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Reconstruction of Trileaflet Pulmonary Valve Using Autologous Pericardium
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How-To-Do-It
Reconstruction of Trileaflet Pulmonary Valve Using Autologous Pericardium Shantanu Pande, MCh ∗ , Surendra K. Agarwal, MCh, Gauranga Majumdar, MCh, Mahendra Narwaley, MS, Ram K. Shukla, MS and Mayank Arora, MS Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Abstract: Tetralogy of Fallot with atretic or absent pulmonary valve may require pulmonary valve replacement or reconstruction. We propose a technique of reconstruction of a trileaflet valve at the level of the pulmonary annulus using untreated autologous pericardium. Six cases operated upon, using this technique, had trivial pulmonary regurgitation with a median gradient of 24 mmHg (18–38) across the newly created valve. This approach can be considered in cases with limited availability of more suitable alternatives. (Heart, Lung and Circulation 2011;20:325–328) © 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Pulmonary valve; Pericardium; Congenital heart disease; Tetralogy of fallot; Pulmonary insufficiency
A
competent valve at the pulmonary position is desirable after repair of Tetralogy of Fallot (TOF). Following repair, the severity of pulmonary insufficiency can increase leading to right ventricular dysfunction [1]. Though pulmonary insufficiency is well tolerated in the initial period after operation, Park and co-workers observed a 31.7% reoperation rate at 10 years follow-up after repair of TOF, in half of whom pulmonary insufficiency was the reason for reoperation [2]. Right heart failure was observed in 21% of patients whilst right ventricular dilatation was present in 7% of patients at long term follow-up [3]. Tetralogy of Fallot is sometimes associated with an atretic pulmonary valve, or rarely, with absence of the pulmonary valve [4]. In these anatomical situations a transannular patch (TAP) is required, with or without pulmonary valve replacement or reconstruction. We present a technique of using untreated autologous pericardium to construct a trileaflet valve at the pulmonary annulus.
Materials and Methods This study includes six patients operated upon between November 2005 and November 2008. During this period a total of 72 cases of TOF were operated upon in the department. A single surgeon performed this technique in all the cases described. The trileaflet pericardial valve was Received 23 June 2010; received in revised form 14 January 2011; accepted 17 January 2011 ∗
Corresponding author. Tel.: +91 522 2668800x2212; fax: +91 522 2668017. E-mail address: [email protected] (S. Pande).
constructed at the pulmonary annulus in all the cases. The diagnosis was TOF in five patients (four with dysplastic pulmonary valve and one with absent pulmonary valve) and one patient had severe pulmonary stenosis with infective endocarditis.
Surgical Technique Surgery was performed through a median sternotomy, on a standard aortocaval cardiopulmonary bypass. The patient was cooled to 28 ◦ C and an aortic cross clamp was applied. Antegrade, cold blood cardioplegia was used for myocardial preservation. Infundibular resection was performed through the right atrial approach and completed through the main pulmonary artery if required. The ventricular septal defect was closed using a Dacron patch through the right atrium in the usual way. Right ventricular outflow tract reconstruction was performed after removing the aortic cross clamp on the perfused beating heart. The pulmonary valve was reconstructed using a rectangular patch of untreated autologous pericardium. The length of the patch was calculated as 3.14 times the diameter of the proposed size of annulus (minimally acceptable diameter). An extra 5 mm was added to compensate for loss of length during stitching. The width of the patch was calculated as 1.5 times the minimally acceptable diameter of the annulus. Suturing along the length of patch (lower end) was started at the level of the pulmonary annulus from the left side (towards the aorta) and continued along the posterior annulus until the right sided end of the divided annulus was reached (Fig. 1). The patch was then sutured onto the main pulmonary artery (MPA) at both ends of the divided annulus and at the middle of the pul-
© 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2011.01.014
326 HOW-TO-DO-IT
Pande et al. Tricuspid Pericardial Pulmonary Valve
Heart, Lung and Circulation 2011;20:325–328
Figure 1. (A) Incision in the main pulmonary artery (MPA) segment. (B) Opened main pulmonary artery segment. (C) Opened main pulmonary artery and suturing of pericardial patch on one edge of the MPA and then to the annulus towards the other edge, in middle pericardium is sutured to the posterior pulmonary artery wall. (D) Patch sutured to the other edge of MPA and then turned to the starting edge. (E) Patch sutured to the starting edge. (F) Completed transannular patch on MPA showing suture line on the TAP, where patch creating the valve is sutured inside.
monary artery posteriorly between the two divided edges of MPA (Fig. 1). This was sutured for a length of 0.9 times the minimally acceptable diameter, starting at the level of annulus and moving distally on the MPA, thus forming the commissures. The remaining patch was then turned from the right side anteriorly to reach the left side of the divided MPA and sutured to the MPA as described above. This creates a trileaflet valve at the level of pulmonary annulus. The TAP is sutured in the usual way, starting from the distal MPA to the proximal right ventricular outflow tract. The lower edge of the anterior portion of the pericardial patch (used for newly created pulmonary valve) was sutured to the TAP at the level of annulus.
Results The median age of patients (5 M, 1 F) was six years (4.5–12 years) and weight was 15.5 Kg (12–28 Kg). The median cardiopulmonary bypass time was 105 min (95–125) and aortic cross clamp was 45 minutes (40–65). The median hospital stay was eight days (6–12) with no operative mortality. All the patients are alive and in NYHA class I at a followup of 6–42 months. Echocardiography at last follow-up revealed a median gradient of 24 mmHg (18–34) across the reconstructed valve. The degree of residual pulmonary insufficiency was graded as trivial in four cases and mild in two cases. Fig. 2 shows a competent pulmonary valve at 42-months follow-up.
Figure 2. Echocardiographic parasternal short axis view showing created pulmonary valve at 42 months of follow-up.
Discussion The need for pulmonary valve replacement, though low, is constant and is independent of the type of repair [5]. The results of the use of pericardium to create a valve at aortic position are encouraging and are comparable to results with available bioprostheses [6]. This finding
supports efforts to utilise the pericardium to create a competent pulmonary valve. This technique uses untreated autologous pericardium to create a trileaflet valve at the level of native pulmonary annulus. A similar technique of making a trileaflet pulmonary valve, inside a conduit, with good angiographic results at follow-up has been described [7]. The durability of these valves in the long term remains questionable however [8]. Several attempts have been made to construct a hand-fashioned autologous pericardial valved conduit intraoperatively [9–14]. All of them used some variation in suturing of the pericardial tissue to create a competent valve and conduit with limited long term success. In creating a new pulmonary valve using autologous pericardium, there are two basic concerns which may affect their long term result. The first is the physical construction of the pericardial valve leaflets, which should be moulded to be closer to the natural valve shape. This has been found to positively influence leaflet stress distribution and coaptation [15], and the conduit root is moulded to incorporate sinuses, which are known to be critical for the durability of a valved conduit [16]. In our series the natural sinuses of the native pulmonary artery were utilised, at least for posterior cusps. For adequate cooptation of the valve cusps, a cuspal size of one and a half times the diameter of the pulmonary annulus is required as previously proposed [17]. The second factor for concern is the use of autologous untreated pericardium. Rapid deterioration of fresh autologous pericardial leaflets placed in the blood stream has been demonstrated although the mechanism responsible is not fully understood [18]. Hence, a fresh autologous valve may be expected to retract soon, leaving a pericardial conduit with an incompetent valve, as observed in some studies [9,10]. For this reason, it is considered obviously necessary to treat the autologous pericardial tissue with glutaraldehyde to increase the durability of valvular leaflets [19]. This treatmentkills the cells in autologous pericardium, slowing the mechanical degeneration [18]. It has been proposed, however, that the untreated autologous pericardium may escape the mineralisation which occurs with glutaraldehyde treated pericardium [20]. The untreated pericardium may still have viable cells as observed in other implanted autologous tissues [19,21]. In our study a pliable non-calcified and adequately functioning valve was documented after up to 42 months follow-up. Nonetheless, long term follow-up is required to evaluate the efficiency of the mechanical construction and the fate of untreated autologous pericardium. Although a larger group of patients may be required to prove the utility of this technique, this remains a viable option in selected cases where the availability or the cost of more suitable options like homograft or valved conduits are the limiting factors.
References [1] Fuster V, McGoon DC, Kennedy MA, Ritter DG, Kirklin JW. Long-term evaluation (12 to 22 years) of open heart surgery for tetralogy of Fallot. Am J Cardiol 1980;46:635–42.
Pande et al. Tricuspid Pericardial Pulmonary Valve
327
[2] Park CS, Lee JR, Lim HG, Kim WH, Kim YJ. The long-term result of total repair for tetralogy of Fallot. Eur J Cardiothorac Surg 2010;38:311–7. [3] Discigil B, Dearani JA, Puga FJ, Schaff HV, Hagler DJ, Warnes CA, Danielson GK. Late pulmonary valve replacement after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2001;121:O344–51. [4] Alsoufi B, Williams WG, Hua Z, Cai S, Karamlouu T, Chan CC, Coles JG, Glen S, Van Arsdell, Caldarone CA. Surgical outcomes in the treatment of patients with tetralogy of fallot and absent pulmonary valve. Eur J Cardiothorac Surg 2007;31:354–9. [5] Hickey EJ, Veldtman G, Bradley TJ, Gengsakul A, Manlhiot C, Williams WG, Webb GD, McCrindle BW. Late risk of outcomes for adult with repaired tetralogy of Fallot from an inception cohort spanning four decades. Eur J Cardiothorac Surg 2009;35:156–64. [6] Al Halees, Al Shahid M, Al Sanei A, Sallehuddin A, Duran C. Up to 16 years follow-up of aortic valve reconstruction with pericardium: a stentless readily available cheap valve? Eur J Cardiothorac Surg 2005;28:200–5. [7] Matsuda H, Katawa H, Miyamoto K, Tokuan Y, Kasai Y, Kobayashi J, Matsuki O, Kawashima Y. Hand-made valved conduit with high-porosity knitted graft and glutaraldehydetreated autologous pericardial trileaflet valve. Artif Organs 1990;14:392–4. [8] Nunn GR, Bennetts J, Onikul E. Durability of hand-swen valves in the right ventricular outlet. J Thoac Cardiovasc Surg 2008;136:290–7. [9] Schlichter AJ, Kreutzer C, Mayorquim RC, Simon JL, Roman MI, Vazquez H, Kreutzer EA, Kreutzer GO, Jonas SR. Five- to fifteen-year follow-up of fresh autologous pericardial valved conduits. J Thorac Cardiovasc Surg 2000;119:869–79. [10] Schlichter AJ, Kreutzer C, Mayorquim RC, Simon JL, Vazquez H, Roman MI, Kreutzer GO. Long-term follow-up of autologous pericardial valved conduits. Ann Thorac Surg 1996;62:155–60. [11] Kumar MN, Prabakar G, Kumar N, Shahid M, Becker AE, Duran CM. Autologous glutaraldehyde-treated pericardial valved conduit: an experimental study. Ann Thorac Surg 1995;60(Suppl.):S200–4. [12] Koh M, Yagihara T, Uemura H, Kagisaki K, Hagino I, Ishizaka T, Kitamura S. Long-term outcome of right ventricular outflow tract reconstruction using a handmade tri-leaflet conduit. Eur J Cardiothorac Surg 2005;27:807–14. [13] Chotivatanapong T, Kasemsarn C, Yosthasurodom C, Chaiseri P, Sungkahapong V, Hengrussamee K. Autologous pericardial valved conduit for the Ross operation. Asian Cardiovasc Thorac Ann 2005;13:321–4. [14] Kreutzer C, Kreutzer GO, De CMR, Roman MI, Vazquez H, Simon JL, Kreutzer EA, Schlichter AJ. Early and late results of fresh autologous pericardial valved conduits. Semin Thorac Cardiovasc Surg Pediatr Card Surg 1999;Annu 2:65–76. [15] Lim KH, Candra J, Yeo JH, Duran CM. Flat or curved pericardial aortic valve cusps: a finite element study. J Heart Valve Dis 2004;13:792–7. [16] Kumar SP, Kumar MN, Ali ML, Becker A, Duran CM. Critical role of the sinuses of Valsalva in the durability of valved conduits. J Heart Valve Dis 1996;5:160–7. [17] He GW, Kuo CC, Mee RB. Pulmonic regurgitation and reconstruction of right ventricular outflow tract with patch. An experimental study. J Thorac Cardiovasc Surg 1986;92:128–37. [18] Cheung DT, Choo SJ, Grobe AC, Marchion DC, Luo HH, Pang DC, Favara BE, Oury JH, Duran CM. Behavior of vital and killed autologous pericardium in the descending aorta of sheep. J Thorac Cardiovasc Surg 1999;118:998–1005.
HOW-TO-DO-IT
Heart, Lung and Circulation 2011;20:325–328
328 HOW-TO-DO-IT
Pande et al. Tricuspid Pericardial Pulmonary Valve
[19] Kumar SP, Prabhakar G, Kumar M, Kumar N, Shahid M, Ali ML, Becker A, Duran CM. Comparison of fresh and glutaraldehyde-treated autologous stented pericardium as pulmonary valve replacement. J Card Surg 1995;10:545–51. [20] Abolhoda A, Yu S, Oyarzun JR, McCromick JR, Bogden JD, Gabbay S. Calcification of bovine pericardium: glutaralde-
Heart, Lung and Circulation 2011;20:325–328
hyde versus no-react biomodification. Ann Thorac Surg 1996;62:169–74. [21] Mishaly D, Birk E, Elami A, Vidne BA. Autologous monocusp pulmonary valve: preliminary result. Ann Thorac Surg 1996;61:1811–5.
How-To-Do-It
Reconstruction of Trileaflet Pulmonary Valve Using Autologous Pericardium Shantanu Pande, MCh ∗ , Surendra K. Agarwal, MCh, Gauranga Majumdar, MCh, Mahendra Narwaley, MS, Ram K. Shukla, MS and Mayank Arora, MS Department of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
Abstract: Tetralogy of Fallot with atretic or absent pulmonary valve may require pulmonary valve replacement or reconstruction. We propose a technique of reconstruction of a trileaflet valve at the level of the pulmonary annulus using untreated autologous pericardium. Six cases operated upon, using this technique, had trivial pulmonary regurgitation with a median gradient of 24 mmHg (18–38) across the newly created valve. This approach can be considered in cases with limited availability of more suitable alternatives. (Heart, Lung and Circulation 2011;20:325–328) © 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Pulmonary valve; Pericardium; Congenital heart disease; Tetralogy of fallot; Pulmonary insufficiency
A
competent valve at the pulmonary position is desirable after repair of Tetralogy of Fallot (TOF). Following repair, the severity of pulmonary insufficiency can increase leading to right ventricular dysfunction [1]. Though pulmonary insufficiency is well tolerated in the initial period after operation, Park and co-workers observed a 31.7% reoperation rate at 10 years follow-up after repair of TOF, in half of whom pulmonary insufficiency was the reason for reoperation [2]. Right heart failure was observed in 21% of patients whilst right ventricular dilatation was present in 7% of patients at long term follow-up [3]. Tetralogy of Fallot is sometimes associated with an atretic pulmonary valve, or rarely, with absence of the pulmonary valve [4]. In these anatomical situations a transannular patch (TAP) is required, with or without pulmonary valve replacement or reconstruction. We present a technique of using untreated autologous pericardium to construct a trileaflet valve at the pulmonary annulus.
Materials and Methods This study includes six patients operated upon between November 2005 and November 2008. During this period a total of 72 cases of TOF were operated upon in the department. A single surgeon performed this technique in all the cases described. The trileaflet pericardial valve was Received 23 June 2010; received in revised form 14 January 2011; accepted 17 January 2011 ∗
Corresponding author. Tel.: +91 522 2668800x2212; fax: +91 522 2668017. E-mail address: [email protected] (S. Pande).
constructed at the pulmonary annulus in all the cases. The diagnosis was TOF in five patients (four with dysplastic pulmonary valve and one with absent pulmonary valve) and one patient had severe pulmonary stenosis with infective endocarditis.
Surgical Technique Surgery was performed through a median sternotomy, on a standard aortocaval cardiopulmonary bypass. The patient was cooled to 28 ◦ C and an aortic cross clamp was applied. Antegrade, cold blood cardioplegia was used for myocardial preservation. Infundibular resection was performed through the right atrial approach and completed through the main pulmonary artery if required. The ventricular septal defect was closed using a Dacron patch through the right atrium in the usual way. Right ventricular outflow tract reconstruction was performed after removing the aortic cross clamp on the perfused beating heart. The pulmonary valve was reconstructed using a rectangular patch of untreated autologous pericardium. The length of the patch was calculated as 3.14 times the diameter of the proposed size of annulus (minimally acceptable diameter). An extra 5 mm was added to compensate for loss of length during stitching. The width of the patch was calculated as 1.5 times the minimally acceptable diameter of the annulus. Suturing along the length of patch (lower end) was started at the level of the pulmonary annulus from the left side (towards the aorta) and continued along the posterior annulus until the right sided end of the divided annulus was reached (Fig. 1). The patch was then sutured onto the main pulmonary artery (MPA) at both ends of the divided annulus and at the middle of the pul-
© 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2011.01.014
326 HOW-TO-DO-IT
Pande et al. Tricuspid Pericardial Pulmonary Valve
Heart, Lung and Circulation 2011;20:325–328
Figure 1. (A) Incision in the main pulmonary artery (MPA) segment. (B) Opened main pulmonary artery segment. (C) Opened main pulmonary artery and suturing of pericardial patch on one edge of the MPA and then to the annulus towards the other edge, in middle pericardium is sutured to the posterior pulmonary artery wall. (D) Patch sutured to the other edge of MPA and then turned to the starting edge. (E) Patch sutured to the starting edge. (F) Completed transannular patch on MPA showing suture line on the TAP, where patch creating the valve is sutured inside.
monary artery posteriorly between the two divided edges of MPA (Fig. 1). This was sutured for a length of 0.9 times the minimally acceptable diameter, starting at the level of annulus and moving distally on the MPA, thus forming the commissures. The remaining patch was then turned from the right side anteriorly to reach the left side of the divided MPA and sutured to the MPA as described above. This creates a trileaflet valve at the level of pulmonary annulus. The TAP is sutured in the usual way, starting from the distal MPA to the proximal right ventricular outflow tract. The lower edge of the anterior portion of the pericardial patch (used for newly created pulmonary valve) was sutured to the TAP at the level of annulus.
Results The median age of patients (5 M, 1 F) was six years (4.5–12 years) and weight was 15.5 Kg (12–28 Kg). The median cardiopulmonary bypass time was 105 min (95–125) and aortic cross clamp was 45 minutes (40–65). The median hospital stay was eight days (6–12) with no operative mortality. All the patients are alive and in NYHA class I at a followup of 6–42 months. Echocardiography at last follow-up revealed a median gradient of 24 mmHg (18–34) across the reconstructed valve. The degree of residual pulmonary insufficiency was graded as trivial in four cases and mild in two cases. Fig. 2 shows a competent pulmonary valve at 42-months follow-up.
Figure 2. Echocardiographic parasternal short axis view showing created pulmonary valve at 42 months of follow-up.
Discussion The need for pulmonary valve replacement, though low, is constant and is independent of the type of repair [5]. The results of the use of pericardium to create a valve at aortic position are encouraging and are comparable to results with available bioprostheses [6]. This finding
supports efforts to utilise the pericardium to create a competent pulmonary valve. This technique uses untreated autologous pericardium to create a trileaflet valve at the level of native pulmonary annulus. A similar technique of making a trileaflet pulmonary valve, inside a conduit, with good angiographic results at follow-up has been described [7]. The durability of these valves in the long term remains questionable however [8]. Several attempts have been made to construct a hand-fashioned autologous pericardial valved conduit intraoperatively [9–14]. All of them used some variation in suturing of the pericardial tissue to create a competent valve and conduit with limited long term success. In creating a new pulmonary valve using autologous pericardium, there are two basic concerns which may affect their long term result. The first is the physical construction of the pericardial valve leaflets, which should be moulded to be closer to the natural valve shape. This has been found to positively influence leaflet stress distribution and coaptation [15], and the conduit root is moulded to incorporate sinuses, which are known to be critical for the durability of a valved conduit [16]. In our series the natural sinuses of the native pulmonary artery were utilised, at least for posterior cusps. For adequate cooptation of the valve cusps, a cuspal size of one and a half times the diameter of the pulmonary annulus is required as previously proposed [17]. The second factor for concern is the use of autologous untreated pericardium. Rapid deterioration of fresh autologous pericardial leaflets placed in the blood stream has been demonstrated although the mechanism responsible is not fully understood [18]. Hence, a fresh autologous valve may be expected to retract soon, leaving a pericardial conduit with an incompetent valve, as observed in some studies [9,10]. For this reason, it is considered obviously necessary to treat the autologous pericardial tissue with glutaraldehyde to increase the durability of valvular leaflets [19]. This treatmentkills the cells in autologous pericardium, slowing the mechanical degeneration [18]. It has been proposed, however, that the untreated autologous pericardium may escape the mineralisation which occurs with glutaraldehyde treated pericardium [20]. The untreated pericardium may still have viable cells as observed in other implanted autologous tissues [19,21]. In our study a pliable non-calcified and adequately functioning valve was documented after up to 42 months follow-up. Nonetheless, long term follow-up is required to evaluate the efficiency of the mechanical construction and the fate of untreated autologous pericardium. Although a larger group of patients may be required to prove the utility of this technique, this remains a viable option in selected cases where the availability or the cost of more suitable options like homograft or valved conduits are the limiting factors.
References [1] Fuster V, McGoon DC, Kennedy MA, Ritter DG, Kirklin JW. Long-term evaluation (12 to 22 years) of open heart surgery for tetralogy of Fallot. Am J Cardiol 1980;46:635–42.
Pande et al. Tricuspid Pericardial Pulmonary Valve
327
[2] Park CS, Lee JR, Lim HG, Kim WH, Kim YJ. The long-term result of total repair for tetralogy of Fallot. Eur J Cardiothorac Surg 2010;38:311–7. [3] Discigil B, Dearani JA, Puga FJ, Schaff HV, Hagler DJ, Warnes CA, Danielson GK. Late pulmonary valve replacement after repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2001;121:O344–51. [4] Alsoufi B, Williams WG, Hua Z, Cai S, Karamlouu T, Chan CC, Coles JG, Glen S, Van Arsdell, Caldarone CA. Surgical outcomes in the treatment of patients with tetralogy of fallot and absent pulmonary valve. Eur J Cardiothorac Surg 2007;31:354–9. [5] Hickey EJ, Veldtman G, Bradley TJ, Gengsakul A, Manlhiot C, Williams WG, Webb GD, McCrindle BW. Late risk of outcomes for adult with repaired tetralogy of Fallot from an inception cohort spanning four decades. Eur J Cardiothorac Surg 2009;35:156–64. [6] Al Halees, Al Shahid M, Al Sanei A, Sallehuddin A, Duran C. Up to 16 years follow-up of aortic valve reconstruction with pericardium: a stentless readily available cheap valve? Eur J Cardiothorac Surg 2005;28:200–5. [7] Matsuda H, Katawa H, Miyamoto K, Tokuan Y, Kasai Y, Kobayashi J, Matsuki O, Kawashima Y. Hand-made valved conduit with high-porosity knitted graft and glutaraldehydetreated autologous pericardial trileaflet valve. Artif Organs 1990;14:392–4. [8] Nunn GR, Bennetts J, Onikul E. Durability of hand-swen valves in the right ventricular outlet. J Thoac Cardiovasc Surg 2008;136:290–7. [9] Schlichter AJ, Kreutzer C, Mayorquim RC, Simon JL, Roman MI, Vazquez H, Kreutzer EA, Kreutzer GO, Jonas SR. Five- to fifteen-year follow-up of fresh autologous pericardial valved conduits. J Thorac Cardiovasc Surg 2000;119:869–79. [10] Schlichter AJ, Kreutzer C, Mayorquim RC, Simon JL, Vazquez H, Roman MI, Kreutzer GO. Long-term follow-up of autologous pericardial valved conduits. Ann Thorac Surg 1996;62:155–60. [11] Kumar MN, Prabakar G, Kumar N, Shahid M, Becker AE, Duran CM. Autologous glutaraldehyde-treated pericardial valved conduit: an experimental study. Ann Thorac Surg 1995;60(Suppl.):S200–4. [12] Koh M, Yagihara T, Uemura H, Kagisaki K, Hagino I, Ishizaka T, Kitamura S. Long-term outcome of right ventricular outflow tract reconstruction using a handmade tri-leaflet conduit. Eur J Cardiothorac Surg 2005;27:807–14. [13] Chotivatanapong T, Kasemsarn C, Yosthasurodom C, Chaiseri P, Sungkahapong V, Hengrussamee K. Autologous pericardial valved conduit for the Ross operation. Asian Cardiovasc Thorac Ann 2005;13:321–4. [14] Kreutzer C, Kreutzer GO, De CMR, Roman MI, Vazquez H, Simon JL, Kreutzer EA, Schlichter AJ. Early and late results of fresh autologous pericardial valved conduits. Semin Thorac Cardiovasc Surg Pediatr Card Surg 1999;Annu 2:65–76. [15] Lim KH, Candra J, Yeo JH, Duran CM. Flat or curved pericardial aortic valve cusps: a finite element study. J Heart Valve Dis 2004;13:792–7. [16] Kumar SP, Kumar MN, Ali ML, Becker A, Duran CM. Critical role of the sinuses of Valsalva in the durability of valved conduits. J Heart Valve Dis 1996;5:160–7. [17] He GW, Kuo CC, Mee RB. Pulmonic regurgitation and reconstruction of right ventricular outflow tract with patch. An experimental study. J Thorac Cardiovasc Surg 1986;92:128–37. [18] Cheung DT, Choo SJ, Grobe AC, Marchion DC, Luo HH, Pang DC, Favara BE, Oury JH, Duran CM. Behavior of vital and killed autologous pericardium in the descending aorta of sheep. J Thorac Cardiovasc Surg 1999;118:998–1005.
HOW-TO-DO-IT
Heart, Lung and Circulation 2011;20:325–328
328 HOW-TO-DO-IT
Pande et al. Tricuspid Pericardial Pulmonary Valve
[19] Kumar SP, Prabhakar G, Kumar M, Kumar N, Shahid M, Ali ML, Becker A, Duran CM. Comparison of fresh and glutaraldehyde-treated autologous stented pericardium as pulmonary valve replacement. J Card Surg 1995;10:545–51. [20] Abolhoda A, Yu S, Oyarzun JR, McCromick JR, Bogden JD, Gabbay S. Calcification of bovine pericardium: glutaralde-
Heart, Lung and Circulation 2011;20:325–328
hyde versus no-react biomodification. Ann Thorac Surg 1996;62:169–74. [21] Mishaly D, Birk E, Elami A, Vidne BA. Autologous monocusp pulmonary valve: preliminary result. Ann Thorac Surg 1996;61:1811–5.