Early and 1-year outcome and predictors of adverse outcome following monocusp pulmonary valve reconstruction for patients with tetralogy of Fallot: A prospective observational study

Abstract

Background and Objectives:Repair of tetralogy of Fallot (TOF) with monocusp pulmonary valve reconstruction prevents pulmonary regurgitation (PR) for a variable period. Since postoperative outcome is governed by PR and right ventricular function, we sought to assess the severity of pulmonary regurgitation and right ventricular outflow (RVOT) gradient in the immediate postoperative period and at 1 year and attempted to identify the anatomical substrates responsible for adverse outcomes.Methods:The study included 30 patients. Transthoracic echocardiography was performed before surgery, within 5 days of surgery, and 1 year later. Presence and severity of PR, RVOT gradient, and residual branch pulmonary stenosis were assessed. Right ventricular and monocusp valve functions were studied.Results:Median age was 36.5 months (3-444 months). There were no deaths. Pulmonary regurgitation was mild in 18, moderate in 10, and severe in 2 patients immediately following surgery. At 1 year, 10 patients had severe PR and one had significant RVOT gradient. None of the variables like age, presence of supravalvar pulmonary branch stenosis, main pulmonary artery diameter, or mobility of monocusp valve was found to have any significant association with the progression of PR. McGoon index <1.5 showed a trend toward more PR, while patients with more residual RVOT gradient had lesser regurgitation.Conclusions:Repair of TOF with monocusp pulmonary valve reduces immediate postoperative PR. At 1 year, the monocusp valve underwent loss of function in a significant proportion and PR also progressed. This study could not identify any predictors of progression of PR, though patients with McGoon index <1.5 tended to have more PR while those with more outflow gradient had lesser PR.

Surgical Results of Monocusp Implantation with Transannular Patch Angioplasty in Tetralogy of Fallot Repair

“…Furthermore, the monocusp is simple, inexpensive, and reproducible [ 11 ]. However, Sasikumar et al [ 12 ] reported that calcification and loss of mobility were observed in a significant number of patients 1 year after the operation. Additionally, some studies have reported a significant incidence of inherent valvular insufficiency and/or obstruction [ 7 , 12 , 13 ].…”

The impact of pulmonary valve-sparing techniques on postoperative early and midterm results in tetralogy of Fallot repair

“…In general, it has been reported that the monocusp technique, which has controversial mid and late-term results and seems to have limited durability, has at least adequate function at an early stage and the potential to reduce postoperative mortality and morbidity. [5,12,13] In conclusion, we believe that, considering the early and late benefits, when pulmonary annulus diameter is adequate, every effort should be made to protect the pulmonary valve in patients undergoing total repair for tetralogy of Fallot. In patients with narrow pulmonary annulus undergoing transannular patch, monocusp insertion is a technique that could potentially reduce postoperative morbidity and mortality by conserving function of the pulmonary valve and right ventricle in the early stage.…”

“…The monocusp may be constructed with various materials such as autogenous or bovine pericardium, polytetrafluoroethylene (PTFE) membrane, and extracellular matrix. [12,13] In standard practice, the monocusp is prepared by cutting it as a semicircle to fit the length of the RVOT incision from the apex to the pulmonary annulus and the width of the diameter of the pulmonary annulus. The monocusp is attached by leaving 1 mm excess on both sides and suturing it to the pulmonary valve commissures and the apex of the RVOT incision at three different points.…”

“…The suture used to close the transannular incision is continued on both ends and stitched to the ventriculotomy. [12,13] Likewise, we applied monocusp with autogenous pericardium with the standard technique in all of our patients. While the literature describes various new techniques on pulmonary valve reconstruction, the superiority of these techniques to the standard monocusp application in terms of durability and degeneration is under debate.…”

“…They found similar results in patients who underwent monocusp insertion in terms of early PR development leading to necessary early intervention (91% mild PR, 6% moderate PR, 3% free PR at discharge). However, Sasikumar et al [13] reported that a significant majority of the patients who had undergone monocusp insertion showed monocusp calcification and loss of mobility along with associated pulmonary valve insufficiency and/or pulmonary stenosis within the postoperative first year follow-up. In general, it has been reported that the monocusp technique, which has controversial mid and late-term results and seems to have limited durability, has at least adequate function at an early stage and the potential to reduce postoperative mortality and morbidity.…”