Surgical repair of tetralogy of Fallot using autologous right atrial appendages: short- to mid-term results

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.

Early results of neopulmonary valve creation technique using right atrial appendage tissue

“…Patients were uneventfully weaned from cardiopulmonary bypass, extubated within a short time and discharged uneventfully. Our results confirmed the early outcomes of Amirgofran et al 4 None/trace PI was seen in all their patients during follow‐up. The authors reported mild pulmonary stenosis in four patients and moderate pulmonary stenosis in two patients.…”

“…Various methods have been described for prevention of PI during RVOT reconstruction with transannular patch 1‐8 . These techniques include monocusp valve placement and anterior leaflet augmentation with polytetrafluoroethylene membranes.…”

“…This may show the applicability of this technique in different age groups, but long‐term results of durability is needed. In the series of Amirgofran et al, it was utilized in only 10 patients with TOF and the mean age was 14 months 4 . In their series, the longest follow‐up was 5 years for a patient, but mean follow‐up for the remaining nine patients was 5.3 months.…”

“…Surgical treatment of tetralogy of fallot (TOF) has been performed with low mortality in most congenital heart centers 1,2 . However, the long‐term results of TOF repair have been compromised by pulmonary insufficiency (PI) and associated right ventricular dysfunction 1‐8 . Patients with TOF usually develop free PI in the 10‐ to 20‐year period after total correction, and 10% to 15% of them will need valve replacement 9,10 .…”

“…Previous studies showed the effectiveness of attempts to create neopulmonary leaflets with biological or polytetrafluoroethylene materials, but they seemed functional only in the early postoperative period 11,12 . Recently, Amirghofran and colleagues described a technique of the application of RAA tissue as the neopulmonary valve for the reconstruction of the right ventricular outflow tract (RVOT) during TOF repair 4 . This technique creates a bicuspid valve using native tissue with low residual gradient and it allows reinterventions such as valve‐in‐valve procedure in the long‐term.…”