of pulmonary regurgitation, inadequate relief of stenosis may increase postoperative mortality and the reintervention rate. An experimental study, abstract repair of congenital right ventricular outflow tract obstruction often requires reconstruction with a transannular patch to alleviate pulmonary stenosis. Effect of transannular patching on outcome after repair of. The initial efforts at repair focused on the complete relief of obstruction across the right ventricular outflow tract rvot, usually including an aggressive resection of right ventricular. Pulmonary valve pv incompetence following transannular patch tap repair of tetralogy of fallot tof results in longterm morbidity and mortality. Relief of rvot obstruction can be achieved by means of pulmonary valvotomy, resection of hypertrophied muscle bundles, or placement of a transannular outflow tract patch in those patients with severe pulmonary valve hypoplasia.
Comparison of the midterm results of pulmonary valve. A transannular patch is often used in the contemporary surgical repair of tetralogy of fallot. A patch across the pulmonary valve annulus a transannular patch is often required in order to adequately relieve right ventricular outflow tract obstruction. Ptfe valve red in diastole arrows, blue, moving toward the perimeter of the pulmonary neoartery native artery shown in black and patch of pericardium shown in green. Transannular patch repair is performed when there is marked stenosis of the rvot or pulmonary annulus. A novel predictive value for the transannular patch enlargement in. Transannular patch of the pulmonary artery simulation on a. The first anatomic repair of tof was performed in 1954. In total, 21 patients were treated between september 2008 and february 2010. The narrowing in the pulmonary valve is also repaired with the transannular patch to improve blood flow to the lungs. During the past several decades, several groups have favored the use of either a limited tap, or the use of an infundibular sparring approach. Outcomes of prenatally diagnosed tetralogy of fallot. Occasionally, placement of a tube graft conduit between the right.
Phillips abm, nevin p, shah a, shah a, olshove v, garg r, et al. In patients with tetralogy of fallot tof, use of transannular patch tap may be required in order to relieve significant right ventricular outflow tract obstruction, subsequently resulting in pulmonary insufficiency pi. Ventricular septal defect a hole in the wall of the heart septum. Although many patients tolerate this indefinitely, 30% to 40% will require later valve placement. The need to insert a transannular patch during reconstruction surgery of the right. Twelve of 29 41% patients received prostaglandins at birth. Gore, newark, del patch is then sutured to both margins of the incision.
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. Valvesparing surgery for tetralogy of fallot procedure details. Use of a pulmonary neovalve with a transannular patch for. Surgical strategies protecting against right ventricular. Patching criteria based on pulmonary annular z scores are ambiguous because of the use of varied z score data sets. Background early primary repair of tof normalizes intracardiac flow patterns, which may allow subsequent normal rvot growth. Pulmonary valve replacement in adult congenital cardiac. Cardiac surgeons perform an open heart surgery during a childs first year to treat tetralogy of fallot. Most of these adult congenital heart disease patients underwent tetralogy of fallot repair in childhood. Occasionally, surgical repair of pulmonary stenosis may be required. Our main goal of management of symptomatic neonatal tof is to avoid transannular patch as much as possible, because transannular patch in tof could have an adverse impact on longterm results. 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. 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.
A functioning pulmonary valve does not improve immediate postsurgical outcomes. Elective primary repair of acyanotic tetralogy of fallot. The word tetralogy means a group of 4, and in tetralogy of fallot, there are 4 heart defects that occur in combination. A traditional procedure involves closing the ventricular septal defect and placing a transannular patch a patch across the pulmonary valve connective tissue to. This can lead to significant pulmonary insufficiency and increased right ventricular volumes and ultimately pulmonary valve replacement. The transannular patch technique was used to relieve the obstruction at the level of the annulus, which lead to the wellknown, longterm problems associated with free pulmonary valve regurgitation pr, including right ventricular dilation and dysfunction. The types of patch are a the classic nonvalved patch, b a custommade. Monocusp valve placement in children with tetralogy of fallot undergoing repair with transannular patch. Cardiovascular mr imaging after surgical correction of. Late pulmonary valve placement after tetralogy repair with. Severe pulmonary valve regurgitation following tetralogy of fallot tof repair leads to right ventricular rv volume overload. Although this valve preservation strategy would be successful for most patients, there are some patients who would require a transannular patch as noted in figs.
Aiming to preserve pulmonary valve function in tetralogy. Treatment of fallot tetralogy with a transannular patch. Among 814 patients undergoing repair of tetralogy of fallot with pulmonary stenosis between 1967 and may 1986, transannular patching in the current era was a weak risk factor for death early postoperatively predicted 30day mortality, 4% with a transannular patch and 1. Tetralogy of fallot is the most common congenital heart defect. Patients who have a balloon valvuloplasty in the catheterization laboratory often go home the same day. For example, there are many more patients with patch repair 17.
A, lateral view of the optimal position for pulmonary valve in the right ventricular outflow tract with a transannular patch demonstrating the laminar flow of blood into the pulmonary arteries. Volume overload of the right ventricle is aggravated with any associated tricuspid regurgitation and it is considered the major cause of function impairment and increased morbidity and mortality in those patients 1,2,3. In a case of tetralogy of fallot, blood flow to the lungs and the body is affected. Should patients with transannular patch repair of tetralogy of fallot have pvr by 10yo debate. At present, the majority of fallot patients who undergo transannular patch tap repair are not candidates for tpvr. Tetralogy of fallot tof is the third most common congenital heart defect and the most common form of congenital heart disease to cause cyanosis. However, if there is also a need to widen the outflow tract of the right ventricle, a transannular patch may be required. Chronic pulmonary insufficiency following transannular patch repair of tetralogy of fallot may mandate restoration of a competent pulmonary valve.
Pulmonary valve restitution following transannular patch. Surgical repair of tetralogy of fallot tof with small pulmonic valve pv. Pulmonary valve restitution following transannular patch repair of. In all cases, care is taken to preserve the pulmonary valve and ensure its proper functioning. The anterior wall of the rvot is opened through the annulus of the pulmonary valve. A pericardial or synthetic polytetrafluoroethylene goretex. Repair of the tetralogy of fallot with absent pulmonary valve 38. The monocusp valve has been used to temporarily reduce insufficiency in hopes to improve short and midterm outcomes. Recent advances in native pulmonary valve intervention late after tetralogy of fallot repair have highlighted. Development of a novel hybrid strategy for transcatheter. Transcatheter pulmonary valve replacement tpvr is an accepted therapy for treatment of dysfunctional right ventricular outflow tract rvot conduits. Total repair of tetralogy of fallot radiology reference. Transannular patching is a valid alternative for tetralogy of fallot and complete atrioventricular septal defect repair gianluca brancaccio, guido michielon, sergio filippelli, gianluigi perri, duccio di carlo, fiore s. Iorio, gianluca oricchio, roberta iacobelli, antonio amodeo, roberto m.
We studied the impact of late homograft insertion on the regression of the right ventricular volumes in symptomatic patients. Transesophageal echocardiography is utilized to help assess adequacy of repair. Development of a novel hybrid strategy for transcatheter pulmonary valve placement in patients following transannular patch repair of tetralogy of fallot. Monocusp valve placement in children with tetralogy of. We sought to determine whether a repair that increases the pv annulus and augments. Valvesparing repair with intraoperative balloon dilation. Transannular patching is a valid alternative for tetralogy. Pulmonary valve preservation strategies for tetralogy of. Implantation of the medtronic harmony transcatheter. However any surgical approach that requires a transannular patch will relieve the stenosis, but result in valve leakiness insuffiency. The cohort included 9 patients with a median age of 18. The problems related with primary repair for tetralogy of. Pulmonary valve leaflets that are preserved at initial surgery may grow and develop normal morphology and subsequent valve repair may be possible. Pulmonary valve restitution following transannular patch repair of tetralogy of fallot.
Transannular patching is used to relieve significant pulmonary annular stenosis during tetralogy of fallot repair. Late homograft valve insertion after transannular patch. 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%. Pulmonary neovalve with a transannular patch for repair of tetralogy of fallot will confirm the durability. 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. However, transcatheter pulmonary valve replacement is not applicable to the.
Pulmonary stenosis congenital heart disease cove point. This patch covers part of the wall of the right ventricle as well as widening the pulmonary artery and pulmonary valve. Use of a pulmonary neovalve with a transannular patch for repair. Valvesparing surgery for tetralogy of fallot procedure. Type of surgical repair, use of prostaglandins and postnatal death were among the outcomes investigated. In these situations, the anterior leaflet can be resected in association with a transannular patch with a reasonable possibility that the remaining valve leaflets, if not sacrificed, would be available for a valve restoration procedure by bicuspidization.
Tetralogy of fallot and pulmonary valve replacement. A novel predictive value for the transannular patch. Five patients with initial pulmonary valvesparing operations required reoperation for residual stenoses. Monocusp valve and transannular patch reconstruction of. Tetralogy of fallot is a common form of congenital heart disease amenable to full surgical repair. Pulmonary effects on exercise testing in tetralogy of. Indications for surgery include progressive right ventricular dilatation and dysfunction. Following adequate rewarming, the patient is weaned from cardiopulmonary bypass.
Valvesparing repair with intraoperative balloon dilation implemented at our bch since 2007 technique infundibulotomy vsd closure, muscle bundle resection infundibular nontransannular patch mpa patch augmentation pulmonary valve commissurotomy pulmonary valve annulus dilation balloon inflation to 120 140% of. Transcatheter pulmonary valve replacement is an effective alternative to openheart surgery in some patients with right ventricular out flow tract dysfunction after the repair of tetralogy of fallot. The most common surgical procedures for tof repair include infundibulectomy, transannular pulmonary artery patch repair, and right ventriclepulmonary artery conduit placement. Pulmonic valve annular enlargement with valve repair in tetralogy of.
Valvesparing repairs have recently gained recognition. Placement of a transannular patch is necessary in some patients during tetralogy repair but this results in pulmonary regurgitation. Moreover, we believe that augmentation of antegrade blood flow through the pulmonary valve can stimulate the growth of the pulmonary valve annulus. If a patch is inserted, it may be used to widen the pulmonary artery from the valve upward. B, lateral view of improper position for pulmonary valve in the right ventricular outflow tract with a transannular patch demonstrating the superior aimed trajectory of blood flow towards the patch caused by failing to tilt the valve posteriorly. 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. Pulmonary valve stenosis a narrowed or completely blocked pulmonary valve, which restricts blood flow from the. One patient required a transannular patch repair after the initial valvesparing repair.