Invited Commentary

Abstract

fenestrated leaflet) and was central in 3 patients. There was no more than a physiologic gradient (Ͻ 4 mm Hg) in the 5 patients with tricuspid valves and a gradient of 8, 16, and 23 mm Hg in the 3 patients with bicuspid valves, respectively. These operative findings remained fundamentally unchanged in all patients during follow-up.The patients all had a smooth recovery with same-day extubation and 1-to 2-night stays in the intensive care unit. There was no significant complication postoperatively or during follow-up. CommentRecycling of the pulmonary valve is an interesting concept in patients with tetralogy of Fallot and secondary chronic pulmonary regurgitation. The insertion of a competent valve is an important step in the course of treating these patients to restore or preserve the function of their steadily dilating right ventricle and to prevent the development of ominous ventricular arrhythmias [3, 4]. The disadvantages of valvular prostheses are well known, the most important ones being the need for iterative replacement in the usual treatment of tissue valves and bacterial endocarditis [5][6][7]. The recycling of the native, viable pulmonary valve could circumvent all these problems and bring a long-term solution to these patients.We have been surprised many times to see the size, morphologic characteristics, and quality of the residual leaflets in patients with tetralogy of Fallot. It appears, furthermore, that the leaflets have pursued their growth in accordance with the size of the main pulmonary artery and not with the somatic growth of the patient. This fact provides additional tissue for reconstruction. This explains the successful recycling of bicuspid valves without the induction of valvular stenosis.The surgical technique to recycle the pulmonary valve is extremely simple. It is important to sufficiently dissect the main pulmonary artery around the pulmonary annulus to allow its reapproximation (after resection of most of the transannular patch) in a round fashion. A mattress suture allows a precise approximation of the commissure and helps fashion by appropriate trimming both the main pulmonary artery and the infundibulum. We believe that the valve can be accurately assessed after reconstruction of the main pulmonary artery with injection of saline distal to the valve. Even if the saline rapidly flows through the lung bed, it still can give a good view of the expanding valve and would detect significant regurgitation. The complementary assessment of the valve with transesophageal echocardiography should definitively confirm the appropriateness of the recycling procedure. Even if it were decided at that time to change the valve, the additional patient time under cardiopulmonary bypass would not have exceeded 30 minutes and would be tolerated without significant additional morbidity.We must however emphasize that the conditions necessary to recycle the valve are seldom achieved. This technique represents only 15% of our secondary operations to correct chronic regurgitation. Still we believe that...