Three-step preoperative sequential planning for pulmonary valve replacement in repaired tetralogy of Fallot using computed tomography

Abstract

OBJECTIVES Our goal was to compare results between a standard computed tomography (CT)-based strategy, the ‘three-step preoperative sequential planning’ (3-step PSP), for pulmonary valve replacement in repaired tetralogy of Fallot versus a conventional planning approach. METHODS We carried out a retrospective study with unmatched and matched groups. The 3-step PSP comprised the planning of mediastinal re-entry, cannulation for cardiopulmonary bypass (CPB) and the main procedure, using standard 3-dimensional videos. Operative times (skin incision to CPB, CPB time, end of CPB to skin closure and cross-clamp time) as well as postoperative length of stay and in-hospital mortality were compared. RESULTS Eighty-two patients (49% classical tetralogy of Fallot) underwent an operation (85% with pulmonary homograft) with 1.22% in-hospital mortality. The 3-step PSP (n = 14) and the conventional planning (n = 68) groups were compared. There were no statistically significant differences in the preoperative characteristics. Differences were observed in the total operative time (P = 0.009), skin incision to CPB (P = 0.034) and cross-clamp times (74 ± 33 vs 108 ± 47 min; P = 0.006), favouring the 3-step PSP group. Eight matched pairs were compared showing differences in the total operative time (263 ± 44 vs 360 ± 66 min; P = 0.008), CPB time (123 ± 34 vs 190 ± 43 min; P = 0.008) and postoperative length of stay (P = 0.031), favouring the 3-step PSP group. CONCLUSIONS In patients with repaired tetralogy of Fallot undergoing pulmonary valve replacement, preoperative planning using a standard CT-based strategy, the 3-step PSP, is associated with shorter operative times and shorter postoperative length of stay.

Simultaneous Aortic and Pulmonary Valve Replacement in Repaired Congenital Heart Disease

“…The surgical risk for death in simultaneous aortic and pulmonary valve replacement in our study was 8.4% perioperatively with no mortality during follow-up (mean 7 ± 5 years). Each operation represented an extreme challenge for the clinical team and required individual planning according to the 3-step strategy model [15]. We simulate a "step-by-step" approach in all complex redo-surgical procedures.…”

“…Each operation represented an extreme challenge for the clinical team and required individual planning according to the three-step strategy model. 15 We simulate a “step-by-step” approach in all complex redo-surgical procedures. A three-step sequential planning strategy is performed, comprised of mediastinal re-entry, cannulation for CPB, and the main procedure.…”

Technical Recommendations for Computed Tomography Guidance of Intervention in the Right Ventricular Outflow Tract: Native RVOT, Conduits, and Bioprosthetic Valves

“…Advanced imaging is a critical component of preoperative evaluation and surgical planning for PVR. 128 Specific considerations include pulmonary annular dimension, MPA dimension, and length, the presence or absence of branch pulmonary artery stenosis, the geometry and character of the proximal and distal RVOT as well as the RV body, the location and branching pattern of the coronary arteries, and the relationship of the great arteries and cardiac mass to the sternum. Pulmonary annular and MPA dimensions are important determinants of appropriate choices for PVR.…”

Pediatric Surgical Pulmonary Valve Replacement Outcomes After Implementation of a Clinical Pathway

“…If they had a prior sternotomy, CT imaging of the chest is obtained, as this has been shown to improve surgical planning and possibly lead to shorter OR times and LOS. 25,26 A key driver of the pathway is early extubation in the OR, a practice that has been shown to reduce hospital LOS. [27][28][29][30] In the CICU, scheduling of perioperative antibiotics, analgesics, electrolyte replacements, and planned removal of indwelling catheters had already become clinical routine, allowing these practices to be easily integrated into the CP and streamline the process for all healthcare providers involved.…”