Ventricular Outflow Tract Enlargement Research Articles

Surgical Treatment Outcomes of Tetralogy of Fallot: Experience of the Cardiovascular Department of the Mohammed VI University Hospital in Marrakech.

BackgroundTetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. The surgical approach to TOF continues to evolve, with many centers now favoring early repair for TOF. This study aimed to determine the prevalence of postsurgical complications such as pulmonary insufficiency, residual pulmonary stenosis, and interventricular communication.MethodologyWe conducted a cross-sectional, observational study with a descriptive and analytic focus involving 61 patients who were operated on for TOF.ResultsIn total, 39 (63.9%) patients had a regular TOF and 22 (36.1%) had an irregular TOF. In our study, 32 (56.14%) patients had a pulmonary insufficiency, of whom 20 had a minimal pulmonary insufficiency (62.5% of pulmonary insufficiency cases), and 79.4% of patients with right ventricular outflow tract enlargement had pulmonary insufficiency (p < 0.005). Among patients who did not have a right ventricular outflow tract enlargement, three cases of pulmonary insufficiency were identified with a prevalence of 16.6%. Six (10.52%) patients had residual pulmonary stenosis. In addition, two (3.2%) cases of minimal residual ventricular septal defects were identified in this study.ConclusionsPostoperative complications of TOF treatment are frequent and require medical care throughout the lifetime of patients.

Atrioventricular Groove Patch Plasty as Part of Konno Operation After Arterial Switch Operation

Aortic insufficiency sometimes occurs after arterial switch operation for transposition of the great arteries. Left ventricular outflow tract enlargement by Konno operation and right ventricular outflow tract reconstruction are necessary during the aortic valve replacement in case of small aortic annulus. A vertical incision from the anterior pulmonary artery to the right ventricular outflow tract in Konno operation can be applied if the coronary anatomy is Shaher type 1, 2, 6, and 8. However, a vertical incision jeopardizes the coronary artery which traverses on the right ventricular outflow tract in Shaher type 3a, 3c, 3d, 4, 5c, 7c, and 9. In this difficult situation, atrioventricular groove patch plasty as part of Konno operation is a choice of surgery.

Left Ventricular Involvement in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy Assessed by Echocardiography Predicts Adverse Clinical Outcome

Among studies describing the phenotype of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C), significant discrepancy exists regarding the extent and impact of left ventricular (LV) involvement. The capability of conventional and new quantitative echocardiographic techniques to accurately detect LV involvement in ARVD/C remains unknown. The aim of this study was to test the hypothesis that accuratedetection of LV involvement on echocardiography identifies patients at additional risk for cardiac events during follow-up. Thirty-eight patients with ARVD/C, 16 pathogenic mutation-positive relatives, and 55 healthy control subjects were prospectively enrolled. Conventional echocardiography with additional deformation imaging was performed in all subjects to detect LV involvement. In a subgroup (n=27), cardiac magnetic resonance imaging was performed with late enhancement. All patients and relatives were prospectively followed for events (sustained ventricular tachycardia, appropriate implantable cardioverter-defibrillator intervention, suddencardiac death, and heart transplantation). Conventional echocardiography detected LV involvement in 32% of patients with ARVD/C and in none of the relatives. Deformation imaging revealed LV involvement in 68% of patients with ARVD/C and 25% of relatives and was correlated closely with late enhancement on cardiac magnetic resonance imaging. During a mean follow-up period of 5.9±2.3years, 20 patients with ARVD/C (53%) experienced events, and no events occurred in the relatives. LV involvement detected by deformation imaging (hazard ratio, 4.9; 95% CI, 1.7-14.2) and right ventricular outflow tract enlargement (hazard ratio, 1.2; 95% CI, 1.1-1.3) were the only independentpredictors of outcomes. Deformation imaging detected a high incidence of LV involvement in patients with ARVD/C and their relatives. Compared with conventional echocardiography, deformation imaging is superior in detecting minor LV involvement. LV involvement and an enlarged right ventricular outflow tract are independent prognostic markers of outcomes.

Right Ventricular Outflow Tract Enlargement Prior to Pulmonary Valve Replacement is Associated with Poorer Structural and Functional Outcomes, in Adults with Repaired Tetralogy of Fallot

Pulmonary valve replacement (PVR) is commonly performed late after Tetralogy of Fallot (TOF) repair. We examined the effects of PVR on cardiac structure, function and exercise capacity in adults with repaired TOF. Eighteen adult patients with repaired TOF and severe pulmonary regurgitation (PR) with right ventricular (RV) dilatation requiring PVR for clinical reasons (age; 25±8 years) were recruited to undergo cardiac MRI (1.5T) and cardiopulmonary exercise testing before and 14±3 months after PVR. Reduced indexed RV end-diastolic volume (RVEDVi; 186±32mL/m(2) pre-op vs 114±20mL/m(2) post-op, p<0.001) was observed after PVR. "Normalisation" of RVEDVi (≤108mL/m(2)) was achieved in only seven of 18 patients. Pre-PVR RVEDVi correlated with post-operative change in RVEDVi (change=-72.1±20.4mL/m(2), r=-0.815, p<0.001). Exercise capacity remained high-normal post-PVR (% predicted maximal workload: 93±16% vs 91±12%, p=0.5). Regional RV volumes were assessed; RV outflow tract (RVOT) volumes were compared to the RV muscular corpus. Large pre-PVR RVOT volumes correlated negatively with post-surgical RV ejection fraction, peak VO2 and delta VO2 at anaerobic threshold (p<0.05 for all). Normalisation of RV volume is unlikely to be achieved above a pre-PVR RVEDVi of 165mL/m(2) or more. In particular, an enlarged RVOT prior to PVR predicts suboptimal structural and functional outcomes.

Ventricular tachycardia in English bulldogs with localised right ventricular outflow tract enlargement

To describe the electrocardiographic characteristics of ventricular tachycardia arising from the right ventricular outflow tract and the particular association between this arrhythmia and the presence of localised right ventricular outflow tract enlargement in English bulldogs. Five English bulldogs were referred with a history of syncope or cardiogenic shock. In all dogs, 12-lead surface ECG, thoracic radiograph and echocardiography were collected. In all but one dog 24-hours Holter monitoring and signal-averaged ECGs was examined and in one dog electrophysiological study and radiofrequency catheter ablation of the VT substrate was performed. Documented arrhythmias included a single sustained monomorphic wide QRS tachycardia in four dogs, and an alternans of two different monomorphic forms in one dog. Mean QRS duration during tachy-cardia was 91·6 ±9·83 milliseconds. QRS complexes manifested a left bundle branch block morphology and an inferior axis (81 ±13·73°). R wave notching was present in the caudal (inferior) leads in three tachy-cardias. Lead I was negative in 3 of 6, positive in 1 of 6 and isodiphasic in 2 of 6. Lead aVL was negative in 5 of 6 and positive in 1 of 6. Signal-averaged electrocardiograms revealed late potentials in three dogs. Echocardiography showed a localised right ventricular outflow tract enlargement in all dogs. Cardiac map-ping established two sites of origin of ventricular tachycardia within the right ventricular outflow tract in one dog: caudal free-wall and cranial-septal. The presence of a localised right ventricular outflow tract enlargement and ventricular tachycardia with left bundle branch block morphology could suggest segmental arrhythmogenic right ven-tricular cardiomyopathy in the English bulldog.

Pendulous heart with tamponade

To the editor: We read with interest the article by Mascherbauer et al 1 recently published in Heart and we congratulate our colleagues for an honest effort on shedding some...

Hybrid Pulmonary Valve Implantation: Injection of a Self-Expanding Tissue Valve Through the Main Pulmonary Artery

An 8-year-old (35 kg) boy presented with progressive right ventricular outflow tract enlargement (28 mm) and progressive tricuspid regurgitation after transannular repair of tetralogy of Fallot and was scheduled for pulmonary valve replacement. To spare reoperation on full sternotomy, a transverse mini-thoracotomy through the third intercostal space was used to implant an injectable 29-mm stented porcine valve directly through an incision of the pulmonary artery bifurcation. The procedure was performed while rapid ventricular pacing and right ventricular unload by a short running femorally implanted cardiopulmonary bypass. The stented valve was fixed with three single sutures to avoid embolization. The interventional result was well with full competence of the valve. The boy was discharged at day 4 after the procedure.

Pediatric Autograft Aortic Root Replacement: A Prospective Follow-Up Study

The autograft procedure offers children who require aortic valve replacement the advantage of an autologous valve that has growth potential and does not require anticoagulation. However, the autograft procedure is a double valve operation and its durability depends on the lifetime of both the autograft and the pulmonary valve substitute. We present our clinical experience with pediatric autograft aortic root replacement. Between September 1988 and September 2003, 47 children (mean age, 8 years; standard deviation, 5 years; range, 3 months to 15 years) underwent autograft aortic root replacement. Perioperative characteristics and annual follow-up information were collected prospectively. The male to female ratio was 32 to 15. Eighty-nine percent of patients had congenital aortic valve disease, 47% of patients previously underwent cardiac surgery, and 43% had an aortic valve balloon dilatation. Concomitant left ventricular outflow tract enlargement was performed in 19 patients. In all cases the pulmonary valve was replaced using an allograft. There were no hospital deaths. Mean follow-up was 6.1 years (median 5.4; range, 1 month to 15 years; total of 284 patient years). During follow-up 3 patients died. Cumulative survival was 95% at 1 year and 93% at 12 years. One patient had endocarditis of the pulmonary allograft develop. Three patients required reoperation; two patients for allograft degeneration at 9.4 and 12.8 years, and 1 for combined autograft dilatation and allograft degeneration at 7.7 years postoperatively. Freedom from valve-related reoperation was 86% at 12 years. Pediatric autograft aortic root replacement is associated with acceptable mortality and reoperation rates in the first decade postoperatively. It allows most children to grow into adulthood without the need for anticoagulation and additional valve replacements.

Detachment of the anterior leaflet of the tricuspid valve to expose perimembranous ventricular septal defects

Background Detachment of the septal leaflet of the tricuspid valve has been described for better access to perimembranous ventricular septal defects. Detachment confined to the anterior leaflet is less known, although it provides a better exposure of the subaortic area and puts less jeopardy on the conduction tissues. Methods Data regarding 49 consecutive patients who had congenital perimembranous ventricular septal defect closure were retrospectively reviewed. Thirty-three patients (67%) underwent temporary detachment of the anterior leaflet of the tricuspid valve. The defect was closed with a Gore-Tex patch and a continuous suture. In 10 patients (29%), concomitant right ventricular outflow tract enlargement was performed. Follow-up was obtained in every patient (median time, 11 months; range, 2 to 26 months). Results No early or late death occurred. Closure of the ventricular septal defect was complete, with no more than trivial residual jet leaks found in perioperative echocardiography. All patients were in sinus rhythm. The tricuspid valve never showed more than mild insufficiency after repair. No patient showed subaortic obstruction. Conclusions Detachment of the anterior leaflet of the tricuspid valve to expose the ventricular septal defect is a safe approach that allows rapid closure of the defect with a continuous suture and provides excellent results.

Mitral annular and left ventricular outflow tract enlargement with autologous tissue: Extended application of the Ross-Konno procedure

J Thorac Cardiovasc Surg 2003;125:423-5

Late pulmonary valve replacement after repair of tetralogy of Fallot

Background: Pulmonary regurgitation appears to be well tolerated early after repair of tetralogy of Fallot; however, it may result in progressive right ventricular dilatation and dysfunction necessitating eventual valve replacement. Our objective was to review our experience with late pulmonary valve replacement after complete repair of tetralogy of Fallot. Methods and results: A total of 42 patients (16 female and 26 male) were operated on between July 1, 1974, and January 1, 1998. Mean age was 22 years (range 2-65 years). The mean interval between tetralogy repair and pulmonary valve replacement was 10.8 years (range 1.6 months–33 years). Mean follow-up was 7.8 ± 6.0 years (maximum 23 years). Indications for pulmonary valve replacement included decreased exercise tolerance in 58%, right heart failure in 21%, arrhythmia in 14%, syncope in 10%, and progressive isolated right ventricular dilatation in 7%. Heterograft prostheses were used in 33 patients and homografts in 9. Five patients underwent isolated pulmonary valve replacement; concomitant procedures performed in 37 patients included tricuspid valve repair/replacement (n = 18), residual ventricular septal defect repair (n = 12), atrial septal defect closure (n = 4), pulmonary artery patch angioplasty (n = 17), and right ventricular outflow tract enlargement (n = 13). One patient died early (2%) of multiorgan failure. There were 6 late deaths, 3 of which were cardiac related. Survival was 95.1% ± 3.4% and 76.4% ± 8.9% at 5 and 10 years, respectively. Functional class of patients was improved significantly; preoperatively, 76% of patients were in New York Heart Association class III-IV, and after pulmonary valve replacement, 97% of surviving patients were in class I-II (P =.0001). Moderate to severe reduction in right ventricular function was noted on preoperative echocardiography in 59% and on late echocardiography in 18% (P =.03). Of the 5 patients who had supraventricular arrhythmias before pulmonary valve replacement, 1 had postoperative recurrence and the arrhythmia is controlled with antiarrhythmic therapy; the other 4 are in normal sinus rhythm at late follow-up. Eight patients subsequently underwent pulmonary valve re-replacement without early mortality at a mean interval of 9.0 ± 4.2 years (range 3.8-16.8 years). Freedom from pulmonary valve re-replacement was 93.1% ± 4.7% and 69.8% ± 10.7% at 5 and 10 years, respectively. The only significant risk factor for re-replacement was young age at the time of the initial pulmonary valve replacement (P =.023). Conclusion: Late pulmonary valve replacement after tetralogy repair significantly improves right ventricular function, functional class, and atrial arrhythmias, and it can be performed with low mortality. Subsequent re-replacement may be necessary to maintain functional improvement. (J Thorac Cardiovasc Surg 2001;121:344-51)

Extended aortic root replacement with aortic allografts or pulmonary autografts in children

Objectives: To evaluate the early results and effectiveness of left ventricular outflow tract enlargement with aortic allograft or pulmonary autograft in children with complex left ventricular outflow tract obstruction. Method: The records of 30 children who underwent aortic root enlargement and replacement with either an aortic allograft (22 patients) or pulmonary autograft (8 patients) between January 1987 and June 1997 were reviewed. The predominant diagnosis was complex left ventricular outflow tract obstruction (n = 19), associated with aortic incompetence in 11 children. Before root enlargement, 27 children underwent surgical valvotomy (14 patients), balloon dilatation (10 patients), or both interventions (3 patients). Mean age at root enlargement was 5.4 ± 3.5 years (range, 2 days–16 years). Most of the children (27 patients) underwent a Konno aortoventriculoplasty. Concomitant septal myectomy was performed in 4 children, mitral valve procedure in 5 children, and endocardial fibroelastosis resection in 1 child. Results: Five children (17%) died in hospital. Four of these were infants less than 2 months old. All had acute aortic incompetence as the result of recent intervention necessitating urgent operation. The fifth child, aged 10 years, died of myocardial failure 2 weeks after the operation. During the follow-up period (mean length, 4.1 ± 2.8 years), sudden death occurred in 1 child 3 months after the operation. Follow-up echocardiograms (obtained for 23 of the surviving 24 children within 3 ± 2.3 years) showed a left ventricular outflow tract gradient reduced from a mean of 65 to 11 mm Hg ( P = .001); Z value increased from a mean of –0.5 to 4.1 ( P < .001), and aortic incompetence was trivial or mild except in 2 children. Conclusion: Urgent aortic root enlargement in decompensating neonates carries higher mortality rates. In older children, the early results of root enlargement and implantation of allograft or autograft are good. (J Thorac Cardiovasc Surg 1999;118:503-9)

Experience with one and a half ventricle repair

Objective: This article presents a 10-year experience with one and a half ventricle repair for right ventricular hypoplasia or dysfunction. Methods: From November 1986 to December 1996, 30 patients (mean age 6.7 ± 8.5 years, range 4 months-40 years) with functionally abnormal right ventricles underwent a bidirectional Glenn shunt as part of the repair. Diagnoses included pulmonary atresia with intact ventricular septum (n = 15), Ebstein anomaly (n = 5), levotransposition of the great arteries (n = 3), pulmonary stenosis with right ventricular hypoplasia (n = 2), tetralogy of Fallot (n = 3), dextrotransposition of the great arteries (n = l), and Uhl anomaly (n = l). Concomitantly performed cardiac procedures included atrial septal defect closure (n = 27), fenestration of the atrial septum (n = 2), right ventricular cavity augmentation (n = 8), right ventricular outflow tract enlargement (n = 6), transannular patch (n = 13), modified Blalock-Taussig shunt closure (n = 16), tricuspid replacement (n = 3), tricuspid repair (n = 2), Rastelli procedure (n = 3), tricuspid commissurotomy (n = 2), and double switch (n = l). Results: There were 2 early deaths (6.6%) and 1 late death. Mean early postoperative superior vena caval pressure was 14.12 ± 3.55 mm Hg and mean right atrial pressure was 10.3 ± 5.16 mm Hg. Early oxygen saturation in the operating room with an inspired oxygen fraction of 1 was 97.2 ± 2.5; oxygen saturation was 92.3 ± 4.8 on room air at discharge. Mean oxygen saturations were 93.6% ± 3.6% at 1 year of follow-up ( P = .10) and 93.5% ± 4.1% at 5 years ( P = .12). Overall survival was 90% at 5 years, and 21 patients (77%) were in New York Heart Association class I, 5 (18%) were in class II, and 1 (2.7%) was in class III. Conclusion: This procedure provides a valid alternative for correction of right ventricle hypoplasia or dysfunction. Early and intermediate follow-up results compare favorably with those of the Fontan procedure, but long-term follow-up is needed. (J Thorac Cardiovasc Surg 1999;117:662-8)

Tratamiento quirúrgico de la tetralogía de Fallot con hipoplasia o agenesia del septo conal

The clinical evolution, anatomosurgical aspects, and postoperative evolution of a specific group of Fallot's tetralogy with hipoplasic or agenesic of the conal septum (representing a 7% of our Fallot's tetralogy cases) is presented. A total of 41 patients surgically corrected in our Service between February 1973 and December 1995 has been retrospectively studied. Ages ranged between 13 months and 13 year. Clinically all cases developed moderate or severe hypoxemia. In 43.9% of cases it was necessary to perform a palliative surgery at an age between 15 days and 4 years. There was no hypoxemics spells. In the ECG we have found a QS in the aVR in 40% of cases. There was 7 deaths (17% of mortality rate). Four cases required reoperation. The clinical evolution, ECG, EKO, and hemodynamics findings are commented. In this type of Fallot's tetralogy, specifically in those cases with a pulmonary artery ring of normal size, it is necessary to have a good preoperative diagnoses in order to perform a longitudinal ventriculotomy with right ventricular outflow tract enlargement. Also, it is important to be meticulous with the stitches in the closure of the ventricular septal defect with a patch in order to avoid the potential lesion of the aortic valve.

Conduit reconstruction of the right ventricular outflow tract: Lessons learned in a twelve-year experience

From September 1979 to July 1991, a total of 163 patients have undergone valved conduit reconstruction of the right ventricular outflow tract when a right ventricle-pulmonary artery connection was absent or right ventricular outflow tract enlargement was required. From September 1979 through October 1984, 24 porcine valved conduits were implanted with an operative mortality of 38% (9/24). There were no early failures, but by 9 years after the operation 9 of 15 survivors (60%) had severe conduit obstruction, which resulted in death in 2 patients and reoperation in 6. From May 1985 to June 1991, 24 patients received cryopreserved aortic allografts to correct congenital anomalies. Operative mortality was 25% (6/24) and, again, early conduit function was good. There were 4 (22%) late deaths that were not related to the aortic allograft. At a mean follow-up of 3.4 years, 11 of the 13 survivors (85%) had allograft calcification and 8 of the 13 (62%) had mild to moderate conduit stenosis or regurgitation, or both; two of them required conduit replacement. Distal anastomotic problems that might have been avoided with bifurcated pulmonary allografts were apparent in 4 (36%) patients. Cryopreserved pulmonary allografts were placed in 115 patients between April 1985 and January 1991, with 18 (16%) operative deaths. Late deaths that were not allograft related occurred in 7 of 97 surviving patients (7%). Six patients (6%) underwent reoperation, 2 because of primary pulmonary allograft failure. The 84 remaining patients are free of symptoms with little or no allograft calcification or echocardiographic evidence of significant conduit stenosis or regurgitation. Experience with porcine valved conduits and aortic and pulmonary allografts suggests that pulmonary allografts are the conduit of choice for right ventricular outflow tract reconstruction.

低形成右心流出路に対する，弁つきパッチによる流出路拡大形成術後遠隔成績の検討

低形成右心流出路に対する，弁つきパッチによる流出路拡大形成術後遠隔成績の検討

Diminutive pulmonary artery growth following right ventricular outflow tract enlargement

We have assessed the clinical results and angiographic pulmonary artery growth following construction of the right ventricular outflow tract in 10 children with tetralogy of Fallot or pulmonary atresia. All cases were associated with diminutive pulmonary arteries and considered unsuitable for total corrective surgery. The mean age of the children was 34 months, mean weight 10 kg and mean body surface area 0.48 m 2. The right ventricular outflow tract was constructed by insertion of a patch of dura mater (5 patients), pericardium (2 patients), homograft valved conduit (2 patients) and infundibulectomy (1 patient). The ventricular septal defect was not closed. Study of the patients between 13 and 37 months postoperatively revealed an increase in mean arterial oxygen saturation of 22% ( P < 0.01) and a fall in mean haemoglobin concentration of 1.6 g% ( P < 0.05). Overall change in pulmonary artery diameter compared to that of the trachea was insignificant although in individual cases a 50% increase in diameter was shown. Palliation of symptoms was equivalent to conventional shunting procedures. Closure of the ventricular septal defect was performed successfully in 2 patients at a later date.