Double-barreled conduit for right atrioventricular connection in tricuspid atresia: A new technique

Abstract

child at 4 days of age. A diagnosis of tricuspid atresia was made, and she remained well. Cardiac catheterization, performed at 8 months of age, confirmed the diagnosis of tricuspid atresia with a moderate-sized RV and limiting ventricular septal defect. There was a left-to-right shunt of 2:1. She remained well but became cyanotic and short of breath on exertion at the age of 4 years. A Fontan procedure was then performed (on July 9, 1980), and the RA was connected to the RV with a size 19 mm antibiotic-sterilized homograft. At the same time, the atrial and ventricular septal defects were closed. She made good progress attending a normal school and undertaking sporting activities, but 7 years later, her physical status deteriorated, and further echocardiography and angiography demonstrated moderate homograft regurgitation and stenosis with a gradient of 7 mm Hg. The RV had grown and was producing satisfactory flow. She had a reoperation, at which the RA-RV conduit was replaced with an 18-mm antibiotic-sterilized homograft. She initially did well, but 9 years later, she had reduced exercise tolerance and palpitations. Hemodynamic investigations on this occasion showed a high-velocity diastolic flow through the homograft, an RA “a” wave of 16 mm, and an “a” wave gradient of 10 mm Hg. At the time of the second reoperation, 16 years after her original modified Fontan procedure, the calcified aortic antibiotic-sterilized homograft was removed. The RA and RV orifices were widened, and the resulting defects were closed with two valved conduits. The upper one was a Homografts used to establish a right atrioventricular connection in patients having tricuspid atresia with a good-sized right ventricle (RV) tend to calcify and become obstructive and nonfunctional. Compression of the homograft by the overlying sternum contributes to this process. We present a technique whereby an incompressible heterograft and a homograft are inserted side by side between the right atrium (RA) and the RV in a double-barreled fashion. The heterograft protects itself and the homograft, which is inferior to it, from collapsing because of sternal compression. Improved RA-RV blood flow is possible because the much larger combined orifice area offers much lower resistance. Longer patency may be anticipated because of the lack of sternal compression and the improved hemodynamics. Clinical summary. A murmur was heard in this female DOUBLE-BARRELED CONDUIT FOR RIGHT ATRIOVENTRICULAR CONNECTION IN TRICUSPID ATRESIA: A NEW TECHNIQUE